Approach to a Case of Red Eye

8/17/2019 Approach to a Case of Red Eye

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Assessment of red eye

The right clinical information, right where it's needed

Last updated: Jan 07, 2016


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Table of Contents

Summary 3

Overview 4

Aetiology 4

Emergencies 7

Urgent considerations 7

Red flags 7

Diagnosis 9

Step-by-stepdiagnosticapproach 9

Differential diagnosisoverview 11

Differentialdiagnosis 13

Diagnosticguidelines 24

References 25

Images 27

Disclaimer 50


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Acute redeye is a commonpresenting complaintto primarycare physicians.[1] A detailed historyof thepresentingsymptoms and previous ophthalmological and medical history can narrow the differential diagnosis and aid in

◊

theinterpretationof key examinationfindings.The lack of specialistequipment in theprimary care setting, along

with a very broad differential diagnosis, can cause difficulty in establishing the correct diagnosis, and in suchcases a specialist ophthalmological opinion should be sought.[2] [3] Serious vision-threatening conditions thatpresent as red eye are rare and can occasionally be overshadowed by associated systemic symptoms; in lightof this they should always be considered within the differential and excluded on examination.[4] [Robert Wood

Johnson University Hospital: anatomy of the eye]

Similar conditions :Similar conditions to acute red eye include orbital cellulitis and thyroid eye disease.

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Complications :Well-recognisedcomplications of acutered eye are dependenton the underlying aetiology. Conditions affectingthe cornea, trauma, anterior uveitis, [Fig-16] and angle-closure glaucoma [Fig-17] can lead to impaired visual

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acuity. Scleritis, [Fig-10] corneal ulceration, [Fig-11] high-velocityforeignbodies, andtraumacan lead to perforationof the eye. [Fig-18]

Summary

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Aetiology

Aetiology

The causes of acute red eye can be considered within the following categories:[5]

Adnexal causes

• Trichiasis: posterior misdirection of the eyelashes from the normal site of origin [Fig-3]

• Entropion: inward turning of the eyelid margin [Fig-2]

• Ectropion: outward turning of the eyelid margin [Fig-20]

• Blepharitis: inflammation of the eyelid margin [Fig-4]

• Dry eye: symptoms or signs consistent with a deficiency of the precorneal tear film. [Fig-15]

Conjunctival causes

• Bacterial conjunctivitis: inflammation of the conjunctiva caused by bacterial infection [Fig-5]

• Viral conjunctivitis: inflammation of the conjunctiva caused by viral infection [Fig-1]

• Allergic (vernal) conjunctivitis: inflammation of the conjunctiva occurring during an allergic response [Fig-19]

• Neonatal conjunctivitis: inflammation of the conjunctiva within the first month of life

• Subconjunctival haemorrhage [Fig-7]

• Subtarsal foreign body [Fig-8]

• Conjunctival foreign body.

Corneal causes

• Bacterial corneal ulcer: corneal epithelial defect caused by bacterial infection [Fig-11]

• Viral corneal ulcer: corneal epithelial defect caused by viral infection [Fig-12]

• Fungal corneal ulcer: corneal epithelial defect caused by fungal infection

• Contact lens-related

• Corneal foreign body [Fig-13]

• Corneal abrasion: corneal epithelial defect usually caused by trauma. [Fig-14]

Inflammatory causes

• Anterior uveitis: inflammation of the anterior portion of the uveal tract [Fig-16]

• Scleritis: inflammation of the sclera [Fig-10]

• Episcleritis: inflammation of the episclera. [Fig-9]

Traumatic causes

• Physical [Fig-18]

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OverviewAssessment of redeye

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• Chemical.

Other

• Angle-closure glaucoma: closure of the iridocorneal angle leading to an acute rise in intra-ocular pressure.[Fig-17]

Most commonconditionsThose commonly presenting to a primary care physician are:

• Infective conjunctivitis[6] [Fig-5]

• Allergic conjunctivitis [Fig-19]

• Dry eye [Fig-15]

• Adnexal problems.[7] [Fig-2] [Fig-3] [Fig-4] [Fig-20]

Causesof threatening vision

Causes of red eye threatening vision include those with the potential to lead to reduced visual acuity, such as:

• Angle-closure glaucoma [Fig-17]

• Chemical injuries

• Conditions affecting the cornea

• Trauma

• Anterior uveitis. [Fig-16]

Those that can lead to globe rupture or perforation include: [Fig-18]

• Scleritis [Fig-10]

• Physical trauma

• Corneal ulceration

• High-velocity foreign bodies.

Risk factors

Those associated with specific causes of red eye include:

• Anterior uveitis: [Fig-16] HLA-B27 histocompatibility complex-positive patients,tuberculosis,syphilis, Lyme disease,sarcoidosis, Behcet's disease, and pauciarticular juvenile chronic arthritis.

• Scleritis: [Fig-10] connective tissue disorders including rheumatoid arthritis, granulomatosis with polyangiitis(Wegener’s), SLE, and relapsing polychondritis.

• Episcleritis: [Fig-9] connective tissue disorders including rheumatoid arthritis, granulomatosis with polyangiitis(Wegener’s), and SLE.

5This PDF ofthe BMJ Best Practicetopic is based on the web version that was last updated: Jan 07, 2016.BMJBest Practice topics are regularlyupdated andthe most recent version of the topics canbe found on bestpractice.bmj.com . Use


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• Angle-closure glaucoma: [Fig-17] hypermetropia, mydriatics, and systemic anticholinergic medications.

• Subconjunctival haemorrhage: [Fig-7] HTN and systemic anticoagulation.

• Dry eye: [Fig-15] connective tissue disorders including Sjogren's syndrome, rheumatoid arthritis, and SLE.




