1024827

review-article2021
EJO0010.1177/11206721211024827European Journal of OphthalmologyBonini

EJO European
Journal of
Ophthalmology
Review

European Journal of Ophthalmology

The red eye

1­–7
© The Author(s) 2021
Article reuse guidelines:
sagepub.com/journals-permissions
https://doi.org/10.1177/11206721211024827
DOI: 10.1177/11206721211024827
journals.sagepub.com/home/ejo

Stefano Bonini

Abstract
The red eye is one of the most common cause encountered in ophthalmic practice but a red eye is not always related
to eye diseases, instead, it may be a clinical sign of several systemic diseases which may the alarmin signal of sight-
threatening or life-threatening condition. Frequently, GPs, pediatricians, immunologists, and rheumatologists are the
first landing of patients with a “red eye.” This paper is addressed to non-ophthalmic specialists who may be faced with
patients having a red eye. Inspection of the external eye under standard office lighting or with a bright light can be easily
and accurately made by a general practitioner. Three major caveats should alert the GPs to promptly refer the patient
to the ophthalmologist: the presence of pain; the loss of the natural corneal transparency and specular reflex; and any
patient-described reduction of visual acuity. In most cases, a red eye is due to occasional and mild ocular surface reaction
as consequence of exposure of the external eye to irritants and naturally occurring environmental agents. In these
cases washing the eye with a tear lubricant may help in relief of symptoms. If this treatment fails within a few days, a
consultation with an ophthalmologist is suggested. The role of the general physician is crucial in the decision making to
judge the severity of the ocular condition. Managing a red eye often requires the support of other specialists. Our goal
is not only to preserve vision but to globally cure the patient health.

Keywords
Acanthamoeba keratitis, bacterial keratitis, cornea stem cell, diseases of the ocular surface, diseases of the ocular
surface: exposure keratopathy, immune disease of the cornea, immune disease of conjunctiva, viral keratitis, tear
deficiency states

Date received: 4 March 2021; accepted: 23 May 2021

Introduction relief. Many of these products are recommended to the

Red eye is a clinical sign that indicates a loss of homeosta-
sis of the ocular surface. In most cases, the disruption of
homeostasis is related to an external eye disease or condi-
tion. However, it could also be an expression of inflam-
mation of the interior components of the eye, or it could
be due to a systemic disease that manifests principally at a
site distant from the eye. Red eye is quite often, but erro-
neously, considered to be synonymous with conjunctivitis,
but it may also be a clinical sign of other ocular surface or
systemic diseases that involve the conjunctiva.1
Both sudden and chronic occurrences of a red eye
are common findings in medical practice, and they pre-
sent a challenging dilemma for ophthalmologists, general
practitioners, and pediatricians.2,3 The patient frequently
becomes alarmed and visits the emergency room for
immediate care. It is difficult to estimate the prevalence of
red eye because the numbers may be underestimated due
to self-medication with over-the-counter (OTC) treatments
obtained by the patients in the attempt to gain immediate
patient by physicians, pharmacists, or others (including
relatives and friends). In 2019, an estimated $144 million
OTC eye care products, including artificial tears, homeo-
pathic products, vasoconstrictors, and antiallergic eye-
drops, were used in the US.4
In most cases, a red eye is due to occasional and mild
ocular surface reaction as consequence of exposure of the
external eye to irritants and naturally occurring environ-
mental agents. In fact, redness of the ocular surface together
with increased tearing is a natural defensive mechanism of
the eye to external offending agents.3,5 Eye rubbing may
further increase the intensity of ocular redness. In some
Department of Ophthalmology, University of Rome Campus
BioMedico, Rome, Italy
Corresponding author:
Stefano Bonini, Department of Ophthalmology, University of Rome
Campus BioMedico, Via Alvaro del Portillo 200, Rome 00128, Italy.
Email: s.bonini@unicampus.it
2 European Journal of Ophthalmology 00(0)

Table 1. Causes of red eye according to disease onset.

