The American Journal of Medicine (2006) 119, 302-306
`
`ELSEVIER
`
`UPDATE IN OFFICE MANAGEMENT
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`THE AMERICAN
`JOURNAL of
`MEDICINE@
`
`Management of the Red Eye for the Primary Care
`Physician
`
`Christopher Wirbelauer, MD
`Klinik für Augenheilkunde, Vivantes Klinikum Neukölln, Berlin.
`
`ABSTRACT
`
`For the primary care physician, the occurrence of a red eye is a frequent and prominent finding of a disease
`process in patients. A careful history and simple examination with the observation of typical clinical signs
`are important for the management of this common disorder. The causes can be classified as painful red eye,
`trauma, and other common conditions. The most frequent causes of a red eye, such as dry eye, conjunc-
`tivitis, keratitis, iritis, acute glaucoma, subconjunctival hematoma, foreign bodies, corneal abrasion, and
`blunt or penetrating trauma, are described in this article. Simple diagnostic methods and an emergency
`management with some useful topical ophthalmic preparations are included. Although several conditions
`can be treated by the primary care physician the clinical signs that require an urgent ophthalmic
`consultation are chemical burns, intraocular infections, globe ruptures or perforations, and acute glaucoma.
`© 2006 Elsevier Inc. All rights reserved.
`
`KEYWORDS: Red eye; Primary care; Emergency; Management; Ophthalmology
`
`A red eye usually mirrors the possible reactions of the eye
`to exogenous or endogenous irritations and trauma, and
`gives indications of possible systemic and ocular diseases.
`The primary aim of the management of this common dis-
`order should be the differentiation of the symptom of red
`eye and the assessment of the underlying disease.
`The causes of a red eye can be numerous and can occur
`as an ophthalmic emergency within minutes or hours but
`also as a chronic disease over weeks or months. In general,
`redness of the eye can be caused by hyperemia with dilation
`of the conjunctival, episcleral, or scleral vessels (trauma,
`chemical burns, immunologic reactions); inflammatory re-
`actions from infections (bacterial, viral, fungal); or chronic
`reactions of the external eye from systemic causes (Sjör-
`gen’s syndrome).
`Most causes of eye redness can be recognized by taking
`a careful history and performing simple examinations with
`the following main questions:
`
`Requests for reprints should be addressed to Christopher Wirbelauer,
`MD, Klinik für Augenheilkunde, Vivantes Klinikum Neukölln, Rudower
`Str. 48, D-13353 Berlin, Germany.
`E-mail address: christopher.wirbelauer@vivantes.de.
`
`0002-9343/$ -see front matter © 2006 Elsevier Inc. All rights reserved.
`doi:10.1016/j.amjmed.2005.07.065
`
`● Association with pain
`● History of preceding trauma
`● Seasonal or recurrent occurrence (allergic reactions, iritis)
`● Changes in the eye lid (contact dermatitis, ocular rosacea,
`pemphigoid)
`● Use of eye drops (glaucoma, dry eye)
`
`The assessment of clinical signs should include the an-
`atomic location of redness (eyelids, conjunctiva, cornea,
`sclera and episclera, or intraocular); symptoms in one or
`both eyes; possible associated symptoms (pain, itching, vi-
`sual decrease or loss); and further prominent ocular (muco-
`purulent discharge, watering, blepharospasm, lagophthal-
`mus) or systemic (fever, nausea) findings.
`In particular, the occurrence of ocular pain is an impor-
`tant indicator. Pain can have several sources, originating
`from the eye itself or the periocular region. Painful symp-
`toms can be projected to the eye from other regions. Typical
`causes are changes of the eyelids, ocular muscles, cornea,
`sclera, uvea, or optical nerve. Frequent pain-associated syn-
`dromes are migraine, cluster headache, arteriitis temporalis
`(M. Horton), and zoster or trigeminus neuralgia.
`The most frequent causes of a red eye (Table 1) are
`described here with simple diagnostic methods. Emergency
`
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`Wirbelauer Management of the Red Eye
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`303
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`management with some useful topical ophthalmic prepara-
`tions are included (Table 2). The causes are grouped as
`painful red eye, trauma, and other common conditions.
`
`CLINICAL SIGNIFICANCE
`
`● Red eye symptoms are common.
`● Most causes can be well managed with
`topical therapy, such as eye drops.
`● The most serious causes are associated
`with pain or trauma.
