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red eye (pink eye, ocular erythema)

Etiology: 1) blepharitis 2) conjunctivitis a) allergic conjunctivitis b) viral conjunctivitis c) bacterial conjunctivitis 3) subconjunctival hemorrhage 4) xerophthalmia (dry eye) 5) eyelid malposition or exposure 6) episcleritis 7) scleritis 8) iritis 9) keratitis 10) Herpes zoster ophthalmicus 11) angle-closure glaucoma 12) chalazion 13) foreign body Clinical manifestations: 1) severe pain & reduced visual acuity suggests: a) keratitis b) iritis c) angle-closure glaucoma d) NOT conjunctivitis 2) sharp or superficial pain suggests foreign body 3) deep, aching pain, nausea, vomiting suggests angle-closure glaucoma 4) pain with reading &/or photophobia suggests iritis or keratitis 5) decreased visual acuity suggests keratitis or iritis - halos around lights suggests acute angle-closure glaucoma 6) itching with mucoid or watery discharge suggests allergic conjunctivitis 7) viral conjunctivitis suggested by a) preauricular lymph node tendermess [2] b) upper respiratory infection followed by one, then a second red eye 8) diffuse, unilateral redness with morning crusting of eyelashes suggests bacterial conjunctivitis 9) profusely purulent discharge in a sexually active adult suggests gonorrhea 10) chronic red eye & periauricula adenopathy in a sexually active adult suggests chlamydia 11) consititutional symptoms may be associated with a) keratitis b) iritis c) scleritis Laboratory: - culture prululent discharge (including gonorrhea) Special laboratory: 1) visual acuity 2) pattern of redness a) diffuse (conjunctival) b) around the cornea (ciliary flush) 3) eye discharge 4) corneal opacities 5) anterior chamber depth 6) pupillary irregularity 7) intraocular pressure Management: 1) red flags should prompt ophthalmology consult a) visual disturbance, including diminished visual acuity b) photophobia c) pupillary changes d) ocular pain e) trauma f) hyper-purulent conjunctivitis of gonorrhea 2) keratitis, iritis, scleritis are ophthalmology emergencies 3) acute angle-closure glaucoma is an ophthalmology emergency 4) Herpes zoster ophthalmicus is an ophthalmology emergency 5) ocular manifestations of gonorrhea or chlamydia warrant ophthalmology referral [1] 6) bacterial conjunctivitis without red flags - cold compresses - trimethoprim/polymixin B or erythromycin ophthalmic if immunocompromised, contact lenses, healthcare worker 7) viral conjunctivitis without red flags - supportive care 8) allergic conjunctivitis without red flags - antihistamine, topical vasoconstrictor, mast-cell stabilizer 9) episcleritis (not scleritis) without red flags - supportive care (self limited) 10) do not treat red eye with glucocorticoid [1]

Related

eye eye pain (ocular pain, orbital pain)

Specific

ciliary flush

General

sign/symptom

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 11, 15, 16, 18. American College of Physicians, Philadelphia 1998, 2009, 2012, 2018. - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  2. Geriatric Review Syllabus, 7th edition Parada JT et al (eds) American Geriatrics Society, 2010 - Geriatric Review Syllabus, 8th edition (GRS8) Durso SC and Sullivan GN (eds) American Geriatrics Society, 2013 - Geriatric Review Syllabus, 10th edition (GRS10) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2019
  3. Cronau H, Kankanala RR, Mauger T. Diagnosis and management of red eye in primary care. Am Fam Physician. 2010 Jan 15;81(2):137-44. PMID: 20082509
  4. Bal SK, Hollingworth GR. Red eye. BMJ. 2005 Aug 20;331(7514):438. Review. PMID: 16110072 Free PMC Article
  5. Wirbelauer C. Management of the red eye for the primary care physician. Am J Med. 2006 Apr;119(4):302-6. Review. PMID: 16564769
  6. Leibowitz HM. The red eye. N Engl J Med. 2000 Aug 3;343(5):345-51. Review. PMID: 10922425 http://www.nejm.org/doi/full/10.1056/NEJM200008033430507
  7. Tarff A, Behrens A. Ocular emergencies: red eye. Med Clin North Am. 2017;101:615-39. PMID: 28372717