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Red eye refers to a red appearance of the opened eye, reflecting dilation of the superficial ocular
vessels.
Pathophysiology
Dilation of superficial ocular vessels can result from
Infection
Allergy
Inflammation (noninfectious)
Elevated intraocular pressure
Several ocular components may be involved, most commonly the conjunctiva, but also the uveal tract,
episclera, and sclera.
Etiology
The most common causes of red eye include
Infectious conjunctivitis
Allergic conjunctivitis
Corneal abrasions and foreign bodies are common causes (See Table 12: Approach to the
Ophthalmologic Patient: Some Causes of Red Eye ), but although the eye is red, patients usually
present with a complaint of injury, eye pain, or both. However, in young children and infants, this
information may be unavailable.
Table 12
Some Causes of Red Eye
Cause Suggestive Findings Diagnostic Approach
Conjunctival disorders and episcleritis*
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Corneal disorders†
Corneal abrasion or foreign Onset after injury (but this history may be Clinical evaluation
body inapparent in infants and young children)
Foreign body sensation
Lesion on fluorescein staining
Other disorders
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Evaluation
Most disorders can be diagnosed by a general health care practitioner.
History
History of present illness should address the onset and duration of redness and whether there is
change in vision, itching, a scratchy sensation, pain, or discharge. Nature and severity of pain are
addressed, including whether pain is worsened by light (photophobia). The clinician should determine
whether discharge is watery or purulent. Other questions assess history of injury, including exposure to
irritants and use of contact lenses (including possible overuse, such as wearing them while sleeping).
Prior episodes of eye pain or redness and their time patterns are elicited.
Review of systems should seek symptoms suggesting possible causes, including headache, nausea,
vomiting, and halos around lights (acute angle-closure glaucoma); runny nose and sneezing (allergies,
URI); and cough, sore throat, and malaise (URI).
Past medical history includes questions about known allergies and autoimmune disorders. Drug
history should specifically ask about recent use of topical ophthalmic drugs (including OTC drugs),
which might be sensitizing.
Physical examination
General examination should include head and neck examination for signs of associated disorders (eg,
URI, allergic rhinitis, zoster rash).
Eye examination involves a formal measure of visual acuity and usually requires a penlight, fluorescein
stain, and slit lamp.
Best corrected visual acuity is measured. Pupillary size and reactivity to light are assessed. True
photophobia (sometimes called consensual photophobia) is present if shining light into an unaffected
eye causes pain in the affected eye when the affected eye is shut. Extraocular movements are
assessed, and the eye and periorbital tissues are inspected for lesions and swelling. The tarsal
surface is inspected for follicles. The corneas are stained with fluorescein and examined with
magnification. If a corneal abrasion is found, the eyelid is everted and examined for hidden foreign
bodies. Inspection of the ocular structures and cornea is best done using a slit lamp. A slit lamp also is
used to examine the anterior chamber for cells, flare, and pus (hypopyon). Ocular pressure is
measured using tonometry, although it may be permissible to omit this if there are no symptoms or
signs suggesting a disorder other than conjunctivitis.
Red flags
The following findings are of particular concern:
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Interpretation of findings
Conjunctival disorders and episcleritis are differentiated from other causes of red eye by the
absence of pain, photophobia, and corneal staining. Within these disorders, episcleritis is differentiated
by its focality, and subconjunctival hemorrhage usually is differentiated by the absence of lacrimation,
itching, and photosensitivity. Clinical criteria do not accurately differentiate viral from bacterial
conjunctivitis.
Corneal disorders are differentiated from other causes of red eye (and usually from each other) by
fluorescein staining. These disorders also tend to be characterized by pain and photophobia. If
instillation of an ocular anesthetic drop (eg, proparacaine 0.5%), which is done before tonometry and
ideally before fluorescein instillation, completely relieves pain, the cause is probably purely a corneal
lesion. If pain is present and is not relieved by an ocular anesthetic, the cause may be anterior uveitis,
glaucoma, or scleritis. Because patients may have anterior uveitis secondary to corneal lesions,
persistence of pain after instillation of the anesthetic does not exclude a corneal lesion.
Anterior uveitis, glaucoma, acute angle-closure glaucoma, and scleritis usually can be
differentiated from other causes of red eye by the presence of pain and the absence of corneal
staining. Anterior uveitis is likely in patients with pain, true photophobia, absence of corneal fluorescein
staining, and normal intraocular pressure; it is definitively diagnosed by the presence of cells and flare
in the anterior chamber. However, these findings may be difficult for general health care practitioners to
discern. Acute angle-closure glaucoma usually can be recognized by the sudden onset of its severe
and characteristic symptoms, but tonometry is definitive.
Instillation of phenylephrine 2.5% causes blanching in a red eye unless the cause is scleritis.
Phenylephrine is instilled to dilate the pupil in patients needing a thorough retinal examination. However,
it should not be used in patients who have the following:
Testing
Testing is usually unnecessary. Viral cultures may help if herpes simplex or herpes zoster is suspected
and the diagnosis is not clear clinically. Corneal ulcers are cultured by an ophthalmologist. Gonioscopy
is done in patients with glaucoma. Testing for autoimmune disorders may be worthwhile in patients with
uveitis and no obvious cause (eg, trauma). Patients with scleritis undergo further testing as directed by
an ophthalmologist.
Treatment
The cause is treated. Red eye itself does not require treatment. Topical vasoconstrictors are not
recommended.
Key Points
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