BASICS

DESCRIPTION

The appearance of redness on the surface of the eye resulting from enlargement and dilation or leakage of the blood vessels of the conjunctiva or episclera

EPIDEMIOLOGY

Prevalence

Depends on the etiology of the red eye

RISK FACTORS

• Blepharitis

• Trauma

• Systemic disease (e.g., iritis, chicken pox lesion of conjunctiva, episcleritis/scleritis)

• Contact lens wear

• Loss of protective ocular factors: tear film, corneal sensation, intact corneal epithelium, etc.

• Infection

• Exposure to noxious chemical by direct contact or airborne dispersion

Genetics

Most entities are not genetic unless there is an underlying systemic disorder with genetic influence (e.g., iritis due to arthritis)

GENERAL PREVENTION

• Eye protection for any high-risk activity, especially sports involving balls

• Excellent hygiene when inserting and removing contact lenses from the eye

• Not wearing contact lenses while sleeping and removal immediately upon discomfort

• Routine follow-up with contact lens provider to check fit and ocular surface health

• Screening eye examinations for those at risk of ocular complications (e.g., screen for iritis in juvenile idiopathic arthritis)

• Avoid contact with conjunctivitis and if contact occurs, frequent hand washing

PATHOPHYSIOLOGY

• Blepharitis—disorder of the Meibomian glands of lids leads to suboptimal flow with ocular surface desiccation and/or overgrowth of Staphylococcus epidermidis with hypersensitivity reaction of conjunctiva and cornea

• As the cornea has no blood vessels of its own, when it becomes infected, the surrounding blood vessels enlarge and bring immunomodulators to help fight the infection.

• Infection or inflammation of the conjunctiva or episclera results in blood vessel engorgement.

• Inflammation inside the eye results in “limbal flush”, an engorgement of the circumcorneal vessels.

• Small conjunctival vessels are sensitive to increased blood pressure and microvascular disease causing them to burst and leak blood under the outer membrane of the eye (subconjunctival hemorrhage).

• With overwear and poor fit, contact lenses can decrease the oxygenation of the cornea creating inflammation.

• Cavernous fistula can result in conjunctival vascular engorgement (and “corkscrew vessels”) due to a resistance to venous return and/or increased perfusion pressure.

ETIOLOGY

• Blepharitis

• Disorders of the lashes: trichiasis, lice

• Subconjunctival hemorrhage—trauma or anticoagulation/platelet disorders, strangulation/asphyxia (consider child abuse), Valsalva maneuver, hypertension, and diabetes (all uncommon causes in children)

• Conjunctivitis—viral, bacterial, allergic, or toxic

• Corneal abrasion/foreign body

• Corneal infection: Bacterial, herpes, varicella,

• Iritis—idiopathic, traumatic, or due to systemic disease (juvenile idiopathic arthritis, sarcoidosis, tuberculosis, inflammatory bowel disease, Kawasaki – see chapter)

• Trauma

• Contact lens: keratitis, hypoxia, infectious corneal ulcer, damaged contact lens, etc.

COMMONLY ASSOCIATED CONDITIONS

• Eye pain

• Reduced vision if cause is corneal or intraocular

• Photophobia

• Itchy lids (e.g., allergy, blepharitis)

DIAGNOSIS

HISTORY

• How long has red eye been present (acute vs. chronic)

• History of eye trauma (foreign body, traumatic iritis)

• Past ocular history

– Previous eye surgery making the eye more susceptible to trauma or infection

– Contact lens wearer

• Past medical history—rosacea associated with blepharitis, recent herpes simplex infection, chicken pox, underlying malignancy or immunosuppression, arthritis, inflammatory bowel disease, or fever

• Exposure to foreign bodies, individuals with conjunctivitis, toxins that irritate the eyes, or chemical splash

• Ocular symptoms:

– Eye pain—describe location, duration, and intensity

– Foreign body sensation in eyes

– Discharge from eye—purulent (bacterial), clear or mucous (viral or allergic), stringy white (allergic), or tearing (herpes simplex, corneal ulcer, acute iritis)

– Eye irritation/itching

– Visual loss/blurred vision

– Triad of eye pain, light sensitivity, and blurred vision suggest more serious ocular involvement

PHYSICAL EXAM

• Detailed eye examination including dilated fundus view, especially if decreased vision or trauma

– Visual acuity in both eyes. Reduced visual acuity may suggest corneal etiology or iritis.