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Urgent considerations

(SeeDifferentialdiagnosis for more details)

Angle-closure glaucoma

This is a vision-threatening condition. Pain in the affected eye, blurred vision, halos around lights seen from one eye,

headache, and associated nausea or vomiting are suggestive of angle-closure glaucoma.[Fig-17] If suspected, thenimmediate referral for an ophthalmological opinion and treatment should be sought. Delay in the diagnosis and referralof angle-closure glaucoma has been shown to be detrimental to the final outcome.[8] Immediate treatment consists of carbonic anhydrase inhibitors such as acetazolamide or methazolamide, to decrease aqueous humour formation.

Trauma: chemical injury

Chemical injuries, especially from alkali-based solutions, are potentially extremely serious and can lead to long-termocular surface problems. Immediate irrigation with saline solution to remove the reservoir of chemicals from the eyeshould be attempted before any other procedures. The amount of irrigation required is dependent on the pH of the tearfilm. After the pH has normalised, referral for further ophthalmological management is advised.[9]

Corneal ulcer Bacterial, [Fig-11] viral, [Fig-12] or fungal corneal ulcers are vision-threatening conditions that need to be referred to anophthalmologist to ensure appropriate treatment to limit corneal scarring.

Contact lens-related redeye

This is potentially a vision-threatening condition and needs to be referred to an ophthalmologist to ensure appropriatetreatment to limit corneal scarring. The patient should be advised to cease use of their contact lenses and take thecontact lenses to the local eye hospital where they are seen.

Corneal foreign body

Any history of a high-velocity injury (hammer usage) should be referred for appropriate and immediate imaging, as anyhigh-velocity foreign body may penetrate the globe. This, and non-penetrating corneal foreign bodies, [Fig-13] arepotentially vision-threatening conditions and require referral to an ophthalmologist to ensure appropriate treatment.

Penetratingocular trauma

Very gentle initial examination is required to prevent possible expulsion of intra-ocular contents. Prompt specialisttreatment is required to reduce the risk of sight- and eye-threatening complications.

Scleritis

Scleritis [Fig-10] is potentially a vision-threatening condition. Certain forms of scleritis canlead to perforation of theglobeand reduced visual acuity.[10] If global perforation is suspected, the eye should be shielded and palpation should beavoided. It should be evaluated further by an ophthalmologist. Scleritis is commonly associated with connective tissuedisorders including rheumatoid arthritis, granulomatosis with polyangiitis (Wegener’s), SLE, and relapsing polychondritis.

Neonatal conjunctivitis

This is not life threatening; however, rarely associated systemic infection can be present. If this is suspected, referral topaediatrics for further assessment is advised.

Red flags

• Corneal ulcer (bacterial, viral, or fungal)



E ME R G E N C I E S

EmergenciesAssessment of redeye



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• Contact lens-related red eye

• Corneal foreign body

• Neonatal conjunctivitis

• Penetrating ocular trauma

• Chemical trauma

• Scleritis

• Anterior uveitis

• Angle-closure glaucoma



EmergenciesAssessment of redeye

E M E R G E N C I E S

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Step-by-step diagnostic approach

Current history

When taking the presenting history of red eye, it is important to consider the serious vision-threatening diagnoses alongwith more common causes. By including key questions and noting down pertinent negative features, the differentialdiagnosis can be narrowed and a decision can be made on whether referral for further ophthalmological treatment isrequired or treatment can be given in the primary care setting. Key questions to consider within the history of thepresenting complaint include:[11]

• When the condition started

• Whether the condition is unilateral or bilateral (e.g., a foreign body or trauma is usually unilateral, whereasconjunctivitis may start as unilateral then become bilateral)

• Onset of thesymptoms andsigns (e.g., acute onset mayindicate a corneal foreign body or abrasion or foreign bodytrauma).

In elucidating associated symptoms, the most important to note are the presence of reduced visual acuity or a deepaching pain within theeye, indicating thepresence of a more seriousunderlying diagnosis, such as angle-closure glaucoma,

[Fig-17] anterior uveitis, [Fig-16] or scleritis. [Fig-10]

If the patient complains of a foreign body sensation, the possible diagnoses are conjunctivitis, [Fig-1] [Fig-5] [Fig-6]conjunctival/subtarsal foreign body, [Fig-8] corneal foreign body, [Fig-13] keratitis, and corneal ulcer. [Fig-11] [Fig-12]

If a foreign body is suspected, the patient should be asked whether he or she was wearing eye protection during theactivity.

The nature of the activity will also point to potential penetrating injuries: for example, the use of mechanical saws andhammering can produce high-velocity foreign bodies, which have the ability to penetrate the surface of the globe andbecome intra-ocular.

If the patient wears contact lenses, contact lens-related red eye should be referred for further ophthalmological review,

as corneal ulceration must be excluded.

If there is any discharge present, factors that can help to identify the presence of conjunctivitis [Fig-5] and the possibleunderlying aetiology are:[12]

• If thedischarge is watery, purulent, or mucopurulent (e.g., a watery dischargeis seen in viral conjunctivitis, whereasa profuse mucous discharge is seen in chlamydial conjunctivitis and a purulent discharge in gonococcalconjunctivitis[Fig-21] [Fig-22] )

• If it is worse in the mornings; this may be due to allergy

• If any itch is present; this is usually due to allergy, or is minimal, as in chlamydial conjunctivitis

• If the patient has a history of atopy.

If the patientis photophobic,thiscan indicate possibleunderlying anterioruveitis[Fig-16]or cornealepithelial disturbance.The systemic associations of photophobia, such as meningitis, should always be considered in an unwell patient.[13]

Pastmedical andpast ophthalmological history

Thephysician shouldconsider whether thepatient hashad previous similarepisodesor whether there areany underlyingsystemic associations of conditions known to cause red eye, such as HLA-B27 histocompatibility complex-positivepatients,reactivearthritis,[Fig-23]tuberculosis,syphilis, Lyme disease,sarcoidosis, Behcet'sdisease, pauciarticular juvenilechronicarthritis, connective tissue disorders (including rheumatoid arthritis, Sjogren's syndrome, andSLE), granulomatosiswith polyangiitis (Wegener’s), relapsing polychondritis, and HTN.



