SIGNS AND SYMPTOMS 
History
- Age (especially neonatal and age > 50 yr)
- Time of onset, duration of symptoms
- Exposures (i.e., chemicals, allergens)
- Patient's occupation (i.e., metal worker)
- Associated signs and symptoms (headache, systemic symptoms, other infections)
- Ocular symptoms:
- Pain
- Foreign-body sensation
- Change in vision
- Discharge
- Pruritus
- Contact lens use
- Other comorbidities
Physical Exam
- Thorough physical exam:
- Preauricular or submandibular adenopathy
- Rosacea (may cause blepharitis)
- Facial or skin lesions (herpes)
- Ophthalmologic:
- Visual acuity
- General appearance:
- Universal eye redness or locally
- Conjunctival injection
- Lid involvement
- Purulent or clear discharge
- Obvious foreign body
- Proptosis
- Photophobia
- Eyelash against globe (trichiasis)
- Pupil exam
- Confrontational visual field exam
- Extraocular muscle function
- Slit-lamp exam with fluorescein:
- Anterior chamber cell or flare
- Pinpoint or dendritic lesions in HSV
- Corneal abrasion
- Foreign body
- Lid eversion
- Fundoscopy and tonometry
ESSENTIAL WORKUP
- Consider systemic causes of red eye
- Physical exam as described above
DIAGNOSIS TESTS & INTERPRETATION
Tests should be directed toward the suspected etiology of red eye:
- Dacryocystitis: Culture discharge
- Corneal ulcers: Scrape cornea for culture (often is performed by ophthalmologist)
- Bacterial conjunctivitis:
- Moderate discharge: Obtain conjunctival swab for routine culture and sensitivity (usually Staphylococcus aureus, Streptococcus, and Haemophilus influenzae in unvaccinated children); however, not always needed, as conjunctivitis is often treated presumptively
- Severe discharge: Neisseria gonorrhoeae
- Note special culture media and procedures depending on suspected etiology (i.e., Thayer–Martin plate for GC)
Pediatric Considerations
- Chlamydia trachomatis is the most common neonatal infectious cause of conjunctivitis (monocular or bilateral, purulent or mucopurulent discharge)
- N. gonorrhoeae is the other neonatal infectious etiology; typically presents within 2–4 days after birth; marked purulent discharge, chemosis, and lid edema
- Complications may be severe
Lab
- Often not indicated
- Useful if etiology is thought to be systemic disease
- If bilateral, recurrent, granulomatous uveitis is suspected, send CBC, ESR, antinuclear antibody, VDRL, fluorescent treponemal antibody–absorption, purified protein derivative, ACE level, chest x-ray (sarcoidosis and tuberculosis), Lyme titer, and HLA-B27, Toxoplasma, and cytomegalovirus (CMV) titers
Imaging
Obtain plain films and/or CT scan of the orbits if suspect foreign body, orbital disease, or trauma
Diagnostic Procedures/Surgery
- Tonometry if glaucoma considered
- Slit-lamp exam with cobalt blue light and fluorescein:
- Wood lamp exam with fluorescein in young children
- Removal of simple corneal foreign bodies
DIFFERENTIAL DIAGNOSIS
- Local: Infection, allergy, trauma (also see Etiology)
- Acute angle-closure glaucoma
- Systemic (generally an inflammatory reaction):
[Outline]
PRE-HOSPITAL
- Analgesic and comfort measures
- Initiate irrigation for a chemical exposure
INITIAL STABILIZATION/THERAPY
- Removal of contact lenses if applicable
- Irrigation for chemical insult
- Treat systemic illness if applicable
ED TREATMENT/PROCEDURES
- Direct therapy toward specific etiology
- Medication as indicated
- Special reminders:
- Differentiate between a corneal abrasion and a corneal ulcer
- Eye patching is no longer recommended and often contraindicated for abrasions
- Update tetanus immunization for injury
- Refrain from contact lens use
- Do not spread infection to the unaffected eye or to unaffected individuals
- Diagnosis of conjunctivitis caused by N. gonorrhoeae or C. trachomatis requires treatment of systemic infection for the individual and the source individual(s)
- Always include workup and treatment of systemic disease if this is suspected
Special Topics
Corneal Abrasion
- Noncontact lens wearer:
- Contact lens wearers need pseudomonal coverage:
- Tobramycin, ofloxacin, or ciprofloxacin drops 4 times/d
- Dilate eyes with cyclopentolate 1–2%, 2–4 gtt daily to prevent pain from iritis
- Abrasions will heal without patching
- Systemic analgesics, opiate, or nonopiate
- Re-evaluation if symptomatic at 48 hr
Corneal Ulcer