`● Chemical burns and penetrating injuries
`to the eye should be immediately re-
`ferred to an ophthalmologist.
`
`son spread unless scrupulous care is taken with hand wash-
`ing. Watery discharge, often bilateral, and swollen
`preauricular and submandibular lymph nodes (lymphadeni-
`tis) confirm the viral infection. Give antibiotic drops to
`prevent secondary bacterial infection and treat with artificial
`tears. Refer the patient to an oph-
`thalmologist to monitor for the de-
`velopment of keratitis, which can
`develop after 1 week. The symp-
`toms usually are relieved within 2
`weeks.
`A special case is herpes zoster
`conjunctivitis. The onset is similar
`but is presumed to originate in the
`nerve root. Therefore, it typically
`presents as uniocular involvement
`with a dermatitis similar to shin-
`gles in the distribution of the tri-
`geminal nerve. This presents as a
`vesicular rash over the distribution
`of the ophthalmic division of the
`trigeminal cranial nerve. Pain and
`tingling often precede the rash. The patient is usually unwell
`and in pain. The eye may be affected, resulting in blepha-
`ritis, conjunctivitis, keratitis, uveitis, secondary glaucoma,
`ophthalmoplegia, or optic neuritis. The cornea (keratitis) is
`involved in particular when the tip of the nose is involved
`(Hutchinson sign), because both regions are supplied by the
`nasociliary nerve. The associated keratitis with inflamma-
`tion and disruption of the cornea or anterior uveitis (inflam-
`mation of the anterior segment of the eye) can lead to
`
`PAINFUL RED EYE
`Conjunctivitis
`The causes to consider in patients
`with suspected acute conjunctivi-
`tis are allergic; bacterial (staphy-
`lococci, pneumococci, gonococci,
`haemophilus); viral (adenovirus,
`herpes viruses); and chlamydial.
`The most prominent signs are gen-
`eralized
`conjunctival
`injection
`with gritty discomfort, mild pho-
`tophobia, and variable discharge
`but no loss of visual acuity.
`Allergic conjunctivitis usually
`presents with itching tearing, large
`cobblestone papillae under the up-
`per lid, and conjunctival swelling
`(chemosis), which may assume alarming proportions. It
`usually responds rapidly to topical antihistamines and va-
`soconstrictors. Steroid eye drops also might be indicated but
`must be prescribed by an ophthalmologist. Secondary bac-
`terial
`infection should be prevented with antibiotic eye
`drops.
`The leading symptoms of bacterial conjunctivitis are
`conjunctival redness and mucopurulent discharge, which
`requires frequent antibiotic drops (as often as hourly in
`severe cases) and ointment at night. Clean away the dis-
`charge with moist cotton balls and refer the patient to an
`ophthalmologist if the infection does not settle. However,
`swabs for further bacterial diagnostics are rarely needed.
`Viral
`conjunctivitis
`(epidemic
`keratoconjunctivitis)
`caused by adenovirus (type 8) presents with marked dis-
`comfort and is highly contagious with rapid person-to-per-
`
`Table 1
`
`Causes and Differential Diagnosis of the Red Eye
`
`● Painful red eye
`Conjunctivitis
`Episcleritis and scleritis
`Keratitis and corneal ulcer
`Iritis and intraocular infections
`(endophthalmitis)
`Glaucoma (acute and chronic)
`● Traumatic conditions
`Subconjunctival hematoma (hyposphagma)
`Corneal and conjunctival foreign body
`Corneal abrasion
`Corneal flash burn
`Chemical burns
`Blunt or penetrating trauma to the eye
`● Other common conditions
`Dry eye
`Blepharitis
`
`Table 2
`Patching
`
`Useful Topical Ophthalmic Preparations and Eye
`
`● Antibiotic eye drops or ointment, eg, 0.5%
`chloramphenicol, gentamicin, erythromycin, or
`ofloxacin. Usually first use a broad-spectrum antibiotic
`with an application four times per day to the lower
`conjunctival sac. Ointments are preferably used at
`night.
`● Local anesthetic, eg, proparacaine. Do not use over longer
`periods because of corneal toxicity.
`● Fluorescein corneal stain.
`● Mydriatics, eg, tropicamide (short acting). Do not use in
`patients with suspected acute glaucoma to avoid
`precipitating effects.
`● Miotics, eg, 1% or 2% pilocarpine.
