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Red Eye Clinical
Presentation
Updated: Jun 11, 2019
Author: Robert H Graham, MD; Chief Editor: Andrew A Dahl, MD,
FACS  more...

PRESENTATION

History and Physical Examination

Obtain the following information:

Onset

Visual changes

Foreign body sensation

Trauma

Photophobia

Pain
 Discharge, clear or colored

Prior episodes

Ophthalmologic history, including eye surgery

Bilateral or unilateral

Contact lens use

Comorbid conditions, such as collagen-vascular disease

Perform a complete ophthalmologic examination on all patients,

to include the following:

Visual acuity (each eye should be tested separately)

Extraocular movements

Pen light examination (should test for pupil reactivity, pupil

shape, discharge, pattern of injection, and corneal opacity)

Tests for direct and consensual photophobia

Slit-lamp examination (examine the cornea for edema,

defects, or opacification with and without fluorescein) –
Mastery of slit-lamp technique is a prerequisite for making
the correct diagnosis

Anterior chamber evaluation should be performed for depth,

cells, and flare

Intraocular pressure (IOP) measurements

Eyelid inspection with eversion

Certain signs help distinguish among the various causes of a red

eye.

Conjunctivitis
Conjunctivitis (see the image below), the most common cause of
red eye, is characterized by vascular dilation of the superficial
conjunctival blood vessels, cellular infiltration, and exudation.
Patients with conjunctivitis usually do not experience visual
changes or ocular pain. Conjunctivitis may be allergic, toxic, viral,
or bacterial. Because it is often difficult to distinguish precisely
among the different types, the clinician often assumes a bacterial
cause if the etiology is unclear.

Conjunctivitis. Courtesy of Wikipedia Commons.

Allergic conjunctivitis often presents with pruritus in individuals

with a history of allergic disease. Viral conjunctivitis tends to be
associated with enlarged, tender preauricular nodes, watery
discharge, and upper respiratory tract infection. Viral
conjunctivitis, particularly due to adenovirus infection, is highly
contagious; proper hygiene and hand washing habits should be
emphasized to all patients, roommates, colleagues, and
coworkers. Bacterial conjunctivitis tends to be associated with a
more mucopurulent or purulent discharge. Toxic conjunctivitis
may result from episodic or chronic exposure to chemical
irritants, some capable of causing significant ocular surface
damage. It is essential to identify the toxin or chemical in cases of
acute exposure in order to render appropriately aggressive
treatment.

Blepharitis

Blepharitis (see the image below) is often associated with

conjunctivitis and may be caused by allergic, infectious or
dermatologic processes. Staphylococci are the most common
etiologic organisms.

Blepharitis. Courtesy of Wikipedia Commons.

Canaliculitis

Canaliculitis (see the image below) is characterized by a mildly

red eye (usually unilateral) with slight discharge. Discharge can be
expressed from the canaliculus. Actinomyces, herpes simplex
virus, staphylococci, and pneumococci are the most common
causative organisms.
[15] Retained foreign bodies such as
dacryoliths and silicone plastic punctal plugs must also be
considered.
Canaliculitis of the left lower lid. Courtesy of Peter Rubin, MD, Director, Eye
Plastics Service, Massachusetts Eye and Ear Infirmary, Harvard Medical School.

Keratitis

Keratitis can be of bacterial, viral, fungal, or parasitic origin.

Patients may have decreased visual acuity and photophobia and
often complain of severe eye pain. An epithelial defect may be
evident on slit-lamp examination or may require fluorescein
staining for visualization. Corneal inflammation or infection may
be accompanied by anterior chamber reaction.

Bacterial keratitis (see the image below) is often associated with

contact lens wear, particularly overnight wear. A mucopurulent
discharge is often observed, as well as corneal opacity with
conjunctival hyperemia and photophobia. Viral keratitis usually
presents with watery discharge and a grayish corneal opacity with
photophobia and foreign body sensation. Any opacification of the
cornea in a red eye is considered to represent a corneal infection
until proven otherwise so is an emergent condition. The
opacification may or may not take up fluorescein. This condition
warrants prompt ophthalmic evaluation.
This photograph depicts a child with a bilateral eye condition known as interstitial
keratitis (IK), a stigma related to congenital syphilis.

Dacryocystitis

Dacryocystitis (see the image below) is characterized by localized

pain, edema, and erythema over the lacrimal sac at the medial
canthus of the eye. It is usually unilateral. Often, purulent
discharge from the puncta is noted. Staphylococci are the most
common causative organisms.
[16]
Acute dacryocystitis.

Scleritis

Scleritis (see the image below) is universally accompanied by

pain, especially with tenderness exacerbated by digital pressure.
Gradual onset of red eye and insidious decrease in vision are
typically noted. Recurrent episodes are common. Anterior
chamber inflammation or posterior involvement may affect visual
acuity. The globe is usually tender and the sclera swollen. Deep
scleral injection is accompanied by inflammation of the overlying
episclera and conjunctiva. Scleritis is bilateral in 50% of patients.
Scleritis. Courtesy of Wikipedia Commons.