D I A G N O S I S

DiagnosisAssessment of redeye



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Drug history

The use of any current ophthalmological medications as well as any systemic medications known to precipitate causesof redeye should be noted. These include mydriatics andsystemic anticholinergic medications. Patients on anticoagulantsmay be predisposed to subconjunctival haemorrhage. Persistence of conjunctivitis despite topical antibiotics shouldprompt evaluation for a different aetiology.

Examination

Examination of the eye in a primary care setting requires the use of a Snellen chart, a light source, fluorescein, and acotton wool bud to evert the upper lid.[12] A step-wise approach can be used, with consideration of the differentialdiagnosis from the history.

1. Visual acuity should be checked in all cases, as a reduction may indicate a more serious underlying cause for thered eye.

2. Inspection of the lids and brow should be performed to exclude peri-orbital injury. The position of the lid marginsshould be checkedforthe presenceof trichiasis, [Fig-3] an entropion, [Fig-2] or an ectropion. [Fig-20] If any dischargecan be seen, conjunctivitis should be considered. If the condition is bilateral with purulent discharge, it should betreated as conjunctivitis. [Fig-5]

3. On inspection of the ocular surface and subtarsal surface, the pattern of redness, an important feature, should beassessed. Segmental injection may indicate episcleritis [Fig-9] or the presence of a foreign body. [Fig-8] [Fig-13]Ciliary or limbal (junction of the cornea and sclera) injectionoccurs in anterioruveitis [Fig-16] andcorneal conditions.Redness that is localised and well demarcated with quiet surrounding conjunctiva is seen in subconjunctivalhaemorrhage, [Fig-7] prompting the patient's BP to be checked. Generalised injection, with engorgement of thedeeper scleral vessels and pain on palpation of the globe, indicates the presence of scleritis.[14] [Fig-10] The tarsalconjunctiva should be inspected for papillae, seen in allergic conjunctivitis, [Fig-19] or follicles, seen in chlamydialconjunctivitis. [Fig-6] If there is a history of a foreign body, the upper lid should be everted with a cotton wool budto exclude a subtarsal position. If the foreign body cannot be found and the activity during the incident may haveproduced a high-speed foreign body, then further ophthalmological opinion should be sought to exclude anintra-ocular position. Instilling fluorescein during inspection of the ocular surface can allow the visualisation of foreign bodies, [Fig-13] corneal abrasions, [Fig-14] and corneal ulcers. [Fig-11] [Fig-12] If there is fluorescein staining

present on the cornea or the cornea appears cloudy (seen in angle-closure glaucoma), [Fig-17] referral for furtherophthalmological examinationis advised. Rose bengalstaincan be used in cases where dryeye [Fig-15] is suspectedas the underlying cause.

4. Pupillary reactions. The physician should observe for anisocoria (unequal pupil size), and if this is present shouldrefer for further ophthalmological assessment.[15] Using a pen torch (or equivalent light source), the direct andconsensual pupillary responses should be checked. If the pupillary response is abnormal in the presence of redeye, anterior uveitis [Fig-16] and angle-closure glaucoma [Fig-17] need to be excluded. If thepatient is photophobicon examination, further referral is also advised.[16]

Investigations

Swabs for bacterial, viral, and chlamydial culture can be taken in suspected cases of conjunctivitis. [Fig-1] [Fig-5] [Fig-6]Investigation into the underlying systemic causes of red eye should be performed in a specialist clinic after a definiteophthalmological diagnosis has been given. Certain local causes of redeye including ectropion, entropion, corneal ulcer,contact lens-related red eye, corneal abrasion, corneal foreign body, penetrating and chemical trauma, scleritis, andangle-closure glaucoma should be evaluated further by an ophthalmologist.

Imaging with CT of the orbits should be performed if a high-velocity penetrating injury is suspected.

Intra-ocular pressure is measured by the referral ophthalmologist evaluating for acute glaucoma.




D I A G N O S I S



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Differential diagnosis overview

Common

Trichiasis

Entropion

Ectropion

Blepharitis

Dry eyes

Corneal ulcer (bacterial, viral, or fungal)

Contact lens-related red eye

Keratitis

Corneal foreign body

Corneal abrasion

Subtarsal conjunctival foreign body

Allergic conjunctivitis

Bacterial conjunctivitis

Viral conjunctivitis

Non-traumatic subconjunctival haemorrhage

Uncommon

Chlamydial conjunctivitis

Neonatal conjunctivitis

Penetrating ocular trauma

Chemical trauma

Episcleritis



D I A G N O S I S




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Uncommon

Scleritis

Anterior uveitis

Angle-closure glaucoma




D I A G N O S I S



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Differential diagnosis

Common

◊ Trichiasis

Other tests1st TestExamHistory

»clinical diagnosis:noinitial testPresence of an aberrantlash/cluster of lashes isnoted. [Fig-3]

an aberrant lash/cluster of lashes may be seen;corneal fluorescein stainseen; normal visual acuityand pupillary reactions

insidious onset of ocularunease; patient maydescribe localised ocularirritation; no dischargepresent

◊ Entropion


»specialistclinic review:To determine the

lowereyelidmaybeturnedin;fluoresceinstainmaybe

sudden onset of ocularunease as the eyelid turns

underlying cause:present if the eyelashesin; may result in theinvolutional, cicatricial, orcongenital (child).[Fig-2]

have been rubbing on thecornea; normal visualacuity and pupillaryreactions

eyelashes rubbing on thecornea, causing localisedirritation and watering

◊ Ectropion


»specialistclinic review:To determine the

the lower eyelid may beseen to be coming away

patient may report ocularirritation and unease with

underlying cause:from the globe; noassociated watering; nodischarge involutional, cicatricial, or

paralytic.[Fig-20]

fluorescein stain seen;normal visual acuity andpupillary reactions

◊ Blepharitis


»clinical diagnosis:noinitial testInflamedcrustingof thelidmargins is noted. [Fig-4]

inflamedcrusting of thelidmargins; normal visualacuity and pupillaryreactions; no fluoresceinstain visible

patient may report anintermittent foreign bodysensation, burning, orgrittiness;symptoms oftenworse in the mornings butmay flare at any time; nodischarge present