Acute onset Relapsing/chronic onset Pain and/or blurred vision

Acute glaucoma Anterior uveitis Acute glaucoma
Allergic conjunctivitis Autoimmune diseases Anterior uveitis
Chemical burns Sjogren syndrome Any corneal lesion or ulcer
Foreign body Cicatricial pemphigoid Autoimmune diseases
Herpes simplex virus Atopic keratoconus conjunctivitis Chemical burns
Herpes zoster virus COVID-19 Blepharitis Following ocular surgery
Infective conjunctivitis Corneal ulcers Herpes infection
Subconjunctival hemorrhage Dry eye Herpes simplex virus
Traumatic Episcleritis Herpes zoster virus
UV light exposure Eyedrop toxicity Lyell syndrome
Lyell syndrome Ocular trauma
Ocular lymphoma Scleritis
Scleritis Severe dry eye
Stevens Johnson syndrome Stevens Johnson syndrome
Vernal keratoconjunctivitis

cases, a foreign body may be present, and this can be read-
ily detected by inspection with the aid of a bright light.
In other cases, a red eye may be the alarming sign of
more severe and sight-threatening conditions.6 The diag-
nosis to identify the several etiologic factors that can be
responsible for the red eye requires a brief but targeted
systematic approach to determine the timing of onset, uni-
lateral or bilateral involvement, acute or chronic/relapsing
onset, and the presence of other symptoms such as pain
or photophobia. The previous or concomitant use of other
topical or systemic medications and the ocular response
to previous ocular treatment may be helpful to clarify
the diagnostic dilemma. In contrast, the presence of pain,
blurred vision, and corneal opacities may indicate the pres-
ence of a more severe sight-threating disease (Table 1).
Acute red eye due to ocular surface
disease
Although every clinical disease of the external eye is still
named with the anatomical tissue most affected, for exam-
ple, conjunctivitis, keratitis, etc., it is now well accepted
that in every external eye disease all of the anatomical
components of the ocular surface, that is, the cornea, the
tear film, the lacrimal glands, the lids, and the commensal
flora, participate at the same time in response to any infec-
tious or inflammatory process. Other systems, such as the
neuro-immune-endocrine systems, may be influenced as
well at a site distant from the ocular response.7,8
An acute unilateral red eye may be the result of occa-
sional irritating external agents such as dust, wind, or the
presence of a foreign body (Table 1). Inspection of the
external eye under standard office lighting or with a bright
light can be easily and accurately made by a general prac-
titioner. It requires only the eversion of the upper lid and
pulling down of the lower lid to check the palpebral and
bulbar conjunctivas. In these cases, washing the eye with
a lubricant or, after topical anesthesia, removal of any for-
eign body has an immediate effect in the relief of all signs
and symptoms.
The presence of a partial or massive subconjunctival
hemorrhage may alarm the patient to promptly consult the
ophthalmologist. These subconjunctival lesions are gener-
ally limited in size, well circumscribed, do not affect the
cornea, and they do not cause a reduction of the visual
function (Table 1). Natural and occasional subconjunc-
tival hemorrhages may follow any Valsalva maneuver,
for example, coughing, vomiting, or strenuous exercise.
Repeated and non-traumatic subconjunctival hemorrhage
should be considered as a sign of systemic hypertension,
vascular diseases such as diabetes, or the effects of antico-
agulative agents.
Exposure to solar radiation may affect the conjunctiva
and the cornea, causing a painful superficial punctate kera-
titis (SPK), that can also occur in cases with high reflection
from surfaces like snow (Table 1). SPK is also common
in occupational eye injuries that can occur in unprotected
workers exposed to artificial UV light. Topical lubricants
may alleviate symptoms that can persist for few days until
complete corneal healing occurs.
A red eye can be a typical sign of infectious and
non-infectious conjunctivitis that each requires differ-
ent therapeutic approaches once the etiology has been
defined (Figure 1). Permission to publish their images
was obtained from each patient. Infective conjunctivitis,
either bacterial or viral, may have an acute onset starting
quite often as a unilateral disease but generally involving
the contralateral eye later. Viral infections are generally
more aggressive than bacterial infection, presenting with
a more intense redness, edema of the lids, ptosis, and the
presence of enlarged pre-auricular lymph nodes.9 Topical
antibiotics are effective in hastening the resolution of
Bonini 3

Figure 1. Aspects of different types of red eyes. Acute red eye may be the result of bacterial conjunctivitis (top left) or the
expression of scleritis (top right). Red eye can be associated with the initial steps of a chronic autoimmune disease such as
pemphigoid (bottom left). It presents with corneal neovessels and fornix foreshortening (black arrow). Red eye, appearing as a pink
eye, can be an indicator of mucosal non-Hodgkin lymphoma (bottom right). Permission to publish their images was obtained from
each patient.

