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{{SI}}
{| class="infobox" style="float:right;"
{{CMG}}
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| [[File:Siren.gif|30px|link=Red eye resident survival guide]]|| <br> || <br>
| [[Red eye resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']]
|}
{{Red eye}}
 
{{CMG}}; {{AE}} {{Arash.M}}
 
'''For patient information, click [[Red eye (patient information)|here]]'''
<br>'''For resident survival guide, click [[Red eye resident survival guide|here]]'''


{{SK}} Bloodshot eye
{{SK}} Bloodshot eye


==Overview==
==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.


In [[medicine]], '''''red eye''''' is a non-specific term to describe an [[eye]] that appears red due to illness, injury, or some other condition. "Conjunctival injection" and "bloodshot eyes" are two forms of red eye.
==Classification==
 
There is no established system for the classification of red eye.
Since it is a common affliction, it is unsurprising that [[primary care]] [[Physician|doctor]]s often deal with [[patient]]s with red eyes in their practices.
The goal of the primary care doctor when presented with a red eye is to assess whether it is an [[medical emergency|emergency]] in need of referral and immediate action, or instead a benign condition that can be managed easily and effectively.
 
Red eye usually refers to [[hyperemia]] of the superficial [[blood vessel]]s of the [[conjunctiva]], [[sclera]] or [[episclera]], and may be caused by [[disease]]s or disorders of these structures or adjacent structures that may affect them directly or indirectly.


==Causes==
==Causes==
There are many causes of a red eye including [[conjunctivitis]], [[blepharitis]], acute [[glaucoma]], [[eye injury|injury]], [[subconjunctival hemorrhage]], inflamed [[pterygium]], inflamed [[pinguecula]], and [[dry eye syndrome]].
* The cause of red eye is diagnosed through a comprehensive eye examination and patient's history. The most common cause of red eye is [[conjunctivitis]] and the most common etiology is [[viral]]. There are other causes though, and differential diagnosis must include other diseases such as [[corneal abrasion]], [[blepharitis]], [[subconjunctival hemorrhage]], [[foreign body]], [[iritis]], [[keratitis]], [[chemical burn]], [[glaucoma]], and [[scleritis]] that may confound the physician.<ref name="TarffBehrens2017">{{cite journal|last1=Tarff|first1=Andreina|last2=Behrens|first2=Ashley|title=Ocular Emergencies|journal=Medical Clinics of North America|volume=101|issue=3|year=2017|pages=615–639|issn=00257125|doi=10.1016/j.mcna.2016.12.013}}</ref><ref>{{cite journal |vauthors=Cronau H, Kankanala RR, Mauger T |title=Diagnosis and management of red eye in primary care |journal= |volume= |issue=2 |pages=137–44 |date=January 2010 |pmid= |doi= |url=}}</ref>
[[image:Subconjunctivalhemmorhage.jpg|frame|Subconjunctival hemmorhage]]
* [[Conjunctivitis]], [[episcleritis]] and [[subconjunctival haemorrhage]] make up about 70% of the primary care red eye consultations.


==Investigation==
===Sight-threatening causes===
Some [[sign (medicine)|sign]]s and [[symptom]]s of red eye represent warnings that the underlying cause is serious and requires immediate attention.
The most common causes of sight-threatening causes of red eye include<ref name="pmid27493748">{{cite journal| author=Kilduff C, Lois C| title=Red eyes and red-flags: improving ophthalmic assessment and referral in primary care. | journal=BMJ Qual Improv Rep | year= 2016 | volume= 5 | issue= 1 | pages=  | pmid=27493748 | doi=10.1136/bmjquality.u211608.w4680 | pmc=4964165 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27493748  }} </ref>
The [[person]] conducting a thorough [[eye examination]] should be attentive to the warning signs and symptoms during the eye exam.
* [[Keratitis]]
* [[Scleritis]]
* [[Acute glaucoma]]
* [[Orbital cellulitis]]
* Foreign body trauma
* Chemical burns