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Common

◊ Dryeyes


»clinical diagnosis:noinitial testDry eyes are diagnosed onclinical appearance.[Fig-15]

visual acuity can beaffected; ocularvasculature may appearengorged, rose bengalstaining may be present;stringy discharge may beseen

patient may reportirritation, burning, foreignbody sensation, ornon-specific ocularunease; photophobia andstringydischarge mayalsobe described

◊ Corneal ulcer (bacterial, viral, or fungal)


»cornealscrapeformicroculture and sensitivity:

reduced visual acuity,often severe conjunctival

patient may initially reporta foreign body sensation,

positive in bacterial orfungal causeTo be performed in aspecialist clinic. In thecase

injection; a swollen eyelidand discharge may bevisible; corneal fluoresceinstain seen; ulcer may bebacterial, viral, or fungal

which progresses tophotophobia, blurredvision, pain, and discharge;the eyelids may also swell

of a suspected bacterialulcer, samples of theinfiltrate within the ulcerare taken, using a blade orneedle bevel, and sent forGram stain and culture (2

blood agar plates, 1chocolate agar, and 1Sabouraud plate).[5]

Ulcer may be bacterial,[Fig-11] viral, [Fig-12] orfungal in aetiology.

◊ Contact lens-related red eye



reduced visual acuity;severe conjunctival

contact lens wearer mayinitially report a foreign


injection may be present;a swollen eyelid anddischarge may be visible;corneal fluorescein stainseen

body sensation thatprogresses tophotophobia, blurring,pain, and discharge; theeyelid may also swell of a suspected bacterial

ulcer, samples of theinfiltrate within the ulcerare taken, using a blade orneedle bevel, and sent for




D I A G N O S I S



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Common

◊ Contact lens-related red eye


Gram stain and culture (2blood agar plates, 1chocolate agar, and 1Sabouraud plate).[5]

◊ Keratitis



corneal ulcer that may bebacterial, viral, or fungal;

patient may report intensepain, discharge,


reduced visual acuity; aswollen eyelid anddischarge may be visible

photophobia, increasedlacrimation;the eyelidmayalso swell

of a suspected bacterialulcer, samples of theinfiltrate within the ulcerare taken, using a blade orneedle bevel, and sent forGram stain and culture (2blood agar plates, 1chocolate agar, and 1

Sabouraud plate).[5]

Ulcer may be bacterial,[Fig-11] viral, [Fig-12] orfungal in aetiology.

◊ Corneal foreign body


»imaging withCTof theorbits: intra-ocularforeignbody may be presentImaging of the orbit isrequired to exclude an

a foreign body may beseen either on the cornea,under the upper lid, orwithin the lower fornix;normal visual acuity andpupillary reactions

a foreign body sensationprogressing tophotophobia andpain maybe reported; thesensationis frequently preceded bya gust of wind or followinguse of hammering orgrinding equipment

intra-ocular foreign bodyin cases of high-velocityinjuries.[17]

Foreignbodiesmayalsobenoted clinically onexamination of thecornea,upper lid conjunctiva, or

lower fornix. [Fig-13]



D I A G N O S I S




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Common

◊ Corneal abrasion


»clinical diagnosis:noinitial testCorneal abrasion can beseenwith fluorescein stain.[Fig-14]

reduced visual acuity;normal pupillary reactions;single eye, conjunctivalinjection with cornealfluorescein stain seen; theeyelid may be swollen; nodischarge

acute onset of ocularunease; this may havebeenprecededbyahistoryof minor trauma

◊ Subtarsal conjunctival foreign body


»clinical diagnosiswithfluorescein staining:

possible reduced visualacuity; injected

often reducedvision; smallparticle foreign body into

fluorescein stainingpositiveForeign body can bevisualised with fluoresceinstaining. [Fig-8]

conjunctiva, oftenlocalised; foreign bodyvisible on conjunctiva onevertion of eyelid (eitherupper or lower), often bestvisualised with fluoresceinstaining; corresponding

eye, often wind-blown withlow velocity; persistentsharp scratching foreignbody sensation, worse onblinking; watering, oftenprofuse; no discharge

fine linear cornealabrasions; normal pupilresponse

◊ Allergic conjunctivitis


»clinical diagnosis:noinitial testVernal conjunctivitis maydevelop a cobblestoneappearance. [Fig-19]

normal visual acuity;diffusely injectedconjunctiva; chemosis(bulging of theclear/injected conjunctivallayerwith fluidunderneath,

often described as looking

history of allergenexposure (could includetopical eye medication);possible seasonalrecurrence or associatedatopic symptoms (vernal);

rapidonset after exposure;likejellyonthewhiteoftheitch; watery, stringy

discharge eye); fine velvety papillaeon tarsal conjunctiva, maydevelopgiant cobblestoneappearance (vernal); clearcornea, no fluoresceinstain; erythema andoedema to lids; normalpupil response; nopre-auricular lymph nodespalpable




D I A G N O S I S



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Common

◊ Bacterial conjunctivitis


»conjunctival swabsfor micro culture anddiffusely injectedconjunctiva; mucoid ordiscomfort, foreign bodysensation; purulentsensitivity includingChlamydia:positivePositive cultures takenfrom the conjunctivae or

purulent discharge; clearcornea, no fluoresceinstain; normal visual acuityand pupil response

discharge (if severe,consider gonococcalaetiology); often initiallyunilateral, becomingbilateral; eyelid erythema discharge [Fig-5] canand oedema; vision enable treatment to beminimally or unaffected;not itchy

initiated or changedappropriately.

