Acute Red Eye

Aka: Acute Red Eye

1. Differential Diagnosis
   1. Conjunctivitis (Infectious and Noninfectious)
      1. Hyperacute Bacterial Conjunctivitis (Gonorrhea)
      2. Acute Bacterial Conjunctivitis (e.g. Staphylococcus aureus, Streptococcus Pneumoniae)
      3. Viral Conjunctivitis (e.g. Adenovirus, enterovirus, coxsackievirus, VZV, HSV)
      4. Chlamydia Conjunctivitis (Inclusion Conjunctivitis)
      5. Allergic Conjunctivitis
   2. Dry eye (Keratoconjunctivitis Sicca)
   3. Blepharitis
   4. Corneal Abrasion (or Eye Foreign Body)
   5. Subconjunctival Hemorrhage
   6. Narrow Angle Glaucoma
   7. Iritis
   8. Uveitis
   9. Keratitis (Corneal Inflammation)
   10. Episcleritis
   11. Scleritis
   12. Chemical Eye Injury
   13. Eyelid abnormalities
       1. Entropion
       2. Lagophthalmos with globe exposure
       3. Trichiasis
       4. Molluscum Contagiosum
   14. Orbital disorders
       1. Preseptal and Orbital Cellulitis
       2. Idiopathic orbital inflammation
          1. Pseudotumor Cerebri
2. Indications: Ophthalmology consultation
   1. Symptoms suggesting need for emergent or urgent ophthalmology evaluation
      1. Moderate to severe Eye Pain and
      2. Vision Loss
      3. Irregular pupil
      4. Corneal involvement
      5. Blurred vision with photophobia
   2. Acute Conditions prompting emergent or urgent ophthalmology evaluation
      1. Herpes Keratitis (HSV)
      2. Hyperacute Bacterial Conjunctivitis (Gonorrhea)
      3. Iritis
      4. Uveitis
      5. Keratitis
      6. Acute angle Glaucoma
      7. Scleritis
      8. Corneal Ulcer
      9. Eye Trauma
      10. Eye Chemical Burn
   3. Other conditions where routine ophthalmology evaluation should be considered
      1. Episcleritis
      2. Dry eye
      3. Blepharitis
3. Exam
   1. Visual Acuity (always)
      1. Consider Topical Eye Anesthetic first if light sensitive
      2. Delay only in cases of Chemical Eye Injury (irrigation precedes acuity exam)
   2. Visual fields by confrontation
      1. Defect suggests Retinal, Optic Nerve or CNS injury
   3. Pupil exam
      1. Evaluate for pupil size and reactivity
      2. Swinging Flashlight Test
   4. Corneal examination
      1. Ciliary Flush
      2. Fluorescein stain for Corneal Epithelial Disruption
      3. Upper Eyelid Eversion for Eye Foreign Body
   5. Intraocular Pressure
   6. Findings
      1. Eye Discharge
      2. Eye Foreign Body
      3. Corneal Abrasion or Laceration
4. Evaluation
   1. Evaluate Visual Acuity
      1. Normal Vision
         1. Conjunctivitis
         2. Corneal Abrasion
      2. Decreased Vision
         1. Narrow Angle Glaucoma
         2. Uveitis
      3. Acute Loss of Vision
         1. Optic Nerve disease
         2. Retinal Detachment
         3. Vitreous Hemorrhage
         4. Giant Cell Arteritis
         5. Central Retinal Artery Occlusion
   2. Determine Eye Anatomy involved
      1. Subconjunctival Hemorrhage
      2. Conjunctival Hyperemia
         1. Focal hyperemia suggests Episcleritis
      3. Ciliary Flush
   3. Conjunctival Eye Discharge
      1. No discharge
         1. Episcleritis
         2. Subconjunctival Hemorrhage
      2. Intermittent discharge
         1. Dry eye (Keratoconjunctivitis Sicca)
      3. Continuous discharge
         1. Profuse discharge
            1. Gonorrhea
         2. Serous discharge (watery, clear or yellow tinged)
            1. Mild or no eye itch: Viral Conjunctivitis
            2. Significant eye itch: Allergic Conjunctivitis
         3. Purulent discharge (creamy white or yellowish) or Mucoid discharge (Scant, white, stringy exudate)
            1. Chlamydia Conjunctivitis
            2. Acute Bacterial Conjunctivitis
   4. Corneal Opacities or irregularities in surface
      1. Keratic precipitates
      2. Corneal edema
      3. Leukoma
      4. Irregular reflection
      5. Corneal Epithelium disruption (Fluorescein staining)
   5. Eye Pain
      1. Uveitis
      2. Acute Glaucoma
      3. Scleritis
      4. Corneal lesions (Keratitis, Corneal Ulcer, Eye Foreign Body)
   6. Anterior chamber abnormalities
      1. Narrow or shallow Anterior Chamber Depth
      2. Blood (Hyphema)
      3. Pus (Hypopyon)
   7. Other Findings
      1. Pupil Irregularity in size and reactivity
      2. Intraocular Pressure with Schiotz tonometer
         1. Omit for obvious infection
      3. Detect Proptosis
      4. Limited Extraocular Movements
5. References
   1. Cronau (2010) Am Fam Physician 81(2): 137-45
   2. Galor (2008) Cleve Clin J Med 75(2): 137-44
   3. Wirbelauer (2006) Am J Med 119(4): 302-6