Resident Editor: Patrick Azcarate, MD
Faculty Editor: Emily Mak OD, Paul Nadler, MD; Cynthia Chiu, MD
Background
- This is a common complaint and few evidence-based management guidelines exist.
- Although the majority of presentations can be managed in the primary care setting, the key is to promptly identify potentially vision-threatening conditions and refer appropriately. Some conditions may start as benign but can progress to a vision-threatening variant if not promptly recognized and treated.
Evaluation:
- A thorough history should include asking about: vision changes, pain, photophobia, foreign body sensation or foreign body exposure, conjunctival discharge, history of trauma or contact lens use (increases the suspicion of keratitis and corneal ulcer). A sexual history may be relevant (gonococcal conjunctivitis)
- Perform an eye exam with a focus on: visual acuity, penlight exam for pupillary reaction/asymmetry and anterior chamber examination, direct observation and ophthalmoscopy, and fluorescein staining if appropriate (see the Eye Anatomy and Physical Exam chapter section on Ocular Exam).
Common Causes (usually not imminently vision-threatening)
|
Cause |
Specific Etiologies |
Typical Presentation |
Treatment* |
|---|---|---|---|
|
GENERALLY PAINFUL |
|||
|
Iritis or Anterior Uveitis (vs traumatic = emergency)
Uvea = iris + ciliary body + choroid (vascular middle layer of eye) |
Infection (HSV, VZV, toxoplasmosis, TB, Syphilis, Lyme) HLA-B27 associated conditions (e.g., IBD, ankylosing spondylitis, Reiter’s, Still’s disease) Medications: Rifabutin, Moxifloxacin, Cidofovir, IV bisphosphonates Sarcoidosis |
Constant “aching” pain developing acutely over hours Photophobia Decreased visual acuity Constricted unreactive pupil, ciliary flush (hyperemia at limbus) Slit lamp: WBC’s in anterior chamber, rarely hypopyon |
Topical cycloplegic for mild/mod; atropine for severe Treat underlying infection Urgent referral within 24-48 hours |
|
Episcleritis |
Idiopathic (75%) and not associated with systemic disease If bilateral, consider systemic inflammation/ autoimmune disorder: HSV, vasculitis, Lyme, bisphosphonate use |
Acute onset of pain Foreign body sensation Tearing Recurrent episodes common Normal acuity Sectoral dilation of episcleral vessels
|
Usually self-limited and resolves within 3 weeks with or without tx Phenylephrine 2.5% test à one drop and look for blanching of episcleral vessels in 10-15 min Tx sxs with: Artificial tears or NSAIDs PRN Urgent referral if sxs persistent/ recurrent or if difficulty distinguishing from scleritis (scleritis with worse pain “boring,” photophobia, blue-purple sclera) |
|
Corneal Abrasion
(Cornea is richly innervated by V1) |
Scratching or hitting eye (direct injury, foreign body, contact lens, etc.) |
Normal or decreased acuity Surface irregularity with penlight exam
Pain (inability to open eye to foreign body sensation), photophobia, tearing
|
Topical anesthetic for exam only Dx: Fluorescein staining Tx: Antibiotic ointment/gtts, and pain control with NSAID’s or systemic opiates (no topical anesthetics!) Monitor recovery q1-2 days Urgent referral if no improvement in 2 days, markedly decreased acuity, or large central abrasion |
|
Stye = Hordeolum |
Acute purulent focal inflammation of eyelid (Staph/Strep) |
Acute onset Tender, smaller lid mass on lid margin No lasting granuloma |
Warm compresses Lid massages/ABx ophthalmic ung Refer if no resolution after 3-4 weeks for I&D or steroid injection |
|
Chalazion (like hordeolum, but more subacute) |
Oil glands of eyelid become obstructed and then chronically inflamed |