bacterial conjunctivitis (Figure 1, top left), a self-limited
disease without functional complications. No effective
therapy exists for viral conjunctivitis, but topical steroids
may reduce the intense inflammation. Viral conjunctivitis
may be complicated by the development of sub-epithelial
corneal infiltrates that can be responsible for blurred vision
and may persist for months or years.
Severe ocular inflammation of the cornea and the inter-
nal eye may be associated with a red and painful eye.
Almost any loss of corneal transparency can be seen in
standard office lighting or with a bright light. Any corneal
lesion, either traumatic or possibly of infectious origin,
should be promptly referred to an emergency ophthalmic
center. Corneal abrasions are generally traumatic and may
follow occasional injury such as those caused by fingers
of a baby touching the parent’s cornea. These lesions are
painful and associated with intense photophobia, but gen-
erally they subside in few days. Antibiotic eyedrops and
topical lubricants are generally prescribed to avoid infec-
tions of the damaged ocular surface.
As suggested above, the application of topical lubri-
cants and antibiotic eyedrops is often the most appropri-
ate and simplest way to treat red eye. However, a short
digression and an important caveat is warranted here
regarding the use of topically applied medicines. Eyedrops
containing preservatives, antibiotics, steroids, other immu-
nosuppressive agents, or other medications may be helpful
in relieving red eye, and other symptoms. However, the
persistence of symptoms or the development of new symp-
toms suggest that a more complex clinical scenario exists.
For instance, the preservatives in tear substitutes and other
topically applied solutions can be toxic to the corneal epi-
thelial cells,10,11 and topically applied steroids can induce
glaucoma.12 Thus the aggressive and indiscriminate use of
eyedrops may cause a toxic reaction in the external eye or
the whole eye and could be a misleading factor for clinical
diagnosis of the red eye that was initially presented. Under
these conditions, consultation with an ophthalmologist is
needed.
Corneal epithelial lesions, due to herpes simplex virus
or herpes zoster are responsible for typical dendrites or
geographic epithelial damages. These patients have an
inflamed conjunctiva with lid edema, photophobia, and
blurred vision.13 Topical antivirals, following microbio-
logic laboratory confirmation, may heal the epithelium in
1 week. However, in the worst cases, the virus or immune
reaction caused by the virus itself may damage the under-
lying corneal stroma.
Similarly, corneal ulcers due either to Acanthamoeba
species and Pseudomonas aeruginosa are associated with
4 European Journal of Ophthalmology 00(0)
a red painful eye (Table 1).14 These corneal ulcers are
mostly seen in contact lens wearers. The patients present
with a red eye, loss of corneal transparency, pain, intense
photophobia, and a massive edema of the lids that makes
the clinical examination difficult to perform. Referral to an
emergency ophthalmic center is mandatory, and a diagno-
sis should be established to promptly start the appropriate
treatment.15–18
Acute non-infective red eye may be the consequence of
an allergic reaction of the external eye (Table 1). A mul-
titude of substances such as occasional contact with irri-
tants, local or systemic medication, or allergy to nickel or
food may cause a red eye. These allergies can be difficult
to diagnose, but they are generally self-limited and disap-
pear in few days, even without treatment. However, if the
symptoms do not quickly subside, a definitive diagnosis is
required, and the treatment is typically easy to achieve and
relief from the symptoms soon follows.
Acute red eye mimicking ocular
surface diseases
A red eye may also be the result of internal eye disease
or the manifestation of a systemic disease that targets the
external eye. These conditions are generally associated
with mild to severe pain, blurred or marked reduction of
vision, and evident loss of the corneal transparency, all of
which require prompt referral to an ophthalmic emergency
center.
Inflammation of the anterior uvea (Table 1), the inter-
nal membrane of the eye, and more specifically of the iris
and ciliary body, may be caused by a variety of ocular and
systemic diseases. In these patients, the painful red eye is
accompanied by visual blurring and photophobia. Clinical
inflammation of the anterior chamber, which lies posterior
to the corneal endothelium, requires examination by slit-
lamp microscopy. However with a bright light, the physi-
cian can see a pupillary restriction (miosis), which is an
expression of inflammation of the anterior uvea.
Acute glaucoma (Table 1) due to a sudden increase
of the intraocular pressure also causes a red and pain-