`● Steroid preparations should generally not be used without
`an ophthalmic consultation because of possible
`aggravation of inflammation or induction of glaucoma.
`However, a combined preparation of antibiotics and
`steroids is often useful.
`● Eye patch: double-patch technique is common to
`immobilize lid margin to minimize pain and recurrent
`irritation of large abrasions.
`● Eye shield: used to prevent pressure or contact to the eye
`when a globe rupture is suspected.
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`304
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`The American Journal of Medicine, Vol 119, No 4, April 2006
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`Start antibiotic eye drops or acyclovir ointment, and refer
`the patient to an ophthalmologist. Steroid eye drops are
`absolutely contraindicated in these cases. Corneal destruc-
`tion and perforation with visual
`loss or blindness are
`possible.
`
`Iritis and Intraocular Inflammations
`(Endophthalmitis)
`Iritis can be caused by exogenous infection from a perfo-
`rating wound or corneal ulcer. Otherwise, it represents an
`ill-understood endogenous mechanism linked with human
`leukocyte antigen-B27 and seronegative arthropathy, as in
`ankylosing spondylitis, Reiter’s syndrome, ulcerative coli-
`tis, Crohn’s disease, and Still’s disease. Other possible
`causes include sarcoidosis,
`toxoplasmosis,
`tuberculosis,
`syphilis, and herpes zoster ophthalmicus.
`In acute iritis there is a marked ciliary injection, constant
`pain also into the brow or temple developing over hours,
`blurred vision, and photophobia. The pupil contracts (mio-
`sis) and tiny aggregates of cells may be seen on the inner
`surface of the cornea (keratitic precipitates). In severe cases,
`an exudate can form in the anterior eye chamber (hy-
`popyon), and the iris may adhere to the anterior lens surface,
`causing posterior synechiae.
`In acute iritis the patient should be counseled by an
`ophthalmologist for treatment with steroid eye drops and
`cycloplegics to prevent posterior and anterior synechiae,
`which can lead to cosmetic and visual defects. Iritis may
`also become recurrent and further progress to secondary
`glaucoma.
`
`Glaucoma (Acute and Chronic)
`Acute glaucoma is associated with a narrowed anterior
`chamber with obstruction of the outflow of aqueous hu-
`mour, which leads to a massive increase in intraocular
`pressure. It is more common in middle-aged or elderly
`hypermetropes (long-sighted persons) and East-Asians, and
`is precipitated by pupillary dilatation. There is severe throb-
`bing, boring pain accompanied by nausea, vomiting, and
`prostration. Visual acuity is markedly reduced with halos
`around lights. On examination, the eye is reddened and the
`cornea becomes hazy with a fixed, semidilated oval pupil.
`On gentle palpation the eye feels hard because of increased
`intraocular pressure.
`Acute glaucoma is an ocular emergency with impending
`blindness if untreated. This condition requires urgent refer-
`ral to an ophthalmologist. If the symptoms are clearly de-
`fined, therapy can be started with miotic drops such as
`pilocarpine 1% or 2% every 5 minutes for up to 1 hour.
`Acetazolamide (carboanhydrase inhibitor) 500 to 1000 mg
`orally or slowly intravenously (IV), an antiemetic such as
`metoclopramide 10 mg IV, analgesia for severe pain, and in
`some cases hyperosmotic agents (1 mL/kg 50% glycerol by
`mouth if not vomiting, 1-2 g/kg mannitol IV, or both) may
`be needed. The definitive therapy consists of peripheral
`laser or surgical iridectomy.
`
`Figure 1
`Typical clinical picture of redness caused by episcle-
`ritis (note the dilated conjuctival and episcleral vessels).
`
`blindness if untreated. Therefore, always refer the patient to
`an ophthalmologist for consultation. Systemic treatment
`with acyclovir 800 mg orally 5 times daily with 3% acy-
`clovir ophthalmic ointment decreases pain, corneal damage,
`and uveitis.
`Chlamydial conjunctivitis usually occurs in young adults
`causing chronic bilateral conjunctivitis with mucopurulent
`discharge. The cornea may be involved (keratitis). The
`diagnosis is difficult but should be suspected when conven-
`tional antibiotic therapy fails. Associated urethritis or sal-
`pingitis may suggest the cause. Treat with oral tetracycline.
`
`Episcleritis and Scleritis
`Episcleritis is a localized inflammation beneath the conjunc-
`tiva adjacent to the sclera (Figure 1), whereas scleritis is a
`more painful localized inflammation of the sclera itself.