Subacute onset Non-tender lid mass on inside lid |
No Abx Warm compresses Usually resolves spontaneously in wks-mths Refer for I&D if persistent > 4 weeks |
|
Inflammed Pterygium |
Benign triangular degenerative lesion of the conjunctiva acquired from UV exposure or chronic irritation |
Usually asymptomatic (develops over yrs) Raised, yellow, fleshy lesion on nasal side of conjunctival extending into peripheral cornea If inflamed- red and irritated |
UV protection to prevent Artificial tears PRN Routine referral if invades cornea |
|
Cause |
Specific Etiologies |
Typical Presentation |
Treatment* |
|---|---|---|---|
|
GENERALLY NOT PAINFUL |
|||
|
Subconjunctival Hemorrhage |
Minor blunt trauma, vigorous Valsalva, prolonged coughing or vomiting, conjunctivitis, HTN, bleeding diathesis, anticoagulants |
Asymptomatic Usually unilateral Normal acuity, no discharge, no pain Sharply circumscribed area Underlying sclera completely obscured |
Usually self-limited w/i 2-3 weeks Artificial tears PRN Consider BP check, platelets, coags, skin exam for petechia/bleeding diathesis If recurrent, evaluate for hematologic or neoplastic disorder and consider referral In the setting of facial/orbital trauma, high suspicion for globe rupture |
|
Entropion: lower eyelid folds inward
Ectropion: lower eyelid turns out
Trichiasis: eyelashes turned in toward cornea |
Entropion/Ectropion: Idiopathic/senile, mechanical, paralytic, restrictive (eyelid scarring)
Trichiasis: chronic blepharitis, long-term topical medication (glaucoma), trachoma |
Facial hemiparesis if paralytic etiology
Exposure keratopathy
Eyelashes can rub cornea and irritate it
Corneal thinning or ulceration if severe |
Artificial tears PRN Tape eyelids closed for sleeping Forceps removal if only a few lashes involved (usually grow back) Surgical correction if severe |
|
Conjunctivitis Viral
Bacterial
Allergic
Toxic= “conjunctivitis medicamentosa” |
*Most likely cause/ highly contagious adenovirus>>HSV
Gram + > gram – Gonorrheal (hyperacute) in sexually active adults
Pollen, dust, dander
Use of ophthalmic meds |
Watery discharge, gritty feeling After URI or exposure Palpable preauricular LN
Abrupt onset, purulent discharge with debris/ matting of eyelashes
Itching (prominent symptom), tearing of eye, bilateral. Nasal congestion Red eye with eyelid edema and scaling
|
Usually self-limited within 2 wks Meticulous hand washing Do NOT share towels, avoid close contact, no pools X 2 weeks
Bacterial culture swab Urgent referral if no improvement in 7-10 days, emergent if suspect gonococcal etiology Abx gtts X 7-10d Warm compresses
Remove allergen Artificial tears Topical anti-histamine
Remove offending agent Artificial tears
|
|
Blepharitis = Meibomitis |
Infection (Staphylococcal) Dermatologic disease (Seborrheic dermatitis) |
Usually bilateral erythema/edema/ itchiness of eyelid Foreign body sensation Misdirection/loss/ crusting/matting of eyelashes Red conjunctiva Excessive tearing |
Warm compresses Lid massage and washing Topical Azithromycin/ Erythromycin or Bacitracin ophthalmic ointment (not usual bacitracin) If resistant to tx or unilateral refer to ophtho to evaluate for masquerade syndrome (sebaceous cell CA) |
Vision-threatening Causes
|
Cause |
Specific Etiologies |
Typical Presentation |
Treatment* |
|---|---|---|---|
|
GENERALLY PAINFUL |
|||
|
Penetrating injury |
Trauma or surgery Fall Occupations with flying pieces of sand, wood, metal, glass |
Normal or decreased acuity, limited EOM, shallow anterior chamber depth, scleral perforation, corneal laceration, uveal prolapse |