ful eye. The intraocular pressure, which normally ranges
between 10 and 21 mmHg, may rise to 70 mmHg with
this condition.19 The patients may also have pupillary
dilation (mydriasis) in the affected eye, and nausea and
vomiting may be associated with diffuse but intense pain
in the periorbital area.
An eye that has a red-to-purple appearance along
with pain and visual blurring may be the sign of a scleri-
tis (Table 1; Figure 1, top right). These ocular conditions
need prompt referral because scleritis may be prodromic or
associated with a systemic or lethal disease, for example,
rheumatoid arthritis or Wegener’s granulomatosis.20,21
Stevens-Johnson syndrome and Lyell syndrome
(Table 1) are severe, acute, and dramatic adverse drug
reactions primarily affecting the skin, but involving other
mucosal tissues as well. Acute ocular involvement with
loss of visual function, neovascularization of the cornea,
and scarring of the ocular surface warrant a prompt refer-
ral to an emergency department.22
Acute and more intense red eye follows most chemical
burns (Table 1).23,24 Prompt referral to an emergency oph-
thalmic center is needed but a prolonged washing of the
eye is suggested as a first approach.
Relapsing or chronic red eye
Dry eye and ocular allergy (Table 1) represent the most
common causes of relapsing or chronic red eye with a
prevalence ranging from 5% to 50% and 20% to 30%,
respectively.25 Dry eye is a multifactorial disease with
ocular symptoms, tear film instability, tear hyperosmolar-
ity, ocular surface inflammation and damage, and neuro-
sensory abnormalities.26 Keratoconjunctivitis sicca is also
a term to indicate dry eye and frequent corneal involve-
ment in the inflammatory process. Complete and exhaust-
ing diagnostic and treatment guidelines have been recently
published by the Tear Film and Ocular Surface Society
(TFOS).27
Mild to very severe and symptomatic diseases are
grouped together in dry eye. In the mildest forms of dry
eye and blepharitis, the use of tear substitutes together with
lid hygiene may be useful to relieve symptoms. Dry eye is
also one of the main criteria to diagnose other systemic
diseases such as Sjogren syndrome (Table 1) and other
autoimmune diseases associated with red eye.28,29 These
conditions represent a more symptomatic and disabling
disease for the patients and require a more aggressive and
multi-disciplinary treatment with topical or systemic ster-
oids and immunosuppressive agents.27 Acute allergic con-
junctivitis (Table 1), either seasonal or perennial, causes a
recurrent or chronic red eye following contact with a sen-
sitizing allergen.30 In these cases, the seasonal recurrences
or the history of previous or concomitant allergic diseases
such as asthma, rhinitis, or atopic dermatitis may help in
the differential diagnosis. Artificial tears or antiallergy
eyedrops may control the clinical symptoms.
In contrast to acute allergic conjunctivitis, ocular aller-
gies with seasonal relapses or chronic progression, such
as vernal kerato-conjunctivitis (VKC) and atopic kerato-
conjunctivitis (AKC), represent a major challenge for oph-
thalmologists. VKC (Table 1) is an allergic inflammation
of the ocular surface generally affecting young boys in
their first decade of life. All of the anatomical structures
of the ocular surface participate in this allergic inflam-
mation. The conjunctiva becomes red and chemotic, the
cornea develops a superficial punctate keratitis or even
corneal ulcer, the palpebral conjunctiva of the upper lid
acquires a characteristic cobblestone appearance, and the
tear film has increased levels of inflammatory mediators
Bonini
and cytokines. The disease subsides after puberty, gener-
ally without ocular consequences. However, it may require
aggressive treatment for the relief of symptoms and atten-
tion to avoid complications for prolonged use of topical
steroids.31,32
AKC (Table 1) is generally associated with atopic
dermatitis and occurs in the first years of life or in adults
50 years of age or older.33 In AKC, similar to VKC, cor-
neal complications may cause permanent reduction of
the visual function. Topical tear substitutes or antiallergic
nonsteroidal eyedrops may control the intense itching and
photophobia. However, both VKC and AKC often require
the use of topical steroids or immunosuppressive agents,
for example, cyclosporine or tacrolimus, during the severe
recrudescence of the disease.33–35
Mild to severe red eye can be difficult to diagnose
because it may be related to a multitude of constitutional
and mechanical factors that require careful anamnestic
investigations. For instance, a unilateral red eye that is
unresponsive to medical treatments is often due to floppy
eyelid syndrome.36 This condition is generally unilateral
and has been described in obese people that lose body
weight too quickly. The physical contact of the upper lid
with the pillow while sleeping may evert the lid, leav-
