Author:
Franklin D.Friedman
Description
- May be caused by almost any eye disorder
- Often benign; but may represent systemic disease
- Caused by vascular engorgement of conjunctiva
- Main causes:
- Inflammatory
- Allergic
- Infection
- Trauma
- Conjunctivitis is the most common etiology
Etiology
- Inflammatory:
- Uveitis:
- Iritis
- Episcleritis
- Common but generally benign
- Scleritis
- Uncommon, inflammation of the sclera
- Systemic inflammatory reactions
- Allergic:
- Due to histamine release and increased vascular permeability, resulting in:
- Swelling of conjunctiva (chemosis)
- Watery discharge
- Pruritus
- Usually bilateral
- Infectious:
- Keratitis
- Infectious conjunctivitis
- Orbital cellulitis:
- Generally spread from sinus, skin, or blood
- Dacryocystitis:
- As result of lacrimal duct blockage
- Canaliculitis
- Endophthalmitis:
- Intraocular infection, may be post op
- Traumatic:
- Corneal abrasion
- Subconjunctival hemorrhage (SCH)
- Foreign body
- Occult perforation
- Other:
- Pinguecula and pterygium, hemorrhage, blepharitis, dry eye (dysfunctional tear) syndrome, acute angle-closure glaucoma, ophthalmia neonatorum, conjunctival tumor
Signs and Symptoms
History
- Age (especially neonatal and age >50 yr)
- Time of onset, duration of symptoms
- Exposures (i.e., chemicals, allergens)
- Occupation (i.e., metal worker)
- Associated signs and symptoms (headache, systemic symptoms, other infections)
- Ocular symptoms:
- Pain
- Photophobia
- Foreign-body sensation
- Change in vision
- Discharge
- Pruritus
- Contact lens use
- Other comorbidities
Physical Exam
- Thorough physical exam:
- Preauricular or submand ibular 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
Diagnostic 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 d 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, CXR (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
- Assess pH in chemical exposures
Differential Diagnosis
- Local: Infection, allergy, trauma (also see Etiology)
- Acute angle-closure glaucoma
- Systemic (generally an inflammatory reaction):
- Arthritic disease
- Ankylosing spondylosis
- Ulcerative colitis
- Reiter syndrome
- TB
- Herpes
- Syphilis
- Sarcoidosis
- Toxoplasma
- CMV
Prehospital
- Analgesic and comfort measures
- Initiate irrigation for a chemical exposure
- Protective shield if globe penetration
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 not 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:
- Ointment or drops:
- Erythromycin ointment every 4 hr
- Polytrim drops 4 times/d
- Contact lens wearers need pseudomonal coverage:
- 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
- Topical anesthetics may be used for up to 72 hr without impairing corneal epithelial healing
- 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 b.i.d 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
- 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 per day
- Mydriatics and cycloplegics:
- Atropine: 1%, 2%: 1-2 gtt/d to q.i.d
- Cyclopentolate: 0.5%, 1%, 2%: 1-2 gtt p.r.n
- Homatropine: 2%: 1-2 gtt
- Phenylephrine: 0.12%, 2.5%, 10%: 1-2 gtt b.i.d-t.i.d
- Tropicamide: 0.5%, 1%: 1-2 gtt p.r.n
- Corticosteroid antibiotic combination drops (use only with ophthalmology consultation):
- Blephamide: 1-2 gtt q1-8h
- Cortisporin: 1-2 gtt q3-4h
- Maxitrol: 1-2 gtt q1-8h
- Pred G: 1-2 gtt q1-8h
- Tobradex: 1-2 gtt q2-6h
- Glaucoma agents (always use with ophthalmology consultation):
- Acetazolamide: 250-500 mg PO QD-q.i.d
- Betaxolol 0.25%, 0.5%: 1-2 gtt b.i.d
- Carteolol 1%: 1 gtt b.i.d
- Levobunolol 0.25%, 0.5%: 1 gtt QD-b.i.d
- Dipivefrin 1%: 1 gtt b.i.d
- Mannitol: 1-2 g/kg IV over 45 min
- Pilocarpine 0.25%, 0.5%, 1%, 2%, 3%, 4%, 6%, 8%, 10%: 1-2 gtt t.i.d-q.i.d (use only if mechanical closure is ruled out)
- Timolol 0.25%, 0.5%: 1 gtt b.i.d
- Topical anesthetic agent
- Tetracaine hydrochloride ophthalmic solution, 0.5% 1 gtt as needed for no more than 72 hr
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
- BagheriN, WajdaBN. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease. 7th ed.Philadelphia, PA: Wolters Kluwer; 2017.
- JacobsDS. Evaluation of the red eye . UpToDate. Available at http://www.uptodate.com/contents/evaluation-of-the-red-eye. Accessed February 7, 2018.
- SethuramanU, KamatD. The red eye: Evaluation and management . Clin Pediatr. 2009;48:588-600.
- TarffA, BehrensA. Ocular emergencies: Red eye . Med Clin N Am. 2017;101:615-639.
See Also (Topic, Algorithm, Electronic Media Element)