A deep violet discoloration of the globe may be observed because

of dilation of the deep venous plexus. The clinician must beware
of the white eye because this may be due to ischemia. It is an
ophthalmic condition that warrants prompt ophthalmologic
referral. Most patients have some form of autoimmune condition.

Episcleritis

In episcleritis, unlike conjunctivitis, the inflammation tends to be

limited to isolated patches, not involving the eye diffusely. Dilated
episcleral vessels are observed between the white sclera.
Injection of the more superficial conjunctival vessels should be
differentiated from that of the deeper violaceous episcleral
vessels. Some more persistent cases may encompass the entire
visible ocular surface, as well as more posterior episclera.

A history of recurrent episodes is common. Mild-to-moderate

tenderness over the area of injection may be observed. Vision is
usually unaffected. A watery discharge may be present. Patients
should be examined for corneal complications (15%) and uveitis
(7%). Episcleritis is usually a self-limited process, but
ophthalmologic consultation is required if the condition is
persistent or recurrent. A much smaller percentage of patients
with episcleritis test positive for systemic autoimmune disease
than do patients with scleritis.

Corneal injury

First and foremost, the patient’s eye should be stained with

fluorescein to detect evidence of corneal abrasion (see the image
below). Penetration of the globe should be excluded via thorough
slit-lamp examination, IOP testing, and Seidel testing with a
fluorescein strip, when indicated. The lid should always be
everted to exclude retained foreign material.

Corneal abrasion.

Iritis

In iritis, the eye develops a perilimbal redness known as ciliary

flush due to dilation of the radial vessels. In conjunctivitis, by way
of comparison, the intensity of vascular engorgement decreases
toward the limbus. Cells and flare are present in the anterior
chamber and may be seen with the slit lamp under high
magnification in specific light conditions. Visual acuity, direct and
consensual photophobia, pain in the involved eye, posterior
synechiae between the iris and lens, and keratitic precipitates on
the endothelium may be observed.

The pupil of the affected eye is usually constricted and irregular if

synechiae have formed. A mild watery discharge may be present.
Iritis is often unilateral or asymmetric. Complications include
glaucoma, cataract formation, and macular dysfunction;
ophthalmologic consultation is required. Unfortunately, iritis is
often overlooked in the context of the overwhelmingly higher
incidence of bacterial conjunctivitis, as well as a strong
reluctance for primary care providers to prescribe topical steroids
or even seek ophthalmologic evaluation for what might
erroneously be perceived as a self-limited bacterial surface
infection. Thus, significant damage can occur when iritis goes
unnoticed by the first provider to encounter these patients.

Dry eye syndrome

In most cases of dry eye syndrome (DES), or keratoconjunctivitis

sicca (KCS), the eye appears normal. On slit-lamp examination,
decreased tear meniscus at the lower lid margin may be noted.
[17] The corneal epithelium shows areas with varying degrees of
fine punctate stippling in the interpalpebral fissure, which stain
with rose bengal or fluorescein if more severely damaged.

Glaucoma

Narrow-angle glaucoma is an ophthalmologic emergency.

Patients complain of severely painful red eye. Visual acuity is
reduced and worsens over time. Haloes around light are common
owing to corneal edema. Patients are usually older than 50 years
and frequently hyperopic with a short axial length and small
anterior chamber depth. The pupil may be mid-dilated and may be
nonreactive to light. Slit-lamp examination reveals corneal edema
and a shallow anterior chamber with mild cells and flare.

IOP is elevated, usually to a level higher than 45 mm Hg

(reference range, < 21 mm Hg). The anterior chamber angle may
be very narrow. Nausea and vomiting are common. Gonioscopy
should be performed to confirm the diagnosis and immediate
referral made for appropriate medical and laser surgical therapy
to create the essential peripheral iridotomy.

Pterygium

Pterygium is a benign conjunctival growth made of triangular

band of fibrovascular tissue caused by long-term exposure to
ultraviolet light, dust, and low humidity. It usually arises from the
nasal side of the sclera. It may encroach onto the cornea
(pterygium) or extend on either side of the cornea (pinguecula).

Subconjunctival hemorrhage

Subconjunctival hemorrhage may appear as a flat, thin

hemorrhage or as a thick collection of blood. The most common
visual manifestation is a bright red patch with relatively normal
surroundings. There may be a history of red eye and, possibly,
mild irritation; however, patients are usually asymptomatic. Slit-
lamp examination reveals the precise location of the hemorrhage
under the conjunctiva. The view of the sclera may be obscured by
blood, which may be dark red if the collection is thick.
[18]

Differential Diagnoses
 
 

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