ing open the inferior part of the ocular surface. As con-
sequence, the external eye, that is, the conjunctiva and
cornea, are exposed at night. Thus, conjunctival redness,
corneal epithelial damage, and tearing are the typical signs
when these patients wake up in the morning. Closing the
eye with a tape for few days may confirm the diagnosis and
reduce the intensity of the ocular surface inflammation.
Hormonal imbalance and the presence of polycystic
ovary syndrome in young women may cause red eye and
symptoms that can be confused with dry eye and/or ocular
allergy.37 Filaments of mucus and intolerance to contact
lenses are common findings. Although the pathogenesis is
still not defined, the treatment of any hormonal imbalances
may help in the resolution of the disease.
Mild but persistent conjunctival infection, for example,
chlamydia and others, can be unresponsive to topical treat-
ment and can be responsible for red eye.38 Specific micro-
biologic tests are suggested for resistant and symptomatic
young patients that require systemic antibiotic treatment.
A chronic red eye may also be the result of anti-glau-
coma medication or the effects of preservatives in topi-
cal treatments applied to the ocular surface.11 Alternative
treatment or the suspension of any topical therapy some-
times improves the redness of the eye. Unpreserved eye-
drops should always be used when available.
Any long standing ocular surface inflammation may
cause fibrosis and evolve to cicatricial conjunctivitis with
complete anatomical and functional alteration of the ocu-
lar surface.39 This is particularly evident in some ocular
autoimmune diseases such as ocular cicatricial pemphi-
goid (Table 1) or corneal ulcer of autoimmune origin
5
that is unresponsive to topical therapy (Figure 1, bottom
left).40–42 Aggressive systemic immunosuppressive agents
can prevent the progression of these potentially blinding
diseases.43
Any chronic or acute red eye requires attention by a
general practitioner and/or pediatrician because the eye
may be the target of mucosal lymphoma (Table 1; Figure
1, bottom right). The presence of an asymptomatic,
chronic pink-to-red eye with conjunctival hyperplasia and
that is unresponsive to conventional eyedrops should alert
the physician of a potentially serious condition associated
with the mucosal-associated lymphoid tissue (MALT).44 A
brief but specific history should be requested before any
other action is taken. In addition to the presence of a red or
pink eye and information gained through the patient his-
tory, the loss of the natural corneal transparency and spec-
ular reflex, the presence of pain, and any patient-described
reduction of visual acuity suggests a more complicated
etiology and indicates that a prompt referral to an ophthal-
mologist is necessary.
The diagnosis of a red eye is generally clinical but a
careful history together with an accurate slit lamp exami-
nation is required to understand the etiology of this clinical
sign. In addition, and mainly for scientific purposes, grad-
ing scales of ocular hyperemia or its digital version, may
be helpful to quantify the intensity of clinical redness, to
share a common language among clinical scientists and in
monitoring the progression of ocular surface changes.45,46
In summary, managing a red eye can be a difficult task,
even for ophthalmologists. The role of the general physi-
cian is crucial in the decision making to judge the severity
of the ocular condition. If the patient refers pain or reduc-
tion of visual acuity, a consultation with an eye doctor is
suggested. In cases of mild and occasional occurrence of
red eye, additional information may indicate to the phy-
sician if the nature of the red eye is infective, allergic,
or related to dry eye. In these cases, temporary relief of
symptoms may be achieved with antibiotic eyedrops, mild
antiallergics, or ocular lubricants. If this treatment fails
within a few days, a consultation with an ophthalmologist
is suggested. Diagnosing and managing a chronic and/or
recurring red eye can be especially challenging and often
requires the support of other specialists such as rheumatol-
ogists, dermatologists, immunologists, and pediatricians.
We should always be reminded that our goal is not only to
cure the eye, but also the patient.
Acknowledgement
The author thanks Dr. Britt Bromberg at Xenofile Editing (https://
xenofileediting.com) for his skillful editorial assistance
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
6 European Journal of Ophthalmology 00(0)
Funding
The author(s) disclosed receipt of the following financial sup-
port for the research, authorship, and/or publication of this arti-
cle: Section of Ophthalmology, University of Rome Campus
BioMedico.
ORCID iD
Stefano Bonini https://orcid.org/0000-0002-7787-2144
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