Red eye resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Seyed Arash Javadmoosavi, MD[2]

Synonyms and keywords: An approach to red eye, Red eye diagnostic approach, Red eye workup algorithm

Overview

Red eye is an essential sign of eye inflammation. Although it is usually benign and can be managed by primary care physician, It is important to distinguish between benign and sight-threatening diagnoses. Its most common cause is conjunctivitis. However, the other common causes are subconjunctival hemorrhage, blepharitis, scleritis, corneal abrasion, glaucoma and foreign body. Red eye can be concomitant with photophobia, eye discharge, pain, itiching and visual changes.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

• Acute angle closure glaucoma (AACG)
• Endophthalmitis
• Anterior uveitis
• Neonatal conjunctivitis
• Bacterial keratitis
• Chemical burn
• Traumatic eye injury
• Scleritis
• Corneal ulcer
• Hyperacute conjunctivitis

Common Causes

• Conjunctivitis
• foreign body
• blepharitis
• scleritis
• subconjunctival hemorrhage

Diagnosis

In the assessment of a patient with red eye, taking a precise history and examination and identifying red flags is essential.
Red flags include:

• Reduced visual acuity
• Deep pain within the eye
• Unilateral red eye
• Contact lens use
• Photophobia

Taking history includes:

• Onset and duration
• Unilateral or bilateral symptoms
• Visual changes
• Pain
• Eye discharge
• Photophobia
• Whether the person wears contact lenses
• Similar episodes in the past
• Medication

Examination includes:

• Check the person's visual acuity.
• Assess for evidence of facial trauma.
• Check for any discharge from the eyes.
• Examine the eyelids
• Examine the conjunctiva
• Check the pattern of redness
• Perform fluorescein eye stain test. If the cornea stains this can be an indication that a corneal abrasion or ulcer is present.
• Check pupillary reaction
• Check patient's blood pressure if subconjunctival hemorrhage is suspected.

Mild to Severe

Patients with red eye

Mild or no pain with mild blurring or normal vision

Moderate to severe pain

Hyperemia

Vision loss, Distorted pupil, Corneal involvement

Local

Diffuse

Vesicular rash, Corneal ulcer, Iritis, Acute angle gluacoma, Chemical burn, Traumatic eye injury

Episcleritis

Discharge

Emergency Ophthalmology referral

No

Yes

Subconjunctival hemorrhage

Intermittent

Continuous

Dry eye

Watery or Serous

Mucopurulent to Purulent

Itching

Clamydial Conjunctivitis

Acute bacterial conjunctivitis

Mild to non

Moderate to severe

Viral Conjunctivitis

Allergic Conjunctivitis

Acute or Chronic

red eye

Chronic

Acute

Bilateral

Unilateral

Bilateral

Unilateral

Consider the following: ❑ Pain If has tired eyes, burning or itching: keratoconjunctivitis ❑ No pain Lid retraction Exophthalmos Diplopia Endocrine orbitopathy

Consider the following: ❑ Pain Lid malposition: Entropion Ectropion Trichiasis ❑ No pain Lagophthalmos

Consider the following: ❑ Pain Photokeratitis ❑ No pain Chemosis Seasonal Allergen Allergic conjunctivitis

Consider the following: ❑ Pain Suspicion of: Foreign body Perforation Acute angel closure glaucoma ❑ No pain Subconjunctival hemorrhage

Treatment

The management of the red eye will depend on the underlying cause.

Life-threatening causes

Acute angle closure glaucoma	Endophthalmitis	Necrotizing Scleritis	Herpetic keratitis	Chemical injury
Lowering of IOP: Acetazolamide 500mg IV or PO + topical Beta blockers, Alpha 2 agonists, Prostaglandin analogue Reduce pain: Topical steroids (prednisolone) Reduce nausea and vomiting: Anti emetics (Metoclopramide)	intravitreal injections of vancomycin and ceftazidime Or combination of vancomycin and amikacin Topical Fluoroquinolones (levofloxacin) Vitrectomy in severe cases	Oral Corticosteroids Or (TNF)-inhibiting anti-inflammatory (adalimumab) or (infliximab)	Ganciclovir 0.15% ophthalmic gel Topical steroid Surgical debridement in severe cases	Emergency treatment Irrigation with isotonic saline or lactate ringer tear substitutes Further treatment Collagenase inhibitors acetylcysteine Topical steroids Ascorbate

Anterior uveitis	Subconjunctival hemorrhage	Neonatal conjunctivitis	Corneal ulcer
Topical corticosteroids The most common is prednisolone acetate 1% dexamethasone 0.1% prednisolone sodium phosphate 1%	Treat the cuase Contact lens usage Ocular amylodoisis Conjunctivochalasis Conjunctival tumors Systemic vascular diseases Carotid cavernous fistulas(CCF)	❑ Gonococcal conjunctivitis third-generation cephalosporins (Ceftriaxone 25-50mg/kg) ❑ Chlamydial conjunctivitis Erythromycin for 14 days or azithromycin 20 mg/kg/day for 3 days ❑ Herpetic conjunctivitis topical vidarabine or trifluridine for 10 days Evaluate and treat for systemic herpes	Corneal scrap Topical antibiotics (chloramphenicol 1%)

Other causes

Foreign body	Conjunctivits	Blepharitis	Scleritis
Foreign body removal emergently Pain control (cycloplegic eye drops or topical tetracaine) Antibiotics (anti-pseudomonas coverage)	Bacterial Chloramphenicol 0.5% eye drops, Gentamicin 0.3% eye drops, Tetracycline 1% eye ointment Viral Self-limiting just cold compresses to relieve discomfort Allergic Antihistamines (eye drops or orally), Steroid eye drops can be added by cromolyn sodium 4% eye drops and lodoxamide 0.1% eye drops	Bacterial Topical antibiotic, corticosteroid HSV Topical ganciclovir or Oral acyclovir or valacyclovir if non-resolving	First line Topical corticosteroid eyedrops (Prednisolone acetate 1.0%) Oral NSAIDs (Ibuprofen 600 mg) Second line Oral corticosteroids Prescribed when oral NSAID treatment fails

Do's

• Using artificial tears in patients with dry eye.
• Protection against UV rays.
• Observe hygiene protocols.

Don'ts

• Avoid wearing contact lenses.
• Avoid using sharp equipment especially in children.