`Rheumatoid arthritis may be associated. The eye is locally
`red and sore with reflex watering but no discharge. Progres-
`sion to eyeball perforation can occur in scleritis.
`Test blood samples for white blood count, sedimentation
`rate, and rheumatoid factor. Start a nonsteroidal anti-inflam-
`matory agent such as diclofenac 50 mg orally 3 times per
`day. Refer the patient to an ophthalmologist for definitive
`treatment, including nonsteroidal or steroid eye drops.
`
`Keratitis and Corneal Ulcer
`Keratitis is an inflammation of the cornea with many pos-
`sible causes, including viruses such as herpes simplex and
`adenovirus, bacterial infection of a corneal ulcer, abrasion,
`exposure, or contact lens wear. The distinguishing feature
`from conjunctivitis is the prominent pain with diminution of
`vision if there is a central ulcer or exudate in the anterior eye
`chamber (hypopyon). The ulcer may be seen as white floc-
`culent infiltrate. Cultures should be taken before starting
`local antibiotic therapy.
`Fluorescein staining will demonstrate a marginal or cen-
`tral ulcer. In herpes simplex keratitis the ulcer is typically
`branching or dendritic, and corneal sensation is decreased.
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`those with extensive rust rings should be removed by an
`ophthalmologist.
`After foreign body removal, the application of antibiotic
`ointment is recommended, and the patient should be re-
`viewed within 2 days to exclude an infection. In more
`severe cases, a short-acting cycloplegic to relieve ciliary
`spasm may be needed.
`
`Corneal Abrasion
`Corneal abrasion is usually caused by a foreign body or
`direct injury from a finger, stick, or piece of paper. There is
`intense pain, watering, and blepharospasm. Local anesthetic
`eye drops may be needed before the eye can be opened
`properly. Fluorescein staining can reveal the epithelial dam-
`age of the cornea. Although an eye patch is no longer
`recommended, antibiotic eye drops or ointment should be
`applied to prevent an infection.
`The cornea should be healed within 1 to 2 days, but if
`there is delayed healing or a recurrence, refer the patient to
`an ophthalmologist.
`
`Corneal Flash Burn
`Corneal flash burn is a superficial keratitis that occurs after
`extensive exposure to ultraviolet light, from welding, ski-
`ing, or a sun lamp without using protective goggles. There
`is intense pain, burning, blurred vision, watering, and bleph-
`arospasm occurring after a delay of a few hours. Diffuse
`corneal haziness and fluorescein staining reveals a pitted
`corneal surface. Double-patch the eyes for pain relief. Dim
`lighting and systemic analgesics are recommended. Recov-
`ery usually occurs within 12 to 24 hours.
`Remember that topical anesthetics should not be applied
`in repeated doses because most are also cellular toxins and
`will retard healing, as well as prevent natural reflexes of the
`cornea to protect against further damage.
`
`Chemical Burns
`In chemical burns, alkalis are far more dangerous than
`acids, and include common agents such as cement, plaster
`powder, oven cleaner, and drain cleaner. Alkali burns pro-
`duce a liquefaction necrosis of the conjunctiva and cornea,
`which continue to dissolve soft tissue until completely re-
`moved. Acid burns produce a coagulation necrosis of the
`cornea, and further invasion of the eye structures is limited
`by this process. The treatment priority is immediate, copi-
`ous, prolonged irrigation with normal saline, and local an-
`esthetic eye drops may initially be needed. It is important to
`evert the upper eyelids to remove any particulate matter and
`to irrigate the superior fornix of the conjunctiva. Also, radial
`conjunctival incisions might be needed for faster removal of
`the agents. Refer the patient as soon as possible to an
`ophthalmologist for further examination.
`
`Blunt or Penetrating Trauma to the Eye
`Injury to the eye should always be considered in any trauma
`to the face. It must not be forgotten when other injuries
`
`Figure 2
`Typical clinical picture caused by a subconjunctival
`hematoma (hyposphagma).
`
`Chronic open-angle glaucoma also leads to a mild in-
`crease in intraocular pressure and possible eye redness, but
`the changes occur over several months or years leading to
`optic nerve damage, scotomas, and loss of peripheral vision.
`This is not an emergency condition.
