Red eye

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Resident
Survival
Guide

Red eye Microchapters

Patient Information

Overview

Classification

Causes

Differentiating Red eye from other Diseases

Treatment

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Seyed Arash Javadmoosavi, MD[2]

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Synonyms and Keywords: Bloodshot eye

Overview

Red eye is one of the most common complaints managed by primary care physicians though in some cases it heralds a serious and life-threatening condition needing urgent referral to ophthalmologist. The etiology of red eye can be infectious, traumatic, inflammatory, allergic, autoimmune and rarely secondary to tumors. Red eye stems from pathologies of eye lid, conjunctiva, cornea, sclera and uvea. Signs and/or symptoms such as photophobia, pain, visual acuity, itchiness, foreign body sensation and if the condition is unilateral or bilateral, must be documented. Whenever a red flag is identified in a patient presenting with red eye, the clinician must refer the patient for a same-day ophthalmologist consult.

Classification

There is no established system for the classification of red eye.

Causes

Sight-threatening causes

The most common causes of sight-threatening causes of red eye include[3]

Differentiating Red eye from other Diseases

While evaluating patients presenting with red eye, a crucial step is to identify the patients that have sight-threatening causes. This can be evaluated by asking historical questions about associated symptoms and performing a complete ocular examination. Associated symptoms include:[4][5]

Differential diagnosis of red eye[6][1]
Condition Signs Symptoms Causes Treatment
Viral conjunctivitis Supportive care and preservative-free artificial tears
Bacterial conjunctivitis Topical antibiotics
Allergic conjunctivitis
  • Normal visual acuity and pupil reaction
  • Red eye
  • Painless tearing
  • Watery discharge
  • Intense itching
Environmental antigens Supportive care and topical antihistamines
Blepharitis
  • Swollen eyelids
  • Dandruff-like scaling on eyelashes
  • Irritated eyes
  • Itching
Chronic inflammation of eyelids (staphyloccocal infections)
Subconjunctival hemorrhage Bright red patch on sclera
  • Mild pain
  • No discharge
  • No visual disturbance
Refer for further investigation
Episcleritis
  • Mild pain
  • Watery discharge
Idiopathic inflammation
Keratitis Bacterial

Viral

Bacterial

Viral

  • Topical or/and oral anti-virals
  • Topical steroids
Iritis
  • Constricted and irregular pupil reaction
  • Decreased visual acuity
Idiopathic inflamation Topical steroids
Acute angle closure glaucoma
  • Reduced visual acuity
  • Non-reactive pupils
  • Dilated pupils
Scleritis
  • Decreased visual acuity
  • Sclera edema
Systemic diseases Refer urgently

Treatment

In patients presenting with red eye, it is important to take a full detailed history and physical examination. In assessment of patient's red eye, the diagnosis can be narrowed by distinguishing other associated symptoms.


DDx Epidemiology Manifestation Cause Treatment
Viral conjunctivitis[7] More than 80% of all acute conjunctivitis Adenovirus is most common cause
Bacterial conjunctivitis[7] Up to 50% of all acute conjunctivitis Most cases are self-limiting but
Allergic conjunctivitis[7] More than 40% of population
  • Red eye
  • Itching
Environmental antigens
Blepharitis[8] More than 40% of patients presenting with red eye
Subconjunctival hemorrhage[9] About 3% of patients with red eye
  • Mild to moderate pain
  • Red eye
Refer to investigate for underlying cause
Glaucoma[10] More than 70 million cases worldwide
  • Reduced visual acuity
  • Dilated pupils
  • Red eye
Risk factors Lowering intraocular pressure
Scleritis[11] Between 0.2% to 0.6% of patients with red eye
  • Severe and constant pain
  • Pain typically worsens with eye movement
  • Tearing
  • Photophobia
  • Decreased vision
It can be associated with some systemic disorders

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Related Chapters

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  1. 1.0 1.1 Tarff, Andreina; Behrens, Ashley (2017). "Ocular Emergencies". Medical Clinics of North America. 101 (3): 615–639. doi:10.1016/j.mcna.2016.12.013. ISSN 0025-7125.
  2. Cronau H, Kankanala RR, Mauger T (January 2010). "Diagnosis and management of red eye in primary care" (2): 137–44.
  3. Kilduff C, Lois C (2016). "Red eyes and red-flags: improving ophthalmic assessment and referral in primary care". BMJ Qual Improv Rep. 5 (1). doi:10.1136/bmjquality.u211608.w4680. PMC 4964165. PMID 27493748.
  4. Narayana, Sirisha; McGee, Steven (2015). "Bedside Diagnosis of the 'Red Eye': A Systematic Review". The American Journal of Medicine. 128 (11): 1220–1224.e1. doi:10.1016/j.amjmed.2015.06.026. ISSN 0002-9343.
  5. Sethuraman U, Kamat D (2009). "The red eye: evaluation and management". Clin Pediatr (Phila). 48 (6): 588–600. doi:10.1177/0009922809333094. PMID 19357422.
  6. Gilani CJ, Yang A, Yonkers M, Boysen-Osborn M (2017). "Differentiating Urgent and Emergent Causes of Acute Red Eye for the Emergency Physician". West J Emerg Med. 18 (3): 509–517. doi:10.5811/westjem.2016.12.31798. PMC 5391903. PMID 28435504.
  7. 7.0 7.1 7.2 Azari AA, Barney NP (2013). "Conjunctivitis: a systematic review of diagnosis and treatment". JAMA. 310 (16): 1721–9. doi:10.1001/jama.2013.280318. PMC 4049531. PMID 24150468.
  8. Putnam CM (2016). "Diagnosis and management of blepharitis: an optometrist's perspective". Clin Optom (Auckl). 8: 71–78. doi:10.2147/OPTO.S84795. PMC 6095371. PMID 30214351.
  9. Tarlan B, Kiratli H (2013). "Subconjunctival hemorrhage: risk factors and potential indicators". Clin Ophthalmol. 7: 1163–70. doi:10.2147/OPTH.S35062. PMC 3702240. PMID 23843690.
  10. Weinreb RN, Aung T, Medeiros FA (2014). "The pathophysiology and treatment of glaucoma: a review". JAMA. 311 (18): 1901–11. doi:10.1001/jama.2014.3192. PMC 4523637. PMID 24825645.
  11. Galor A, Thorne JE (2007). "Scleritis and peripheral ulcerative keratitis". Rheum Dis Clin North Am. 33 (4): 835–54, vii. doi:10.1016/j.rdc.2007.08.002. PMC 2212596. PMID 18037120.