– Check pupillary size and shape. Mid-dilated pupil in iritis. An irregular pupil may suggest trauma, posterior synechiae of iritis, or and intraocular foreign body.

– Inspect the lids for any crusting, lice, or redness of the lid margin. Look under the upper and lower eyelids for foreign bodies, fine follicles indicating viral infection, and papillae/edema suggesting allergic conjunctivitis.

– Note location of redness and characterize discharge

– Fluorescein staining of cornea for abrasion, ulceration, and dendrites of herpes

– Tonometry

– Assess the red reflex. If abnormal, may suggest globe rupture or hyphema.

• Physical examination

– Preauricular lymph nodes (viral conjunctivitis)

– Other signs of trauma (consider child abuse)

– Stiff or tender joints (juvenile idiopathic arthritis)

– Abdominal tenderness

– Other infection in immunosuppression

DIAGNOSTIC TESTS & INTERPRETATION

Lab

• Bacterial culture of eye discharge if copious

• If iritis is suspected:

– CBC with differential, ESR, ANA, ACE level (sarcoidosis), RPR, serum calcium, and rheumatoid factor

– Urinalysis

– PPD

– Lyme titers

– See uveitis chapter for further evaluation

Imaging

• If suspecting globe rupture or intraocular foreign body—CT of orbits

• Chest radiograph if suspecting iritis

DIFFERENTIAL DIAGNOSIS

• Acute conjunctivitis—viral, bacterial, allergic, or toxic

• Blepharitis

• Subconjunctival hemorrhage

– Consider nonaccidental trauma with bilateral subconjunctival hemorrhages in infants, especially in those with facial petechiae. May be secondary to asphyxia/strangulation or severe chest compression (1)[C].

• Iritis

• Trauma

• Corneal or intraocular foreign body

• Corneal ulceration or infection

• Contact–lens induced keratitis

TREATMENT

MEDICATION

First Line

• Blepharitis—consider topical erythromycin ointment

• Allergic conjunctivitis—topical antihistamines and mast cell stabilizers

• Viral conjunctivitis—artificial tears for symptomatic relief; some authors have suggested topical antibiotics, if severe, to prevent secondary bacterial infection (2)[C].

• Bacterial conjunctivitis—topical antibiotics (see chapter)

• Corneal infection

– Bacterial infiltrate—consider scraping and culture before treatment with fortified and high-dose topical antibiotics (see chapter)

– Herpes simplex dendrite—topical and/or systemic antivirals

– Do not use topical steroids

• Iritis—topical steroids and cycloplegia, treat secondary glaucoma

• Hyphema—topical steroids and cycloplegic glaucoma medication if needed. Eye shield and avoidance of antiplatelet medication to prevent secondary bleed. (see chapter)

Second Line

• Systemic antibiotics may be needed if periocular or orbital infection

• Systemic steroids or immunosuppressive agents may be needed in iritis (see chapter)

ADDITIONAL TREATMENT

General Measures

Cool compresses are helpful for symptomatic relief

Issues for Referral

• As appropriate for underlying systemic disease

• To child-protective agency if concern of possible abuse

Additional Therapies

• Baby shampoo eyelash scrubs for blepharitis

• Warm compresses may also be helpful

• Massage for nasolacrimal duct obstruction (see chapter on ‘Nasolacrimal Duct Obstruction, Adults’)

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

• Because of high potential for visual loss and other complications, serial follow-up for corneal disease and iritis

• If contact lens related, do not restart contacts until seen by provider

Patient Monitoring

By ophthalmologist for chronic eye disease (e.g., iritis, herpes simples keratitis)

PATIENT EDUCATION

• Promote appropriate eye protection for sports

• Baby shampoo eyelash scrubs for blepharitis

PROGNOSIS

• Excellent if appropriate treatment instituted

• Depends on etiology

COMPLICATIONS

• Corneal disease: perforation, scar, and amblyopia

• Trauma—blood staining of cornea, amblyopia, optic atrophy, and glaucoma

• Iritis—glaucoma, cataract, band keratopathy, and recurrence

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