◊ Viral conjunctivitis


»conjunctival swabsfor micro culture and

diffusely injectedconjunctiva; tarsal

discomfort, foreign bodysensation; watery

sensitivity includingconjunctival follicles; cleardischarge (not purulent),Chlamydia (to excludecornea initially, possibleoften profuse; usuallythosediagnoses):positivein bacterialor fungalcauseViral conjunctivitis isusually a clinical diagnosis.

[Fig-1]

small patches of sub-epithelial infiltratesdeveloping 2 to 3 weeksafter onset; occasionally

palpable pre-auricular

initially unilateral,becoming bilateral;associatedURI symptoms;recent contact history of

someone with red eye;lymph nodes; no cornealvision minimally or

unaffected Conjunctival swabs areperformed to exclude

fluorescein stain; normalvisual acuity and pupilresponse bacterial or fungal

diagnoses. Positivecultures can enabletreatment to be initiatedor changed as needed.

◊ Non-traumatic subconjunctival haemorrhage


»clinical diagnosis:noinitial testSubconjunctivalhaemorrhage is seen as a

well-circumscribed area of confluent haemorrhageunderneath conjunctiva,often sectorial; cornea

spontaneous;occasionallyhistory of Valsalvamanoeuvre, coughing, orsneezing; usually

well-circumscribedarea of clear, no fluorescein stain;asymptomatic; occasionalconfluent haemorrhagenormal visual acuity andmild discomfort, orunderneath conjunctiva.[Fig-7]

pupil response; possiblesystemic HTN; BP shouldbe measured in all cases



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Common

◊ Non-traumatic subconjunctival haemorrhage


and managed as perguidelines[18]popping sensation atonset; possibleassociationwith systemic HTN oranticoagulant medication

Uncommon

◊ Chlamydial conjunctivitis


»conjunctivalswab/scrapespecificallyforChlamydia: positivePositive cultures takenfrom the conjunctivae or

diffusely injectedconjunctiva; large tarsalconjunctival follicles; clearcornea, no fluoresceinstain; normal visual acuityand pupil response

discomfort, foreign bodysensation; mucusdischarge, often profuse;usually initially unilateral,becomingbilateral;chronicsymptoms despite topicalantibiotics; rarely

discharge [Fig-6] canenable treatment to be

associated genito-urinary initiated or changed asneeded.symptomsofinflammation

or discharge; visionminimally or unaffected;minimally or not itchy

◊ Neonatal conjunctivitis


»conjunctival swabsfor micro culture and

diffusely injectedconjunctiva; purulent

vaginal delivery,presentation within 1

sensitivity includingdischarge; clear cornea,nomonth of birth;purulentorchlamydial:positive forChlamydia Positive cultures canenable treatment to be

fluorescein stain; normalpupil response; tarsalconjunctival follicularreaction does not occur in

mucoid discharge, oftenprofuse, usually bilateral;occasionally associatedgenito-urinary symptoms

initiated or changed asneeded.

neonates, even withchlamydial infection

of inflammation ordischarge in the mother




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Uncommon

◊ Penetratingocular trauma


»CT head/orbits:observation of radio-opaque foreign bodyImaging of the orbit isrequired to exclude an

reduced visual acuity;conjunctival injection;subconjunctivalhaemorrhage, oftenextensive; conjunctival or

identification of the nature,force, and time of theinjury, particularly withhigh-velocity smallfragments (e.g., produced

intra-ocular foreign body,corneal laceration at entryby metal-on-metalespecially in cases of high-velocity injuries.[17]

site, with possible uvealtissue prolapse (dark

hammering or powertools); often reduced

pigmentedtissue);shallowvision;painfromonset,canbe minor Clinically, penetration can

be noted by laceration atanterior chamber (spacebetween cornea and iris)

entry site with possiblecompared with the otheruveal tissue prolapsed.

[Fig-18]

eye; hyphaema (blood in

the anterior chamber);irregular pupil; cataract;reduced red reflex;associated lid and facialinjuries

◊ Chemical trauma


»pHof tear film: p H = 7 i n

normal tear film; therefore

possible reduced visual

acuity; injected

hx of irritant chemical

instillation; exact details of may be elevated in alkaliconjunctiva, areas of pallorthetime,duration, pH,andinjury and lowered in acidinjury

could indicatesevereburn;particles may be observedandremoved fromfornices

constituents of thechemical are vital, as wellas any treatment provided

on lid eversion; epithelialacutely; often reducedfluorescein staining tovision;painfromonset,canconjunctiva and cornea;be severe; watering, often

profuse corneal haze withobscuring of iris details if severe; lid erythema,oedema, and burns;

normal pupil response

◊ Episcleritis


»FBC: result depends onunderlying causeEvaluation for causes of episcleritis [Fig-9] should

sectorial redness in one orbotheyes; a nodulecan bepresent over the area; nofluorescein stain; normal

acuteonsetofrednessandpain; often the patientdescribes the redness in aspecificareaoftheeyeand

be performed in avisual acuity and pupillaryreactions

may have noticed a smallnodule adjacent to this



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Uncommon

◊ Episcleritis


area; no discharge; patientmay have associated specialistclinic to evaluatefor underlyingautoimmune disease.underlying rheumatoid

arthritis, granulomatosis»ureaand electrolytes:result depends onunderlying causeEvaluation for causes of episcleritis [Fig-9] should

with polyangiitis(Wegener’s), or SLE

be performed in aspecialistclinic to evaluatefor underlyingautoimmune disease.

»ESR: elevated ininflammatory conditionsEvaluation for causes of episcleritis [Fig-9] shouldbe performed in aspecialistclinic to evaluatefor underlyingautoimmune disease.

