The Red Eye

HAMPTON ROY
Department of Ophthalmology, ORIGINAL ARTICLE
University of Arkausar, A red eye is a cardinal sign of ocular inflammation.
Little Rock, AK Most cases are benign and can be managed by the
primary care provider. The key is recognizing cases
requiring ophthalmological consultation by differ-
entiating between ciliary and conjunctival injec-
tion. Ciliary injection indicates inflammation of the
cornea, iris, or ciliary body, whereas conjunctival
injection mainly affects the posterior conjunctival
blood vessels.

INTRODUCTION
A red eye is a cardinal sign of ocular inflammation, which
can be caused by several conditions. Most cases are
benign and can be managed effectively by the primary
care provider. The key to management is recognizing cases
with underlying disease that require ophthalmological
consultation.
A red eye is caused by dilation of blood vessels in the
eye. Diagnosis may be aided by the differentiation
between ciliary and conjunctival injection. Ciliary injec-
tion involves branches of the anterior ciliary arteries and
indicates inflammation of the cornea, iris, or ciliary
body. Conjunctival injection mainly affects the posterior
conjunctival blood vessels. Because these vessels are
more superficial than the ciliary arteries, they produce
more redness, move with the conjunctiva, and constrict
with topical vasoconstrictors.

CORRESPONDENCE
Hampton Roy, MD, 5800 W. 10th Suite 205, Little Rock, AR 72204,
E-mail: hamproy@aristotle.net
The authors have stated that they do not have a significant financial interest or
other relationship with any product manufacturer or provider of services discussed
in this article. The authors also do not discuss the use of off-label products, which
includes unlabeled, unapproved, or investigative products or devices.
Submitted for publication: January 13, 2006. Accepted: January 23, 2006
Comprehensive Therapy, vol. 32, no. 1, Spring 2006
© Copyright 2006 by ASCMS
All rights of any nature whatsoever reserved.
0098-8243/06/32:43–46/$30.00 (Online) ISSN 1559–1190
CAU S E S
The various cause of red eye are discussed here.
Blepharitis
Blepharitis is an inflammation of the eyelids usually
involving the lid margins. Blepharitis may be seborrheic
or may be caused by staphylococcal infection.
Canaliculitis
Canaliculitis is characterized by a mildly red eye (usu-
ally unilateral) with slight discharge. Discharge can be
Note: Throughout article conditions that appear in italics and marked by
an asterisk should be referred to an opthalmologist.