`
`TRAUMATIC CONDITIONS
`Subconjunctival Hematoma (Hyposphagma)
`Two types of subconjunctival hematoma can be presented:
`spontaneous and traumatic. In spontaneous cases with no
`other subjective complaints, this may arise from coughing
`and straining or from atherosclerotic vessels, particularly in
`the elderly, and can be associated with hypertension or a
`bleeding diathesis (Figure 2). Check the blood pressure and
`reassure the patient that the blood will disperse within 2
`weeks. No further treatment is needed.
`In traumatic cases this may be the result of a blunt
`trauma, a surface conjunctival foreign body, or a penetrating
`injury. Gentle digital assessment may reveal reduced eye-
`ball tone, such as in penetrating globe injuries. All patients
`with a suspected serious cause as mentioned above should
`immediately be referred to an ophthalmologist.
`
`Corneal and Conjunctival Foreign Body
`Usually a piece of grit blows in the eye causing pain,
`redness, and watering. The object might be easily seen by
`direct observation and can be removed with a moistened
`cotton tip after applying a local anesthetic. An eye pad is
`then worn until the return of normal sensation. If the object
`affects the upper subtarsal conjunctiva, nothing will be seen
`immediately, but the eye will be red and painful to blink.
`Fluorescein staining will reveal linear corneal abrasions. In
`these cases, the upper eyelid must be everted for full in-
`spection and to remove the foreign body. Remember that
`eyelashes are common foreign bodies and should not be
`missed. However, deep or recalcitrant foreign bodies and
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`appear more dramatic or when periorbital edema obscures
`the eye. Blunt trauma may cause a sequence of minor or
`more relevant injuries, such as periorbital hematoma, sub-
`conjunctival hemorrhage, corneal abrasion or laceration,
`bleeding into the anterior chamber (hyphema), a fixed pupil
`(traumatic mydriasis) or torn iris (iridodialysis), a dislocated
`lens or traumatic cataract, vitreous hemorrhage, a retinal
`tear with retinal detachment, retinal edema, or optic nerve
`damage with unresponsive pupil to direct light. A ruptured
`globe with marked visual loss with a soft eye and a shallow
`anterior chamber, and an orbital fracture with a typical
`“blow-out” fracture of the orbital floor are possible. All of
`these conditions require immediate examination by an oph-
`thalmologist. The patient should lie quietly semi-upright.
`Apply a sterile eye shield, and give appropriate analgesia.
`Penetrating trauma is usually obvious, but on occasions it
`may initially be difficult to recognize. The following inju-
`ries are possible: corneal laceration, often with prolapse of
`the iris into the defect; scleral perforation with chemosis or
`local hemorrhage, which must be differentiated from a triv-
`ial subconjunctival bleed; collapse of the anterior chamber;
`hyphema or vitreous hemorrhage; pupil irregularity; and
`lens dislocation.
`Intraocular foreign bodies are usually metal fragments
`from using a hammer and chisel, metal drill, or grinding
`wheel. Fragments of glass or wood may be involved. The
`symptoms are sudden sharp pain, which is followed by
`localized redness. In some cases, the outside of the eye may
`appear almost normal. In suspected cases, apply antibiotic
`eye drops and protect the eye from further damage with an
`eye shield. Provide analgesia and systemic antibiotics.
`
`All cases of documented penetrating injury to the eye
`and actual or suspected foreign bodies should immediately
`be referred to an ophthalmologist. Eventually, radiography
`of the orbit with soft-tissue films or computed tomography
`should be performed, but never perform magnetic resonance
`imaging if a metal foreign body is possible.
`
`OTHER COMMON CONDITIONS
`Dry Eye
`The typical sign of common dry eye is a foreign body
`sensation, and the feeling can be exacerbated by dry air such
`as air conditioning. Dry eye is found in patients with
`Sjögren’s syndrome.
`Artificial tear eyedrops can be used without prescription.
`If the symptoms persist, a consultation by an ophthalmolo-
`gist is recommended.
`
`Blepharitis
`Blepharitis is a frequent chronic inflammation of the eyelid
`margin causing red, itchy, and crusted lids. Styes and cha-
`lazions can be associated.
`In chronic cases, cleaning and scrubbing of the eyelids
`with mild soap or shampoo and a cotton tip twice per day
`can improve the symptoms. Topical antibiotics and steroids
`might be indicated.
`
`Finally, remember that the clinical signs requiring an
`urgent ophthalmic consultation are chemical burns, in-
`traocular infections, globe ruptures or perforations, and
`acute glaucoma.
`
`