»CRP: elevated ininflammatory conditionsEvaluation for causes of episcleritis [Fig-9] shouldbe performed in aspecialistclinic to evaluatefor underlyingautoimmune disease.

»rheumatoid factor:positive in some patientswith rheumatoid arthritis,systemic lupuserythematosusEvaluation for causes of

episcleritis [Fig-9] shouldbe performed in aspecialistclinic to evaluatefor underlyingautoimmune disease.

»c-antineutrophilcytoplasmicantibody(c-ANCA): positive ingranulomatosis withpolyangiitis (Wegener’s)Evaluation for causes of episcleritis [Fig-9] should




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Uncommon

◊ Episcleritis


be performed in aspecialistclinic to evaluatefor underlyingautoimmune disease.

◊ Scleritis


»FBC: result depends onunderlying cause

Evaluation for causes of scleritis [Fig-10] should be

deep scleral vesselengorgement and pain on

ocular palpation; nofluorescein stain; visual

severe ocular pain andredness (prominent

feature); no discharge;reduced visual acuity may

performed in a specialistacuity and pupillarybe present; past medicalclinic to evaluate forreactionsmaybe abnormalhistory should be reviewedunderlying autoimmunedisease.

depending on thepositionofthescleritisontheglobe(anterior or posterior)

for any known systemicassociations such asconnective tissuedisorders including »ureaand electrolytes:

result depends onunderlying causeEvaluation for causes of scleritis [Fig-10] should be

rheumatoid arthritis,granulomatosis withpolyangiitis (Wegener’s),SLE, and relapsing

polychondritis performed in a specialistclinic to evaluate forunderlying autoimmunedisease.

»ESR: elevated ininflammatory conditionsEvaluation for causes of scleritis [Fig-10] should beperformed in a specialistclinic to evaluate forunderlying autoimmunedisease.

»CRP: elevated ininflammatory conditionsEvaluation for causes of scleritis [Fig-10] should beperformed in a specialistclinic to evaluate forunderlying autoimmunedisease.

»rheumatoid factor:positive in some patients



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Uncommon

◊ Scleritis


with rheumatoid arthritis,SLEEvaluation for causes of scleritis [Fig-10] should beperformed in a specialistclinic to evaluate forunderlying autoimmunedisease.

»c-antineutrophilcytoplasmicantibody(c-ANCA): positive ingranulomatosis with

polyangiitis (Wegener’s)Evaluation for causes of scleritis [Fig-10] should beperformed in a specialistclinic to evaluate forunderlying autoimmunedisease.

◊ Anterior uveitis


»FBC: result depends onunderlying causeEvaluation for anterioruveitis [Fig-16] should be

visual acuity may bereduced; ciliary flushpattern of redness in theaffected eye; close

pain and photophobiawithin theaffectedeye; thepain may be exacerbatedwhen reading or

performed in a specialistexamination of the corneaperforming close work;clinic to evaluate forand anterior chamber mayreducedvision,dependingunderlying autoimmunedisease or other aetiology.

show the presence of keratic precipitates

on the severity; past hx of similar episodes; past

(cellularaggregates on themedical hx should be»ureaand electrolytes:result depends on

underlying causeEvaluation for anterioruveitis [Fig-16] should be

inner corneal surface),inflammatory cells, andflare (increased proteinwithin the anteriorchamber, allowing

reviewed for any knownsystemic associations,such as HLA-B27histocompatibilitycomplex-positive patients,

performed in a specialistvisualisation of the lighttuberculosis, syphilis, Lymeclinic to evaluate forbeamwithin the aqueous),disease, sarcoidosis,underlying autoimmunedisease or other aetiology.

and in severe cases ahypopyon; the pupillary

Behcet's disease, andpauciarticular juvenilechronic arthritis

»CRP: elevated ininfectious andinflammatory conditionsEvaluation for anterior

uveitis [Fig-16] should be

margin may appearirregular and reactionsabnormal if posteriorsynechiae(adhesionofthe




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Uncommon

◊ Anterior uveitis


iris to the anterior lenscapsule) are present performed in a specialistclinic to evaluate forunderlying autoimmunedisease or other aetiology.

»syphilis serology:positive in syphilisEvaluation for anterioruveitis [Fig-16] should beperformed in a specialistclinic to evaluate forunderlying autoimmunedisease or other aetiology.

»angiotensin-convertingenzyme: elevated insarcoidosisEvaluation for anterioruveitis [Fig-16] should beperformed in a specialistclinic to evaluate forunderlying autoimmunedisease or other aetiology.

»HLA-B27histocompatibilitycomplex: positive inaffected patientsEvaluation for anterioruveitis [Fig-16] should beperformed in a specialistclinic to evaluate forunderlying autoimmunedisease or other aetiology.

»auto-antibody screen:positive according tounderlying autoimmune

diseaseEvaluation for anterioruveitis [Fig-16] should beperformed in a specialistclinic to evaluate forunderlying autoimmunedisease or other aetiology.



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Uncommon

◊ Angle-closure glaucoma


»intra-ocular pressuremeasurement: elevatedintra-ocular pressureEvaluation forangle-closure glaucoma

reduced visual acuity;cloudy cornea and a fixed,semi-dilated oval pupil; ongentle digital palpation theglobe feels hard

severe ocular pain oftenassociated with vomiting;blurred vision and halosaround light sources; thepatient's past ocular,medical, and drug hx [Fig-17] should beshould be reviewed to performed by an

ophthalmologist.exclude any knownassociations

Normal intra-ocularpressure is 12 to 21mmHg.

Diagnostic guidelines

International

Conjunctivitis

Lastpublished:2013Publishedby:American Academy of Ophthalmology

Summary: Clinically relevant guideline that highlights diagnosis (differentiating conjunctivitis from other causes of red eye). Also discusses treatment recommendations.