There are six danger signs: conjunctival injection, ciliary flush (circumcorneal injection), corneal edema or opacities, corneal staining, abnormal pupil size, and abnormal intraocular pressure.
==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:<ref name="NarayanaMcGee2015">{{cite journal|last1=Narayana|first1=Sirisha|last2=McGee|first2=Steven|title=Bedside Diagnosis of the ‘Red Eye’: A Systematic Review|journal=The American Journal of Medicine|volume=128|issue=11|year=2015|pages=1220–1224.e1|issn=00029343|doi=10.1016/j.amjmed.2015.06.026}}</ref><ref name="pmid19357422">{{cite journal| author=Sethuraman U, Kamat D| title=The red eye: evaluation and management. | journal=Clin Pediatr (Phila) | year= 2009 | volume= 48 | issue= 6 | pages= 588-600 | pmid=19357422 | doi=10.1177/0009922809333094 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19357422  }} </ref>
* [[Pain]]
* [[Photophobia]]
* [[Visual acuity]]
* History of [[trauma]] or exposure
* History of [[secretion]]
* History of systemic symptoms


===Visual acuity===
{| class="wikitable"
''Reduced [[visual acuity]]'' is indicative of serious ocular disease, such as [[cornea]]l inflammation, [[iridocyclitis]], and [[glaucoma]], and never occurs in simple [[conjunctivitis]] without concurrent corneal involvement.
|+Differential diagnosis of red eye<ref name="pmid28435504">{{cite journal| author=Gilani CJ, Yang A, Yonkers M, Boysen-Osborn M| title=Differentiating Urgent and Emergent Causes of Acute Red Eye for the Emergency Physician. | journal=West J Emerg Med | year= 2017 | volume= 18 | issue= 3 | pages= 509-517 | pmid=28435504 | doi=10.5811/westjem.2016.12.31798 | pmc=5391903 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28435504  }} </ref><ref name="TarffBehrens2017">{{cite journal|last1=Tarff|first1=Andreina|last2=Behrens|first2=Ashley|title=Ocular Emergencies|journal=Medical Clinics of North America|volume=101|issue=3|year=2017|pages=615–639|issn=00257125|doi=10.1016/j.mcna.2016.12.013}}</ref>
! style="background: #4479BA; width: 200px;" |{{fontcolor|#FFF| Condition }}
! style="background: #4479BA; width: 200px;" |{{fontcolor|#FFF| Signs }}
! style="background: #4479BA; width: 200px;" |{{fontcolor|#FFF| Symptoms }}
! style="background: #4479BA; width: 200px;" |{{fontcolor|#FFF| Causes }}
! style="background: #4479BA; width: 200px;" |{{fontcolor|#FFF| Treatment }}
|-
| [[Viral conjunctivitis]]
|
* Normal vision
* Normal pupil size
* Diffuse [[conjunctival]] injections
* [[Preauricular]] [[lymphadenopathy]]
|
* Mild to no pain
* Diffuse [[hyperemia]]
* Mild itching
* Watery to [[serous]] discharge
* Photophobia
* [[Subepithelial]] corneal [[opacities]]
|
* [[Adenovirus]]
* [[VZV]]
* [[HSV]]
|  Supportive care and preservative-free artificial tears
|-
| [[Bacterial conjunctivitis]]
|
* [[Eyelid edema]]
* Normal pupil size
* Normal visual acuity
|
* Mild to moderate pain
* Foreign body sensation
* [[Mucopurulent]] secretions with bilateral [[glued eyes]]
|
* [[Staphylococcus aureus]]
* [[Streptococcus pneumoniae]]
* [[Haemophilus influenzae]]
| 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)
|
* Supportive cares
* Topical [[antibiotics]]
* [[Steroids]] eyedrops
|-
| [[Subconjunctival hemorrhage]]
| Bright red patch on [[sclera]]
|
* Mild pain
* No discharge
* No visual disturbance
|
* [[Hypertension]]
* [[Atherosclerotic vessels]]
* [[Traumatic]] causes
| Refer for further investigation
|-
| [[Episcleritis]]
|
* Dilated [[episcleral]] blood
* Edema of [[episclera]]
|
* Mild pain
* Watery discharge
| [[Idiopathic]] [[inflammation]]
|
* Topical [[lubricants]]
* Oral [[NSAIDs]]
|-
| [[Keratitis]]
|
* Decreased visual acuity
* [[Corneal]] [[opacity]]
* Eyelid edema
|
* Severe pain
* [[Photophobia]]
* [[Mucopurulent]] discharge
* Foreign body sensation
| Bacterial
* [[Staphylococcus]]
* [[Streptococcus]]
Viral
* [[VZV]]
* [[HSV]]
| Bacterial
* Topical [[antibiotics]]
Viral
* Topical or/and oral anti-virals
* Topical [[steroids]]
|-
| [[Iritis]]
|
* Constricted and irregular pupil reaction
* Decreased visual acuity
|
* Moderate to severe pain
* [[Photophobia]]
* Watery discharge
| [[Idiopathic]] [[inflamation]]
| Topical [[steroids]]
|-
| Acute angle closure [[glaucoma]]
|
* Reduced visual acuity
* Non-reactive pupils
* Dilated pupils
|
* Severe and throbbing pain
* [[Photophobia]]
* [[Halos]] when looking at light
|
* Elevated [[intraocular]] pressure
* [[Optic nerve]] damage
|
* Topical [[parasympathomimetics]]
* Topical [[beta-blockers]]
* [[Carbonic anhydrase inhibitors]]
* [[Alpha agnoists]]
|-
| [[Scleritis]]
|
* Decreased visual acuity
* [[Sclera]] edema
|
* Severe pain radiating to [[periorbital]] area
* Increased pain with eye movement
*[[Photophobia]]
* Watery discharge
| Systemic diseases
* [[Rheumatoid arthritis]]
* [[Wegener granulomatosis]]
* [[Sarcoidosis]]
* [[Inflammatory bowel disease]]
| Refer urgently
|}


