Approach to the Problem
A red eye is an eye with vascular congestion of the conjunctiva resulting from inflammation, trauma, conjunctivitis, or glaucoma. Redness may also be secondary to eyelid pathology. Conjunctivitis is the most common cause of a red eye, whereas glaucoma is rare in pediatrics. Conjunctivitis is commonly referred to as “pink eye” when it is caused by a viral or bacterial infection. Conjunctivitis may also have an allergic etiology. Trauma to the eye can cause eye redness in association with corneal abrasions, iritis, and subconjunctival hemorrhage. Red eye may be related to eyelid pathology such as blepharitis and periorbital (preseptal) or orbital (postseptal) cellulitis (see Chapter 13). Red eyes may also be seen in some systemic diseases such as Kawasaki disease.
Key Points in the History
• A history of atopy, allergen exposure, or seasonality will often help distinguish viral from allergic conjunctivitis.
• Pruritus is a common complaint with allergic conjunctivitis.
• While viral and bacterial conjunctivitis may have purulent discharge, early morning lid crusting or gluey eyes usually points to a bacterial etiology.
• The time of presentation is very important in the neonate with conjunctivitis; chemical conjunctivitis usually occurs in the first 24 hours, conjunctivitis secondary to gonococcal infection usually appears within 1 week after birth, and conjunctivitis secondary to chlamydial infection usually appears 1 to 2 weeks after birth.
• Ocular pain with eye movement suggests orbital cellulitis rather than preseptal cellulitis.
• Pain after trauma suggests corneal abrasion or iritis, while subconjunctival hemorrhages are usually painless.
• Decreased vision and marked photophobia suggest a more serious diagnosis, such as glaucoma.
• Consider Kawasaki disease when an irritable child with fever has red eyes but no eye discharge.
Key Points in the Physical Examination
• Chemosis is swelling of the conjunctiva due to allergy or irritation.
• Conjunctivitis associated with pharyngitis is often caused by adenovirus.
• A palpable, preauricular lymph node in association with conjunctivitis is suspicious for viral conjunctivitis.
• Unilateral conjunctivitis with surrounding vesicular lesions is highly suspicious for keratoconjunctivitis resulting from herpes simplex virus.
• A history of gluey or sticky eyelids and physical findings of mucoid or purulent discharge are highly predictive of bacterial infection.
• Forty percent to fifty percent of those who have conjunctivitis in association with acute otitis media (formerly described as the otitis media–conjunctivitis syndrome) may have infection due to nontypeable Haemophilus influenzae.
• Visual acuity, because it may be impaired, should be tested whenever orbital cellulitis is suspected.
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