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Key articles

• McDonnell PJ. How do general practitioners manage eye disease in the community? Br J Ophthalmol.1988;72:733-736. Full text Abstract

• Leibowitz HM. The red eye. N Engl J Med. 2000;343:345-351. Abstract

References

1. McDonnell PJ. How do general practitioners manage eye disease in the community? Br J Ophthalmol.1988;72:733-736. Full text Abstract

2. Strong S. Ophthalmology around the world. studentBMJ. 2006;14:177-220. Full text

3. Vernon SA. Eye care andthe medical student: where should emphasis be placedin undergraduate ophthalmology? J R Soc Med. 1988;81:335-337. Full text Abstract

4. Dayan M, Turner B, McGhee C. Acute angle closure glaucoma masquerading as systemic illness. BMJ.1996;313:413-415. Abstract

5. KunimotoDY,Kanithar KD,MakarM. Differential diagnosisof ocularsymptoms.In: Kunimoto DY, Kanithar KD,MakarM, eds. The Wills Eye Manual, Office and Emergency Room Diagnosis and Treatment of Eye Disease. Philadelphia(PA): Lippincott Williams and Wilkins; 2004:1-5.

6. Azari AA, Barney NP. Conjunctivitis: a systematic review of diagnosis and treatment. JAMA. 2013;310:1721-1729.Full text Abstract

7. Sheldrick JH, Wilson AD, Vernon SA, et al. Management of ophthalmic disease in general practice. Br J Gen Pract.1993; 43:459-462. Full text Abstract

8. David R, Tessler Z, Yassur Y. Long-term outcome of primary acute angle-closure glaucoma. Br J Ophthalmol.1985;69:261-262. Full text Abstract

9. Wagoner MD. Chemical injuries of the eye: current concepts in pathophysiology and therapy. Surv Ophthalmol.1997;41:275-313. Abstract

10. Tuft SJ, Watson PG. Progression of scleral disease. Ophthalmology. 1991;98:467-471. Abstract

11. Bal SK, Hollingworth GR. Red eye. BMJ. 2005;331:438. Abstract

12. Rietveld RP, ter Riet G, Bindels PJ, et al. Predicting bacterial cause in infectious conjunctivitis: cohort study oninformativeness of combinations of signs and symptoms. BMJ. 2004;329:206-210. Full text Abstract

13. Hart CA, Thomson AP. Meningococcal disease and its management in children. BMJ. 2006;333:685-690. Full textAbstract

14. Leibowitz HM. The red eye. N Engl J Med. 2000;343:345-351. Abstract

15. Rose GE,PearsonRV.Unequal pupilsizein patients with unilateral red eye. BMJ. 1991;302:571-572. Fulltext Abstract

16. Chong NV,MurrayPI. Pentorch test in patients withunilateral redeye.Br J GenPract. 1993;43:259. Full textAbstract



R E F E R E N C E S

ReferencesAssessment of redeye

http://bjo.bmj.com/cgi/reprint/72/10/733http://www.ncbi.nlm.nih.gov/pubmed/3191073?tool=bestpractice.bmj.comhttp://www.ncbi.nlm.nih.gov/pubmed/10922425?tool=bestpractice.bmj.comhttp://bjo.bmj.com/cgi/reprint/72/10/733http://www.ncbi.nlm.nih.gov/pubmed/3191073?tool=bestpractice.bmj.comhttp://student.bmj.com/student/view-article.html?id=sbmj0605200http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1291626/pdf/jrsocmed00161-0029.pdfhttp://www.ncbi.nlm.nih.gov/pubmed/3404527?tool=bestpractice.bmj.comhttp://www.ncbi.nlm.nih.gov/pubmed/8761235?tool=bestpractice.bmj.comhttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC4049531/http://www.ncbi.nlm.nih.gov/pubmed/24150468?tool=bestpractice.bmj.comhttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC1372484/pdf/brjgenprac00038-0023.pdfhttp://www.ncbi.nlm.nih.gov/pubmed/8292417?tool=bestpractice.bmj.comhttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC1040578/pdf/brjopthal00136-0025.pdfhttp://www.ncbi.nlm.nih.gov/pubmed/3994941?tool=bestpractice.bmj.comhttp://www.ncbi.nlm.nih.gov/pubmed/9104767?tool=bestpractice.bmj.comhttp://www.ncbi.nlm.nih.gov/pubmed/2052300?tool=bestpractice.bmj.comhttp://www.ncbi.nlm.nih.gov/pubmed/16110072?tool=bestpractice.bmj.comhttp://www.bmj.com/cgi/content/full/329/7459/206http://www.ncbi.nlm.nih.gov/pubmed/15201195?tool=bestpractice.bmj.comhttp://www.bmj.com/cgi/content/full/333/7570/685http://www.ncbi.nlm.nih.gov/pubmed/17008668?tool=bestpractice.bmj.comhttp://www.ncbi.nlm.nih.gov/pubmed/10922425?tool=bestpractice.bmj.comhttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC1669415/pdf/bmj00116-0035.pdfhttp://www.ncbi.nlm.nih.gov/pubmed/2021723?tool=bestpractice.bmj.comhttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC1372425/pdf/brjgenprac00043-0039a.pdfhttp://www.ncbi.nlm.nih.gov/pubmed/8373651?tool=bestpractice.bmj.comhttp://bestpractice.bmj.com/http://bestpractice.bmj.com/http://www.ncbi.nlm.nih.gov/pubmed/8373651?tool=bestpractice.bmj.comhttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC1372425/pdf/brjgenprac00043-0039a.pdfhttp://www.ncbi.nlm.nih.gov/pubmed/2021723?tool=bestpractice.bmj.comhttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC1669415/pdf/bmj00116-0035.pdfhttp://www.ncbi.nlm.nih.gov/pubmed/10922425?tool=bestpractice.bmj.comhttp://www.ncbi.nlm.nih.gov/pubmed/17008668?tool=bestpractice.bmj.comhttp://www.bmj.com/cgi/content/full/333/7570/685http://www.ncbi.nlm.nih.gov/pubmed/15201195?tool=bestpractice.bmj.comhttp://www.bmj.com/cgi/content/full/329/7459/206http://www.ncbi.nlm.nih.gov/pubmed/16110072?tool=bestpractice.bmj.comhttp://www.ncbi.nlm.nih.gov/pubmed/2052300?tool=bestpractice.bmj.comhttp://www.ncbi.nlm.nih.gov/pubmed/9104767?tool=bestpractice.bmj.comhttp://www.ncbi.nlm.nih.gov/pubmed/3994941?tool=bestpractice.bmj.comhttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC1040578/pdf/brjopthal00136-0025.pdfhttp://www.ncbi.nlm.nih.gov/pubmed/8292417?tool=bestpractice.bmj.comhttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC1372484/pdf/brjgenprac00038-0023.pdfhttp://www.ncbi.nlm.nih.gov/pubmed/24150468?tool=bestpractice.bmj.comhttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC4049531/http://www.ncbi.nlm.nih.gov/pubmed/8761235?tool=bestpractice.bmj.comhttp://www.ncbi.nlm.nih.gov/pubmed/3404527?tool=bestpractice.bmj.comhttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC1291626/pdf/jrsocmed00161-0029.pdfhttp://student.bmj.com/student/view-article.html?id=sbmj0605200http://www.ncbi.nlm.nih.gov/pubmed/3191073?tool=bestpractice.bmj.comhttp://bjo.bmj.com/cgi/reprint/72/10/733http://www.ncbi.nlm.nih.gov/pubmed/10922425?tool=bestpractice.bmj.comhttp://www.ncbi.nlm.nih.gov/pubmed/3191073?tool=bestpractice.bmj.comhttp://bjo.bmj.com/cgi/reprint/72/10/733