===Ciliary flush===
==Treatment==
''Ciliary flush'' is usually present in eyes with corneal inflammation, iridocyclitis or [[acute glaucoma]], though not simple conjunctivitis.
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.  
A ciliary flush is a ring of red or violet around the [[cornea]] of the eye.


===Corneal opacification===
Corneal opacities always indicate that a serious disease process is in progress.
Opacification may be detected using an [[ophthalmoscope]] or, in more obvious cases, with a pen light.
These opacities may be keratic, haze-like (usually from corneal [[edema]]), or they may be localized such as with [[ulcer]]ated corneas or those affected by [[keratitis]].


===Corneal epithelial disruption===
{| class="wikitable"
Corneal epithelial disruptions may be detected with [[fluorescein]] staining of the eye, and careful observation with cobalt-blue light.
! style="background: #4479BA; width: 200px;" |{{fontcolor|#FFF| DDx }}
Corneal epithelial disruptions would stain green, which represents some injury of the corneal epithelium.
! style="background: #4479BA; width: 200px;" |{{fontcolor|#FFF| Epidemiology }}
These types of disruptions may be due to corneal inflammations or [[physical trauma]] to the cornea.
! style="background: #4479BA; width: 200px;" |{{fontcolor|#FFF| Manifestation }}
! style="background: #4479BA; width: 200px;" |{{fontcolor|#FFF| Cause }}
! style="background: #4479BA; width: 200px;" |{{fontcolor|#FFF| Treatment }}
|-
| [[Viral conjunctivitis]]<ref name="pmid24150468">{{cite journal| author=Azari AA, Barney NP| title=Conjunctivitis: a systematic review of diagnosis and treatment. | journal=JAMA | year= 2013 | volume= 310 | issue= 16 | pages= 1721-9 | pmid=24150468 | doi=10.1001/jama.2013.280318 | pmc=4049531 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24150468  }} </ref>
| More than 80% of all [[acute conjunctivitis]]
|
* Watery discharge
* Red eye
* [[Chemosis]]
* Bilateral [[conjunctivitis]]
* [[Ipsilateral lymphadenopathy]] (in severe cases)
| [[Adenovirus]] is most common cause
|
* Artificial tears
* Topical [[antihistamines]]
* Cold compresses
|-
| [[Bacterial conjunctivitis]]<ref name="pmid24150468">{{cite journal| author=Azari AA, Barney NP| title=Conjunctivitis: a systematic review of diagnosis and treatment. | journal=JAMA | year= 2013 | volume= 310 | issue= 16 | pages= 1721-9 | pmid=24150468 | doi=10.1001/jama.2013.280318 | pmc=4049531 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24150468  }} </ref>
| Up to 50% of all [[acute conjunctivitis]]
|
* [[Purulant]] discharge
* Red eye
* Adherence of eyelids
* [[Chemosis]]
* Eyelids [[swelling]] (in severe cases)
|
* [[Staphylococcus aureus]]
* [[Streptococcus pneumoniae]]
* [[Haemophilus influenzae]]
* [[Chlamydia]]
* [[Neisseria gonorrhoeae]]
| Most cases are self-limiting but
* Topical [[antibiotics]] reduce the duration
* In [[chlamydial conjunctivitis]]
**  Oral [[azithromycin]] and [[doxycycline]]
* In [[gonococcal conjunctivitis]]
** Both topical and oral [[antibiotics]]
|-
| [[Allergic conjunctivitis]]<ref name="pmid24150468">{{cite journal| author=Azari AA, Barney NP| title=Conjunctivitis: a systematic review of diagnosis and treatment. | journal=JAMA | year= 2013 | volume= 310 | issue= 16 | pages= 1721-9 | pmid=24150468 | doi=10.1001/jama.2013.280318 | pmc=4049531 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24150468  }} </ref>
