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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Related Studies

Ontology: Bloodshot eye (C0005858)

Concepts Sign or Symptom (T184)
SnomedCT 73009009, 246676003
English Bloodshot eyes, Bloodshot eye, blood shot eyes, bloodshot eyes (symptom), bloodshot eyes, bloodshot eye, eye bloodshot, blood eyes shot, blood shot eye, eye blood shot, eyes bloodshot, Red eye, Bloodshot eye (finding), Eye blood shot
Dutch oog bloeddoorlopen, bloeddoorlopen oog
French Oeil injecté de sang
German Auge blutunterlaufen, blutunterlaufenes Auge
Italian Occhio iniettato di sangue
Portuguese Olho injectado de sangue, Olho raiados de sangue
Spanish Ojo inyectado de sangre, ojos inyectados en sangre (hallazgo), ojos inyectados en sangre, ojo rojo, ojo inyectado en sangre, ojo inyectado en sangre (hallazgo)
Japanese 充血した眼, ｼﾞｭｳｹﾂｼﾀﾒ
Czech Krví podlité oko, Oko podlité krví
Hungarian Véraláfutásos szem, Szem véraláfutása
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Redness of eye (C0235267)

Definition (NCI) Lay term applied to any condition with dilation of conjunctival or ciliary blood vessels; innumerable causes, especially irritation and infection.
Definition (NCI_FDA) Lay term applied to any condition with dilation of conjunctival or ciliary blood vessels; innumerable causes, especially irritation and infection.
Concepts Sign or Symptom (T184)
SnomedCT 75705005, 194188000, 703630003
English RED EYE, Redness of eye NOS, Red Eye, Redness of eye, red eyes (symptom), red eye, red eyes, Redness;eyes, eye redness, eyes redness, redness of eye, Redness of eye NOS (disorder), EYE(S), RED, RED EYE(S), Red eye (finding), Red eye, Red eye (disorder), eye; red, red; eye, Eye red, Eyes red, Eye redness, Redness of eyes, redness of the eyes
Dutch oog roodheid, oog rood, roodheid van de ogen, ogen rood, rood oog, Rood oog, oog; rood, rood; oog
French Yeux rouges, Rougeur oculaire, Rougeur des yeux, Oeil rouge, OEIL ROUGE
German Augen rot, Roetung der Augen, rotes Auge, Auge rot, Augenroetung, AUGENROETUNG
Italian Occhio rosso, Arrossamento degli occhi, Arrossamento oculare, Occhi rossi
Portuguese Olhos vermelhos, Olho vermelho, Vermelhidão dos olhos, Vermelhidão ocular, OLHO VERMELHO
Spanish Ojos rojos, Enrojecimiento de los ojos, Ojo rojo, Ojo enrojecido, OJO ROJO, eritema ocular, SAI (trastorno), eritema ocular, SAI, eritema ocular, flogosis ocular, irritación del ojo (trastorno), irritación del ojo, irritación ocular, ojo eritematoso, ojo rojo
Czech Červené oko, Zarudnutí očí, Zarudlé oko, Červené oči
Japanese ﾒﾉﾎｯｾｷ, ﾒﾉｱｶﾐ, 眼の発赤, ﾒﾉﾊｯｾｷ, 眼の赤み, 赤目, ｱｶﾒ
Hungarian Szemvörösség, Vörös szemek, Vörös szem, Szemek vörössége
Derived from the NIH UMLS (Unified Medical Language System)

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