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17. Saeed A, Cassidy L, Malone DE, et al. Plain X-ray and computed tomography of the orbit in cases and suspectedcases of intraocular foreign body. Eye. 2008;22:1373-1377. Abstract

18. National Institute for Health and Care Excellence. Hypertension in adults: diagnosis and management. Aug 2011.https://www.nice.org.uk/ (last accessed 4 Jan 2016). Full text



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Images

Figure 1: Viral conjunctivitis

Private collection - courtesy ofMrHugh Harris



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Figure 2: Entropion





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Figure 3: Trichiasis




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Figure 4: Blepharitis





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Figure 5: Bacterial conjunctivitis




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Figure 6: Chlamydial conjunctivitis





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Figure 7: Subconjunctival haemorrhage




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Figure 8: Subtarsal foreign body: vertical corneal abrasions seen with fluorescein stain





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Figure 9: Episcleritis




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Figure 10: Scleritis





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Figure 11: Corneal ulcer seen with fluorescein stain




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Figure 12:Dendritic ulcer seen with fluorescein stain





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Figure 13: Corneal foreign body




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Figure 14: Corneal abrasion seen with fluorescein stain





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Figure15: Dry eye (stainedwith rose bengal)




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Figure 16: Anterior uveitis with posterior synechiae





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Figure 17: Angle-closure glaucoma: central corneal oedemawith an oval-shapedmid-dilated pupil




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Figure 18: Penetrating corneal injurywith iris prolapse





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Figure 19: Allergic (vernal) keratoconjunctivitis




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Figure 20: Ectropion





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Figure 21: Gonococcal conjunctivitis

CDC Image Library/JoeMiller



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Figure 22: Gonorrhoeal conjunctivitis: resulted in partial blindness

CDC Image Library




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Figure 23: Conjunctivitis: consequence of reactivearthritis

CDC Image Library/JoeMiller



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This information is not intended to cover all possible diagnosis methods, treatments, follow up, drugs and anycontraindications or side effects. In addition such standards and practices in medicine change as new data becomeavailable, and you should consult a variety of sources. We strongly recommend that users independently verify specifieddiagnosis, treatments and follow up and ensure it is appropriate for your patient within your region. In addition, withrespect to prescription medication, you are advised to check the product information sheet accompanying each drugto verify conditions of use and identify any changes in dosage schedule or contraindications, particularly if the agent tobe administeredis new,infrequently used, or hasa narrow therapeuticrange.You mustalwayscheck thatdrugs referencedare licensed for the specified use and at the specified doses in your region. This information is provided on an "as is" basisand to the fullest extent permitted by law the BMJ Group and its licensors assume no responsibility for any aspect of healthcare administered with the aid of this information or any other use of this information.

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Disclaimer Assessment of redeye

D I S C L A I M E R

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Contributors:

// Authors:

Jonathan Smith, FRCOphth,MRCP

Consultant OphthalmologistSunderland Eye Infirmary, Sunderland, UKDISCLOSURES: JS has received travel and accommodation costs from Novartis when attending professional meetings.

Philip Severn, FRCOphth, MRCP

Consultant Ophthalmologist James Cook University Hospital, Middlesbrough, UKDISCLOSURES: PS declares that he has no competing interests.

LucyClarke, MRCS, FRCOphth

Consultant in OphthalmologyRoyal Victoria Infirmary, Newcastle-upon-Tyne, UKDISCLOSURES: LC declares that she has no competing interests.

// Peer Reviewers:

Michael P. Ehrenhaus, MD

Assistant Professor of OphthalmologyCornea External Disease and Refractive Surgery Local Director, Long Island College Hospital Eye Center, Brooklyn, NYDISCLOSURES: MPE declares that he has no competing interests.

UshaChakravarthy,MBBS,FRCS,PhD

Professor of Ophthalmology and Vision SciencesCentre for Vision Science, Queen's University Belfast, Belfast, UKDISCLOSURES: UC declares that she has no competing interests.

Documents

Approach to a Case of Red Eye