| More than 40% of population
|
* Red eye
* Itching
| Environmental antigens
|
* Artificial tears
* [[Saline]] solutions
* Topical [[decongestants]] and [[antihistamines]]
|-
| [[Blepharitis]]<ref name="pmid30214351">{{cite journal| author=Putnam CM| title=Diagnosis and management of blepharitis: an optometrist's perspective. | journal=Clin Optom (Auckl) | year= 2016 | volume= 8 | issue=  | pages= 71-78 | pmid=30214351 | doi=10.2147/OPTO.S84795 | pmc=6095371 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30214351  }} </ref>
| More than 40% of patients presenting with red eye
|
* Superficial discomfort
* Mild [[photophobia]]
* Redness
|
* [[Staphylococcus epidermidis]]
* [[Staphylococcus aureus]]
* [[Proprionibacterium]]
|
* Topical [[antibiotics]] or [[corticosteroids]]
* [[Hyperthermic]] lid compress
|-
| [[Subconjunctival hemorrhage]]<ref name="pmid23843690">{{cite journal| author=Tarlan B, Kiratli H| title=Subconjunctival hemorrhage: risk factors and potential indicators. | journal=Clin Ophthalmol | year= 2013 | volume= 7 | issue=  | pages= 1163-70 | pmid=23843690 | doi=10.2147/OPTH.S35062 | pmc=3702240 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23843690  }} </ref>
| About 3% of patients with red eye
|
* Mild to moderate pain
* Red eye
|
* [[Trauma]]
* Eye surgery
* [[Inflammation]] of [[conjunctiva]]
* [[Conjunctivochalasis]]
* Systemic disorders
** [[Systemic vascular diseases]]
| Refer to investigate for underlying cause
|-
| [[Glaucoma]]<ref name="pmid24825645">{{cite journal| author=Weinreb RN, Aung T, Medeiros FA| title=The pathophysiology and treatment of glaucoma: a review. | journal=JAMA | year= 2014 | volume= 311 | issue= 18 | pages= 1901-11 | pmid=24825645 | doi=10.1001/jama.2014.3192 | pmc=4523637 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24825645  }} </ref>
| More than 70 million cases worldwide
|
* Reduced visual acuity
* Dilated pupils
* Red eye
| Risk factors
* Old age
* Black race
* Use of systemic or topical [[corticosteroids]]
| Lowering [[intraocular]] pressure
* [[Prostaglandin]] analogues
** Latanoprost
* [[Beta-blockers]]
** [[Timolol]]
* [[Alpha-agonists]]
** [[Brimonidine]]
|-
| [[Scleritis]]<ref name="pmid18037120">{{cite journal| author=Galor A, Thorne JE| title=Scleritis and peripheral ulcerative keratitis. | journal=Rheum Dis Clin North Am | year= 2007 | volume= 33 | issue= 4 | pages= 835-54, vii | pmid=18037120 | doi=10.1016/j.rdc.2007.08.002 | pmc=2212596 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18037120  }} </ref>
| 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
* [[Rheumatoid arthritis]]
* [[Wegener’s granulomatosis]]
|
* Topical [[steroids]]
* [[NSAIDs]]
|}
For more information on treatment [[Red eye resident survival guide|click here]].


===Pupillary abnormalities===
==Related Chapters==
An eye with iridocyclitis would have one [[pupil]] that is smaller than the other, which is caused by a [[reflex]] [[muscle]] [[spasm]] of the [[Iris (anatomy)|iris]] sphincter muscle.
*[[List of eye diseases and disorders]]
As is the general rule, conjunctivitis does not affect the pupils.
With acute angle-closure glaucoma, the pupil would be partially dilated and oval.
 
