Acute Red Eye

Aka: Acute Red Eye, Red Eye, Eye Redness, Bloodshot Eye

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II. History

  1. Timing
    1. Acute, subacute or chronic
  2. Associated symptoms
    1. Eye Pain
    2. Eye Discharge
    3. Vision Loss or Blurred Vision
    4. Photophobia
  3. Associated Conditions
    1. Systemic symptoms (Autoimmune Conditions or Vasculitis)
    2. Recent illness or infection

III. Exam: Eye

  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)
    3. Visual Fields by confrontation
      1. Defect suggests Retinal, Optic Nerve or CNS injury
  2. Extraocular Movement
    1. Free and painful movement in all directions
    2. Nystagmus
  3. Pupil exam
    1. Evaluate for pupil size and reactivity
    2. Swinging Flashlight Test
  4. Corneal Exam (typically with Slit Lamp)
    1. Ciliary Flush
    2. Fluorescein stain for Corneal Epithelial Disruption
      1. Corneal Abrasion, Corneal Ulcer or Laceration
      2. Keratitis (e.g. Herpes Simplex Keratitis)
    3. Upper Eyelid Eversion for Eye Foreign Body
    4. Chemosis (Corneal swelling)
    5. Corneal clouding
  5. Anterior Chamber Exam (typically with Slit Lamp)
    1. Cells and Flare (Iritis)
  6. Intraocular Pressure (esp. if >20 mmHg)
    1. Glaucoma (especially acute angle closure)
    2. Retrobulbar Hematoma
  7. Other findings
    1. Proptosis
    2. Papilledema (consider Optic Nerve Sheath Diameter)
    3. Eye Discharge
    4. Eye Foreign Body

IV. Differential Diagnosis

  1. Conjunctivitis (scratchy or gritty Sensation)
    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. Blepharitis
  3. Subconjunctival Hemorrhage
  4. Narrow Angle Glaucoma
  5. Iritis
  6. Uveitis
  7. Episcleritis
  8. Scleritis
  9. Corneal Injury or other involvement (foreign body Sensation)
    1. Dry Eye (Keratoconjunctivitis Sicca)
    2. Corneal Abrasion (or Eye Foreign Body)
    3. Keratitis (Corneal Inflammation)
    4. Chemical Eye Injury
  10. Eyelid abnormalities
    1. Entropion
    2. Lagophthalmos (inability to close eye completely, e.g. Bell's Palsy) with globe exposure
    3. Trichiasis
    4. Molluscum Contagiosum
  11. Orbital disorders
    1. Preseptal Cellulitis
    2. Orbital Cellulitis
    3. Idiopathic orbital inflammation
      1. Pseudotumor Cerebri

V. 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

VI. 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. Corneal Keratic Precipitate (Iritis or Uveitis)
    2. Corneal edema
    3. Leukoma
    4. Irregular reflection
    5. Corneal Epithelium disruption (Fluorescein staining)
  5. Eye Pain (especially if severe)
    1. Anterior Uveitis or hypopion
    2. Acute Glaucoma (acute angle closure Glaucoma or Narrow Angle Glaucoma)
    3. Scleritis or Episcleritis
    4. Hyphema
    5. Endophthalmitis
    6. Corneal lesions
      1. Keratitis
      2. Corneal Ulcer (or Corneal Abrasion, Corneal Laceration)
      3. Eye Foreign Body
  6. Anterior chamber abnormalities
    1. Narrow or shallow Anterior Chamber Depth
    2. Blood (Hyphema)
    3. Pus (Hypopyon)
  7. Proptosis or external swelling
    1. Blepharitis
    2. Hordeolum or Chalazion
    3. Dacryocystitis or Dacryoadenitis
    4. Periorbital Cellulitis
  8. 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

VII. References

  1. Williams (2017) Crit Dec Emerg Med 31(2): 3-12
  2. Cronau (2010) Am Fam Physician 81(2): 137-45 [PubMed]
  3. Galor (2008) Cleve Clin J Med 75(2): 137-44 [PubMed]
  4. Wirbelauer (2006) Am J Med 119(4): 302-6 [PubMed]

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