- Noncontact lens wearer:
- Polytrim ointment 4 times/d
- Ofloxacin, ciprofloxacin drops q2–4h
- Contact lens wearers need pseudomonal coverage (see above)
Severe or Vision-threatening Corneal Ulcers
- Central > 1.5 mm or with significant anterior chamber reaction
- Treat as aforementioned and add increased frequency of antibiotic drops such as 1–2 gtt every 15 min for 6 hr, then every 30 min around the clock
- Ophthalmology consult for further recommendations, which may include ciprofloxacin 500 mg PO BID or fortified antibiotic drops made by pharmacist
- Hospitalization is often recommended in consultation with ophthalmologist
Acute Angle-closure Glaucoma
- Symptoms typically include rapid onset, severe eye pain, redness, decreased vision, and pupil in mid-dilation and unreactive
- Other symptoms may include:
- Nausea and vomiting
- Headache
- Blurred vision and/or seeing halos around light
- Increased tearing
- Diagnosis is further suspected when tonometry detects elevated eye pressure (> 21 mm Hg)
Subconjunctival Hemorrhage
- If large and in the setting of trauma exclude penetrating injury to the globe
- For minor SCH reassure, comfort measures and lubricating drops may speed recovery
Herpes Simplex or Zoster
- Add trifluridine (viroptic) 1%, 2 gtt 9 times/d or vidarabine 3% ointment 5 times/d (ointment preferred for children)
- Ophthalmology consultation
Pediatric Considerations
Herpes infections:
- Usually associated with HSV2 infections
- May be associated with encephalitis or as an isolated lesion
- Neonate onset occurs 1–2 wk after birth
- Presentation: Generally monocular, serous discharge, moderate conjunctival injection
ALERT
Ocular HSV infection carries significant risk of vision loss
Trauma or Uveitis
Rule out foreign body
MEDICATION
- Antibiotic drops:
- Ciprofloxacin 0.3%: 1–2 gtt q1–6h
- Gentamicin 0.3%: 1–2 gtt q4h
- Ofloxacin 0.3%: 1–2 gtt q1–6h
- Polytrim: 1 gtt q3–6h
- Sulfacetamide 10%: 0.3% 1–2 gtt q2–6h
- Tobramycin 0.3%: 1–2 gtt q1–4h
- Trifluridine 1%: 1 gtt q2–4h
- Antibiotic ointments (ophthalmic):
- Bacitracin: 500 U/g ½ in ribbon q3–6h
- Ciprofloxacin 0.3%: ½ in ribbon q6–8h
- Erythromycin 0.5%: ½ in ribbon q3–6h
- Gentamicin 0.3%: ½ in ribbon q3–4h
- Neosporin: ½ in ribbon of ointment q3–4h
- Polysporin: ½ in ribbon of ointment q3–4h
- Sulfacetamide 10%: ½ in ribbon of q3–8h
- Tobramycin 0.3%: ½ in ribbon q3–4h
- Vidarabine: ½ in ribbon 5 times/d
- Mydriatics and cycloplegics:
- Corticosteroid antibiotic combination drops (use only with ophthalmology consultation):
- Glaucoma agents (always use with ophthalmology consultation):
- Acetazolamide: 250–500 mg PO QD–QID
- Betaxolol 0.25%, 0.5%: 1–2 gtt BID
- Carteolol 1%: 1 gtt BID
- Levobunolol 0.25%, 0.5%: 1 gtt QD–BID
- Dipivefrin 1%: 1 gtt BID
- Mannitol: 1–2 g/kg IV over 45 min
- Pilocarpine 0.25%, 0.5%, 1%, 2%, 3%, 4%, 6%, 8%, 10%: 1–2 gtt TID–QID (use only if mechanical closure is ruled out)
- Timolol 0.25%, 0.5%: 1 gtt BID
[Outline]
DISPOSITION
Admission Criteria
- Endophthalmitis
- Perforated corneal ulcers
- Orbital cellulitis
- Concurrent injuries (e.g., trauma)
- If indicated for systemic disease
Pediatric Considerations
Neonates with conjunctivitis suspected to be due to N. gonorrhoeae should be hospitalized for IV antibiotics (cefotaxime), and consideration should be given to septic workup
Discharge Criteria
Ability to follow outpatient instructions
Issues for Urgent Referral
- Dacryocystitis
- Corneal ulcer
- Scleritis
- Angle-closure glaucoma
- Uveitis
- Proptosis
- Orbital cellulitis
- Vision loss
- Uncertain diagnosis
- Gonorrheal or chlamydial conjunctivitis
FOLLOW-UP RECOMMENDATIONS
- Prompt re-evaluation if symptoms not resolving over expected time course
- Avoid use of contact lenses until approved by ocular specialist.
[Outline]
- Gerstenblith AT, Rabinowitz MP. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2012.
- Mahmood AR, Narang AT. Diagnosis and management of the acute red eye. Emerg Med Clin North Am. 2008;26:35–55.
- Roscoe M, Landis T. How to diagnose the acute red eye with confidence. JAAPA. 2006;19:24–30.
- Sethuraman U, Kamat D. The red eye: Evaluation and management. Clin Pediatr (Phila). 2009;48:588–600.
- Wirbelauer C. Management of the red eye for the primary care physician. Am J Med. 2006;119:302–306.
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