===Shallow anterior chamber depth===
Shallow anterior chamber depth usually indicates some problem.
If the eye is red, anterior chamber depth may indicate acute [[glaucoma]], which requires immediate attention.
 
===Abnormal intraocular pressure===
Intraocular pressure should be measured as part of the routine [[eye examination]].
It is usually affected only by iridocyclitis or acute-closure glaucoma, but not by relatively benign conditions.
In iritis and traumatic perforating ocular injuries, pressure is usually low.
 
===Proptosis===
[[Proptosis]], or forward displacement of the globe, may be caused by an [[infection]] of the [[orbit (anatomy)|orbit]], or a cavernous sinus disease.
Most commonly, chronic proptosis is caused by [[thyroid]] diseases such as [[Graves disease]].
 
==Important warning symptoms==
There are three main danger symptoms in a red eye: reduced visual acuity, severe ocular pain, and photophobia (light sensitivity).
 
===Blurry vision===
Blurry vision often indicates serious ocular disease.
If the blurriness improves with [[blink]]ing, it suggests ocular surface discharge of some variety.


===Severe pain===
Those suffering from [[conjunctivitis]] may report mild irritation or scratchiness, but never extreme [[pain]].
Severe pain is an indicator of [[keratitis]], corneal ulceration, [[iridocyclitis]], or acute [[glaucoma]].
===Photophobia===
[[Photophobia]], or fear of light, is usually an indication of [[iritis]].
===Coloured halos===
Coloured halos are an indication of corneal edema, and are a warning that acute glaucoma may be present.
==Complete Differential Diagnosis==
*[[Adenoviruses]]
*[[Ankylosing spondylitis]]
*[[Anticoagulant|Anticoagulant therapy]]
*[[Atopic dermatitis]]
*[[Bacteria|Bacterial toxins]]
*[[Behçet's disease]]
*[[Chlamydia trachomatis]]
*[[Chronic Inflammatory Intestinal Disease]]
*[[Conjunctivitis]]: either viral, bacterial or allergic
*[[Contact dermatitis]]
*[[Contact lens#complications|Contact lens complications]]
*Cosmetics
*[[Crohn's disease]]
*[[Diabetes mellitus]]
*[[Epstein-Barr virus]]
*[[Fever]]
*[[Glaucoma|Acute glaucoma attack]]
*[[Haemophilus]]
*[[Hay fever]]
*[[Hemangioma]]
*[[Hypertension]]
*[[Infective endocarditis]]
*[[Keratitis]]
*[[Leptospirosis]]
*[[Lyme disease]]
*[[Lymphangioma]]
*[[Measels]]
*[[Moraxella]]
*[[Osler-Weber-Rendu Disease]]
*[[Pseudomonas]]
*[[Psoriatic arthritis]]
*[[Reactive arthritis]]
*[[Recurrent corneal erosion]]
*[[Sarcoidosis]]
*[[Staphylococci]][[conjunctivitis]]
*[[Streptococcus]][[conjuncitivits]]
*[[Syphillis]]
*[[Toxoplasmosis]]
*[[Tuberculosis]]
*[[Ulcerative colitis]]
*[[Uveitis]]
*[[Voigt-Koyanagai Syndrome]]
*[[Whipple's disease]]
== Pharmacotherapy ==
=== Acute Pharmacotherapies ===
'''Conjunctivitis'''
*Allergy - NSAID's, ocular decongestants, antihistamines
*Viral - avoid spread
*Bacterial - Antibiotic eye drops
'''Subconjunctival hemorrhage'''
*cool compress
*reassurance
'''Chemical injury'''
*saline immediatley
== Primary Prevention ==
*good hygiene
*proper contact lens maintenence
*hand washing
*eye protection in potentially injuring situations
==See also==
*[[List of eye diseases and disorders]]
{{Eye pathology}}
{{Eye pathology}}
[[Category:Ophthalmology]]
[[Category:Ophthalmology]]
[[Category:Emergency medicine]]
[[Category:Emergency medicine]]
[[Category:Symptoms]]
[[Category:Signs and symptoms]]
[[Category:Signs and symptoms]]


[[ja:充血]]
[[ja:充血]]


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Latest revision as of 19:40, 26 October 2020



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]

For patient information, click here
For resident survival guide, click here

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

For more information on treatment click here.

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.