COMP THER. 2006;32(1)...............................................................43

expressed from the canaliculus. It is often caused by
Actinomyces israelii.
Conjunctivitis
Conjunctivitis is characterized by vascular dilation,
and mattering. Conjunctivitis must be differentiated,
based on allergic, viral, or bacterial etiology. Allergic
disease often has clear matter and is frequently seen in
individuals with a history of allergic disease. Viral
infections tend to have lymphoid follicles on the under-
surface of the lid and enlarged tender preauricular
nodes. Bacterial disease tends to have more purulent,
often yellow discharge.
Corneal Infection
Any opacification of the cornea in a red eye is an
infection of the cornea until proven otherwise.* The
opacification may or may not take up fluorescein. This is
an ophthalmic emergency and should be referred to an
ophthalmologist.
Dacryocystitis
Dacryocystitis is an inflammation of the lacrimal sac
due to obstruction of the nasolacrimal duct. Dacryocysti-
tis is characterized by localized pain and edema over the
lacrimal sac at the medial canthus of the eye. Dacryocys-
titis is usually unilateral. There is often purulent dis-
charge from the puncta. The cause of dacryocystitis in
adults is S. aureus or β-hemolytic Streptococcus. In acute
cases in children, the cause is Haemophilus influenzae.
Episcleritis
Unlike conjunctivitis, the inflammation of episcleritis
tends to be limited to an isolated patch, not involving the
entire eye. There may be some tenderness over the area
of injection. There also may be a history of recurrent
episodes. The cause can be any inflammatory systemic
condition of the body such as rheumatoid arthritis, Sjö-
gren syndrome, coccidioidomycosis, syphilis, zoster, and
tuberculosis.
Foreign Body
The diagnosis for a foreign body is best made with
magnification and good illumination. If a foreign body is
not located, the lid should always be everted to exclude
retained material. The patient’s eye should be stained
with fluorescein to detect evidence of a corneal abrasion.
If the pupil is irregular and penetration of the globe is
suspected, the patient should be referred to an ophthal-
mologist immediately.*
COMP THER. 2006;32(1)...............................................................44
Iritis
Iritis is characterized by a perilimbal flush caused by
dilation of the radial vessels. In contrast to conjunctivitis,
the intensity of vascular engorgement decreases toward
the limbus. There may be decreased visual acuity, and
increased photophobia. In most cases, the cause cannot
be determined. However, any systemic inflammatory dis-
ease can cause iritis.
Keratoconjunctivitis Sicca (Dry Eye)
Dry eye can present as a red, scratchy eye. This may
result from any disease that is associated with deficiency
of tear film components and lid surface or epithelial
abnormalities. Keratoconjunctivitis sicca may be associ-
ated with rheumatoid arthritis and other autoimmune dis-
eases (Sjögren syndrome).
Narrow-Angle Glaucoma
Patients with narrow-angle glaucoma complain of a
severely painful red eye. Haloes around light are com-
mon. Narrow-angle glaucoma occurs in patients with
preexisting narrowing of the anterior chamber angle.
Far-sighted patients and older patients are at an addi-
tional risk to develop narrow-angle glaucoma because
there has been enlargement of the lens.
Subconjunctival Hemorrhage
Subconjunctival hemorrhage is defined as blood under
the conjunctiva. It is caused from bleeding of the con-
junctival or the episcleral blood vessels into the subcon-
junctival space. The hemorrhage can be traumatic,
spontaneous, or related to systemic illness. Subconjunc-
tival hemorrhage is a self-limited condition that resolves
without treatment.
T R E AT M E N T
Blepharitis
First, patients with blepharitis commonly are directed to
use soaked warm compresses and to apply them to the lids
repeatedly. Warm water on a washcloth or microwaved,
soaked cloths can be used. Second, the eyelid margin is
washed mechanically to remove adherent material. Water
often is used, although some prefer using a few drops of
baby shampoo mixed in one bottle cap full of warm water
to form a cleaning solution. The third step is application of
an antibiotic ointment to the eyelid margin after it has been
soaked and scrubbed. Commonly used agents include ery-
thromycin or sulfacetamide ointments for long-term use.
Antibiotic-corticosteroid ointment combinations can be
used but only for short courses because of their undesirable
side effects.
Canaliculitis
Topical antibiotics with lacrimal massage may be ade-
quate for early canaliculitis infections. Warm compresses
may be useful as well. Systemic antibiotics may be nec-
essary for more chronic or severe infections such as those
causing dacryocystitis and canaliculitis.
Conjunctivitis
A LLERGIC
Pharmacological intervention may help alleviate the
symptoms of acute allergic conjunctivitis. Artificial tear
substitutes provide a barrier function and help to improve
the first-line defense at the level of conjunctival mucosa.
Systemic and/or topical antihistamines may be given to
relieve acute symptoms. Topical antihistamines competi-
tively and reversibly block histamine receptors and relieve
itching and redness but only for a short time. A number of
topical antihistamines are available, including epinastine
HCl ophthalmic solution 0.05% and azelastine ophthalmic
solution. Both are potent antihistamines that have a rapid
onset and are effective in relieving the signs and symp-
toms of allergic conjunctivitis.
V IRAL
Treatment for adenoviral conjunctivitis is supportive. No
evidence exists that demonstrates efficacy of antiviral
agents. Patients can be instructed to use cold compresses
and lubricants, such as artificial tears, for comfort. Topical
antihistamines may be used for severe itching but gener-
ally are not indicated because they are minimally helpful
and may cause rebounding of symptoms, as well as local
toxicity and hypersensitivity. Patients with corneal involve-
ment, such as ulceration, herpetic keratitis, or suspected
orbital cellulitis should be referred to an ophthalmologist.
B ACTERIAL
The mainstay of medical treatment for bacterial con-
junctivitis is topical antibiotic therapy. Most practitioners
prescribe a broad-spectrum agent on an empirical basis
without culture, for a routine, mild-to-moderate case of
