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Emergency And Acute Medicine – Red Eye
Red eye is a common presentation caused by vascular engorgement of the conjunctiva and may result from nearly any ocular disorder. Although frequently benign, it can signal serious ocular or systemic disease. Conjunctivitis is the most common cause, but inflammatory, allergic, infectious, traumatic, and glaucomatous etiologies must be considered.
Inflammatory causes include uveitis (anterior or posterior), iritis with perilimbic injection, episcleritis (often idiopathic), and scleritis, which is commonly associated with systemic disease. Allergic conjunctivitis results from histamine-mediated vascular permeability and typically presents bilaterally with chemosis, watery discharge, and pruritus. Infectious causes include bacterial conjunctivitis with purulent discharge, viral conjunctivitis with watery discharge, and less commonly fungal infection. More severe infections include orbital cellulitis, dacryocystitis, canaliculitis, and endophthalmitis. Traumatic causes include corneal abrasion, subconjunctival hemorrhage, foreign body, and occult globe perforation. Other etiologies include pingueculitis, pterygium, blepharitis, dry eye syndrome, conjunctival tumors, ophthalmia neonatorum, and acute angle-closure glaucoma.
History should assess age, onset and duration of symptoms, chemical or allergen exposure, occupation (e.g., metal worker), contact lens use, associated systemic symptoms, and comorbidities. Key ocular symptoms include pain, foreign-body sensation, vision change, discharge, and pruritus. In neonates and patients over 50 years of age, particular caution is required.
Physical examination must include visual acuity in all patients. Assess for diffuse versus localized injection, lid involvement, discharge type, foreign body, proptosis, photophobia, pupil abnormalities, extraocular movements, and visual fields. Examine for preauricular lymphadenopathy and facial lesions suggestive of herpes infection. Slit-lamp examination with fluorescein is essential to evaluate for corneal abrasion, ulceration, dendritic lesions of herpes simplex virus, anterior chamber cell or flare, and foreign body. Lid eversion is required to exclude retained foreign material. Fundoscopy and tonometry should be performed when glaucoma is suspected.
Diagnostic testing is directed by suspected etiology. Culture of discharge may be indicated in dacryocystitis or severe bacterial conjunctivitis, especially if Neisseria gonorrhoeae is suspected, which requires special media such as Thayer–Martin agar. Corneal ulcers require scraping for culture, typically by ophthalmology. Neonatal conjunctivitis is most commonly due to Chlamydia trachomatis, while gonococcal infection presents early with copious purulent discharge and requires urgent treatment. Systemic workup may be necessary in suspected inflammatory or granulomatous uveitis and may include CBC, ESR, ANA, VDRL, FTA-ABS, ACE level, tuberculosis testing, Lyme titers, HLA-B27, and chest imaging. Orbital imaging with CT is indicated when orbital cellulitis, trauma, or foreign body is suspected.
Initial management includes removal of contact lenses and immediate irrigation for chemical injuries. Chemical exposure requires copious irrigation prior to detailed examination. Treatment is directed at the underlying cause. Eye patching is no longer recommended for corneal abrasions and may be contraindicated. Tetanus immunization should be updated in traumatic injuries. Patients should avoid contact lens use until cleared by an eye specialist.
Corneal abrasions in non–contact lens wearers are treated with erythromycin ointment or polymyxin B/trimethoprim drops. Contact lens wearers require antipseudomonal coverage such as ofloxacin, ciprofloxacin, or tobramycin drops. Cycloplegics such as cyclopentolate may reduce pain from associated iritis. Corneal ulcers require more aggressive antibiotic therapy, often with fluoroquinolone drops at frequent intervals, and urgent ophthalmology consultation. Severe or central ulcers may require intensive dosing and possible hospitalization.
Acute angle-closure glaucoma presents with severe eye pain, decreased vision, mid-dilated nonreactive pupil, nausea, vomiting, and elevated intraocular pressure above 21 mm Hg. This is an ophthalmologic emergency requiring pressure-lowering therapy and urgent consultation. Subconjunctival hemorrhage generally requires reassurance unless trauma suggests globe rupture. Herpes simplex or zoster keratitis requires antiviral therapy such as trifluridine drops or vidarabine ointment and ophthalmology consultation. Steroid use should only occur under specialist guidance.
Admission is required for endophthalmitis, perforated corneal ulcers, orbital cellulitis, significant trauma, or systemic involvement. Neonates with suspected gonococcal conjunctivitis require hospitalization and intravenous antibiotics. Urgent ophthalmology referral is necessary for dacryocystitis, corneal ulcer, scleritis, angle-closure glaucoma, uveitis, proptosis, orbital cellulitis, vision loss, uncertain diagnosis, and gonococcal or chlamydial conjunctivitis.
Failure to recognize corneal ulcer, herpetic infection, neonatal bacterial infection, angle-closure glaucoma, or penetrating trauma may result in permanent vision loss. Steroids should never be initiated without ophthalmologic consultation. Prompt reassessment is required if symptoms do not improve as expected.
