Red Eye, Emergency Medicine

Basics

Description

May be caused by almost any eye disorder
Often benign; but may represent systemic disease
Due to vascular engorgement of conjunctiva
Main causes include inflammatory, allergic, infection, or trauma
Conjunctivitis is the most common etiology

Etiology

Inflammatory:
- Uveitis:
  - Anterior and posterior
- Iritis (perilimbic injection)
- Episcleritis (70% are idiopathic)
- Scleritis (50% associated with systemic disease)
- Systemic inflammatory reactions
Allergic:
- Due to histamine release and increased vascular permeability, resulting in swelling of conjunctiva (chemosis), watery discharge, and pruritus; usually bilateral
Infectious:
- Bacterial (purulent mucous discharge), viral (watery or no discharge), or fungal
- Orbital cellulitis
- Dacryocystitis
- Canaliculitis
- Endophthalmitis
Traumatic:
- Corneal abrasion
- Subconjunctival hemorrhage (SCH)
- Foreign body
- Occult perforation
Other:
- Pingueculitis and pterygium, hemorrhage, blepharitis, dry eye syndrome, acute angle-closure glaucoma, ophthalmia neonatorum, conjunctival tumor

Diagnosis

Signs and Symptoms

History

Age (especially neonatal and age >50 yr)
Time of onset, duration of symptoms
Exposures (i.e., chemicals, allergens)
Patients 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)

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):
- Arthritic disease
- Ankylosing spondylosis
- Ulcerative colitis
- Reiter syndrome
- TB
- Herpes
- Syphilis
- Sarcoidosis
- Toxoplasma
- CMV

Treatment

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:
- Ointment or drops:
  - Erythromycin ointment every 4 hr
  - Polytrim drops 4 times/d
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

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

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:
- Atropine 1%, 2%: 1 " 2 gtt/d to QID
- Cyclopentolate 0.5%, 1%, 2%: 1 " 2 gtt PRN
- Homatropine 2%: 1 " 2 gtt
- Phenylephrine 0.12%, 2.5%, 10%: 1 " 2 gtt BID " TID
- Tropicamide 0.5%, 1%: 1 " 2 gtt PRN
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 " 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

Follow-Up

Disposition

Admission Criteria

Endophthalmitis
Perforated corneal ulcers
Orbital cellulitis
Concurrent injuries (e.g., trauma)
If indicated for systemic disease

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.

Pearls and Pitfalls

Failure to recognize and treat ulcers, herpetic infections, neonatal bacterial infections, angle-closure glaucoma, and penetrating trauma
Steroids should only be used with ophthalmology consultation

Additional Reading

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.

Codes

ICD9

364.3 Unspecified iridocyclitis
372.30 Conjunctivitis, unspecified
379.93 Redness or discharge of eye
379.00 Scleritis, unspecified
376.01 Orbital cellulitis
918.1 Superficial injury of cornea

ICD10

H11.829 Conjunctivochalasis, unspecified eye
H20.9 Unspecified iridocyclitis
H57.9 Unspecified disorder of eye and adnexa
H15.109 Unspecified episcleritis, unspecified eye
H05.019 Cellulitis of unspecified orbit
H15.009 Unspecified scleritis, unspecified eye
S05.00XA Inj conjunctiva and corneal abrasion w/o fb, unsp eye, init

SNOMED

75705005 Red eye (disorder)
9826008 Conjunctivitis (disorder)
128473001 Uveitis (disorder)
815008 Episcleritis (disorder)
194005002 orbital cellulitis (disorder)
78370002 Scleritis (disorder)
85848002 Corneal abrasion (disorder)

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