bacterial conjunctivitis. Sodium sulfacetamide, gentamicin,
tobramycin, neomycin, trimethoprim and polymyxin B
combination, ciprofloxacin, ofloxacin, gatifloxacin, and
erythromycin are representatives of commonly used first-
line agents.
Corneal Infection
Any red eye with corneal opacity should be treated as
a medical emergency and referred.* Immediately obtain
ophthalmologic consultation so that cultures may be
taken and treatment initiated. Choice of medications
should be left to the treating ophthalmologist but gener-
ally include broad-spectrum topical antibiotics and
cycloplegic drops.
Dacryocystitis
The treatment of dacryocystitis depends on the clini-
cal manifestations of the disease. Purulent infection
may be treated with oral antiobiotics such as amoxi-
cillin/clavulanate potassium but the treatment of choice
is a dacryocystorhinostomy. Acute dacryocystitis with
orbital cellulitis may necessitate hospitalization. Patients
with chronic dacryocystitis caused by a partial or inter-
mittent nasolacrimal duct obstruction may benefit from
topical steroid drop treatment but may also be candi-
dates for surgery. Because of the surgical aspects of this
disease, referral to an ophthalmologist is probably most
appropriate.*
Episcleritis
Episcleritis is a self-limiting disease producing little
or no permanent damage to the eye. Therefore, many
will not require any treatment. Artificial tears are useful
for patients with mild-to-moderate symptoms. Patients
with severe or prolonged episodes should be referred to
an ophthalmologist because they may require topical
corticosteroids.*
Foreign Body and Corneal Abrasion
A foreign body should be located and removed with a
cotton-tipped applicator. If the foreign body is in the
visual axis or is too small to remove easily, the patient
should be referred to an ophthalmologist. Corneal abra-
sion will produce pain, which may be severe and should
be treated with nonsteroidal anti-inflammatory drops
and, if necessary, a soft bandage contact lens or pressure
patch. Narcotic analgesia is occasionally required on a
short-term basis. Prophylactic antibiotics may be pre-
scribed for use once the pressure patch is removed. If the
corneal abrasion is not healed after wearing a pressure
patch for 24 h, an ophthalmologist should be consulted.
Patching should not be performed in patients at high risk
of infection, such as those who wear contact lenses and
those with trauma caused by vegetable matter. Close fol-
low-up care of corneal abrasions is necessary because of
the ever-present danger of the all corneal ulcers begin
with an abrasion. If pupil is irregular, penetration of the
globe should be suspected and referral to ophthalmolo-
gist is necessary.*
COMP THER. 2006;32(1)...............................................................45
Iritis
Topical corticosteroids are the mainstays of therapy
and should be used aggressively during the initial phases
of therapy. Cycloplegia, a long-acting cycloplegic agent
such as cyclopentolate or homatropine, should be used to
help relieve both pain and photophobia and to prevent
the formation of posterior synechiae. A subconjunctival
injection of depo-steroids may be needed if the patient is
not responding to topical corticosteroids alone.
Keratoconjunctivitis Sicca
The mainstay of treatment for keratitis sicca is lubri-
cation. Artificial tears, preferably preservative-free arti-
ficial tears, and a lubricating ointment are most
commonly used. Mild cases can be treated with drops
four times a day. More severe cases require more
aggressive treatment, such as drops 10–12 times a day.
Thick artificial tear drops or gels also can be used in
more severe cases, although they tend to blur the vision.
Tear ointments such as GenTeal® gel (Novartis Oph-
thalmics, East Hanover, NJ), can be used during the day,
but they generally are reserved to bedtime use because
of the poor vision after placement. If these treatments
do not resolve the problem then punctual plugs should
be considered and the patient would need to be referred
to an ophthalmologist. Treatment keratitis sicca associ-
ated with a connective tissue disorder, including Sjö-
gren syndrome, should be coordinated with an internist/
rheumatologist. Restasis® (cyclosporine ophthalmic
emulstion 0.05%, Allergan, Inc., Irvine, CA) helps the
lacrimal gland secrete a better quality of tear and can
also be used.
Narrow-Angle Glaucoma
Diagnosis may be elusive because of systemic symp-
toms that may mimic cardiovascular or intra-abdominal
disease. Acute angle-closure glaucoma may be misdiag-
nosed as a migraine headache, particularly in those with
a history of migraine. Once diagnosed, immediate treat-
ment is necessary to prevent the rapid ocular damage
caused by very high intraocular pressure. Agents such as
travoprost ophthalmic solution, which is a prostaglandin
analog, or latanoprost can be used as an alternative first-
line agent. Bimatoprost, which is a prostamide that low-
ers interoccular pressure by increasing uveoscleral
outflow and traditional trabecular outflow, may also be
considered. The medical therapy of acute narrow-angle
glaucoma is directed toward preparing the patient for
COMP THER. 2006;32(1)...............................................................46
laser or incisional iridotomy and therefore the patient
should be promptly referred to an ophthalmologist.*
Subconjunctival Hemorrhage
Subconjunctival hemorrhage does not require medical
care. Artificial tears can be used four times a day for mild
irritation. The patient can be advised to limit the use of
elective aspirin products or nonsteroidal anti-inflammatory
drugs. Supportive treatment such as assuring the patient
that this is not a serious disease, is the main management.
CONCLUSIONS
In individuals who present with a red eye, the key of
management is making the correct diagnosis in a timely
fashion. Many conditions such as corneal ulcer, iritis,
penetrating foreign bodies, and narrow-angle glaucoma
are emergencies and need prompt ophthalmologic con-
sultation.* All patients with acute changes in vision
require immediate consultation. Uncomplicated cases of
blepharitis, conjunctivitis, foreign bodies, and subcon-
junctival hemorrhage may be managed by the primary
care physician.
AC K N OW L E D G M E N T
The author thanks Renee Tindall for her editorial and
research assistance.
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