Red eye is a common presentation caused by vascular engorgement of the conjunctiva and may result from nearly any ocular disorder. Although frequently benign, it can signal serious ocular or systemic disease. Conjunctivitis is the most common cause, but inflammatory, allergic, infectious, traumatic, and glaucomatous etiologies must be considered.
Inflammatory causes include uveitis (anterior or posterior), iritis with perilimbic injection, episcleritis (often idiopathic), and scleritis, which is commonly associated with systemic disease. Allergic conjunctivitis results from histamine-mediated vascular permeability and typically presents bilaterally with chemosis, watery discharge, and pruritus. Infectious causes include bacterial conjunctivitis with purulent discharge, viral conjunctivitis with watery discharge, and less commonly fungal infection. More severe infections include orbital cellulitis, dacryocystitis, canaliculitis, and endophthalmitis. Traumatic causes include corneal abrasion, subconjunctival hemorrhage, foreign body, and occult globe perforation. Other etiologies include pingueculitis, pterygium, blepharitis, dry eye syndrome, conjunctival tumors, ophthalmia neonatorum, and acute angle-closure glaucoma.
History should assess age, onset and duration of symptoms, chemical or allergen exposure, occupation (e.g., metal worker), contact lens use, associated systemic symptoms, and comorbidities. Key ocular symptoms include pain, foreign-body sensation, vision change, discharge, and pruritus. In neonates and patients over 50 years of age, particular caution is required.
Physical examination must include visual acuity in all patients. Assess for diffuse versus localized injection, lid involvement, discharge type, foreign body, proptosis, photophobia, pupil abnormalities, extraocular movements, and visual fields. Examine for preauricular lymphadenopathy and facial lesions suggestive of herpes infection. Slit-lamp examination with fluorescein is essential to evaluate for corneal abrasion, ulceration, dendritic lesions of herpes simplex virus, anterior chamber cell or flare, and foreign body. Lid eversion is required to exclude retained foreign material. Fundoscopy and tonometry should be performed when glaucoma is suspected.
Diagnostic testing is directed by suspected etiology. Culture of discharge may be indicated in dacryocystitis or severe bacterial conjunctivitis, especially if Neisseria gonorrhoeae is suspected, which requires special media such as Thayer–Martin agar. Corneal ulcers require scraping for culture, typically by ophthalmology. Neonatal conjunctivitis is most commonly due to Chlamydia trachomatis, while gonococcal infection presents early with copious purulent discharge and requires urgent treatment. Systemic workup may be necessary in suspected inflammatory or granulomatous uveitis and may include CBC, ESR, ANA, VDRL, FTA-ABS, ACE level, tuberculosis testing, Lyme titers, HLA-B27, and chest imaging. Orbital imaging with CT is indicated when orbital cellulitis, trauma, or foreign body is suspected.
Initial management includes removal of contact lenses and immediate irrigation for chemical injuries. Chemical exposure requires copious irrigation prior to detailed examination. Treatment is directed at the underlying cause. Eye patching is no longer recommended for corneal abrasions and may be contraindicated. Tetanus immunization should be updated in traumatic injuries. Patients should avoid contact lens use until cleared by an eye specialist.
Corneal abrasions in non–contact lens wearers are treated with erythromycin ointment or polymyxin B/trimethoprim drops. Contact lens wearers require antipseudomonal coverage such as ofloxacin, ciprofloxacin, or tobramycin drops. Cycloplegics such as cyclopentolate may reduce pain from associated iritis. Corneal ulcers require more aggressive antibiotic therapy, often with fluoroquinolone drops at frequent intervals, and urgent ophthalmology consultation. Severe or central ulcers may require intensive dosing and possible hospitalization.
Acute angle-closure glaucoma presents with severe eye pain, decreased vision, mid-dilated nonreactive pupil, nausea, vomiting, and elevated intraocular pressure above 21 mm Hg. This is an ophthalmologic emergency requiring pressure-lowering therapy and urgent consultation. Subconjunctival hemorrhage generally requires reassurance unless trauma suggests globe rupture. Herpes simplex or zoster keratitis requires antiviral therapy such as trifluridine drops or vidarabine ointment and ophthalmology consultation. Steroid use should only occur under specialist guidance.
Admission is required for endophthalmitis, perforated corneal ulcers, orbital cellulitis, significant trauma, or systemic involvement. Neonates with suspected gonococcal conjunctivitis require hospitalization and intravenous antibiotics. Urgent ophthalmology referral is necessary for dacryocystitis, corneal ulcer, scleritis, angle-closure glaucoma, uveitis, proptosis, orbital cellulitis, vision loss, uncertain diagnosis, and gonococcal or chlamydial conjunctivitis.
Failure to recognize corneal ulcer, herpetic infection, neonatal bacterial infection, angle-closure glaucoma, or penetrating trauma may result in permanent vision loss. Steroids should never be initiated without ophthalmologic consultation. Prompt reassessment is required if symptoms do not improve as expected.
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