Orbital CT (avoid MRI if suspect metallic foreign body) Eye shield & avoid globe pressure Emergent referral for surgical repair |
|
Foreign body |
As above, as well as conjunctival injection, eyelid edema, or visible foreign body +/- rust ring. |
Topical anesthetic PRN Fluorescein staining Saline irrigation PRN Antibiotic gtt to prevent bacterial keratitis Urgent referral for removal F/u daily until eye is healed |
|
|
Hyphema (RBCs in anterior chamber) |
Trauma or surgery Coagulopathy Rarely spontaneous from intraocular neoplasms/ iris neovascularization |
Acute unilateral blurred vision, photophobia May have N/V Dark exudate in lower, inferior chamber of eye |
Eye shield at all times, Bed rest with HOB elevated Tylenol PRN (avoid ASA/NSAIDs-increased bleeding) Emergent referral (may be associated with glaucoma) |
|
Preseptal Cellulitis = peri-orbital (Infection of anterior portion of eyelid, not the orbit or ocular structures) |
Skin infection (Staph/Strep>>H. flu) Trauma, insect bite, sinusitis, hordeolum |
Erythema, edema, warmth, tenderness No proptosis, no abnormal or painful EOM, or loss of vision. (If present, treat as orbital cellulitis)
|
Culture any open wound Consider orbital CT to r/o orbital cellulitis Oral antibiotics Hospitalize if appears toxic or refractory to oral antibiotics |
|
Orbital Cellulitis (Infection of contents of orbit-more serious) |
Direct extension from other infectious sites (sinusitis) Trauma or surgery |
Erythema, edema, warmth, tenderness Fever, acute unilateral blurred vision, eyelid edema, HA Proptosis and restricted, painful EOM |
Emergent hospitalization and referral Orbital CT Broad IV antibiotics |
|
Angle-Closure Glaucoma |
Anterior iris positioning that blocks or reduces aqueous humor outflow Assess for precipitants (e.g., stress, darkened room, anticholinergic or sympathomimetic meds) |
Sxs more frequent at night when pupil more dilated Severe, aching pain, acute unilateral blurred vision, colored halos around lights, photophobia, N/V, HA Severely reduced acuity Increased IOP (60-80mm Hg), hard globe Fixed, mid-dilated pupil Shallow anterior chamber |
Immediate topical beta-blocker (e.g., timolol 0.5), alpha-agonist (e.g. brimonidine 0.15%), carbonic anhydrase inhibitor (e.g., dorzolamide 2%), IV acetazolamide 500mg, or osmotic agents by a specialist Emergent referral for laser iridotomy to prevent optic nerve ischemia |
|
Chemical burn |
Alkali exposure (more dangerous than acidic agents): cement, lye, oven/drain cleaners Acids, solvents, detergents |
Blurry vision, eyelid spasm Periorbital skin burns Corneal edema or opacification Conjunctivitis |
Topical anesthetic PRN Emergent, copious, prolonged irrigation with saline/water ≥30 min Wait 5-10 min, then check pH in inferior fornix using litmus paper or U/A strip for goal pH 7.0-7.2 Emergent referral after lavage |
|
Thermal/UV Keratopathy |
Welding, skiing, or sun lamp use without adequate eye protection No chemical exposure |
Mod/severe pain Foreign body sensation Tearing, photophobia, blurred vision, eyelid spasm all worsening 6-12 hours after exposure |
Tape eyelids closed Antibiotic ointment QID Cycloplegic drops and/or oral analgesics PRN Urgent referral w/in 24-48 hours |
|
Keratitis or Corneal Ulcer |
Bacterial (More urgent than viral)(Staph, Strep, Pseudomonas) Fungal HSV/HZV Atypical mycobacteria Severe dry eye, topical anesthetic abuse, or residual foreign body Acanthamoeba in contact lens users |
Unilateral blurred vision, photophobia, discharge Decreased visual acuity if central Corneal haziness Presence of hypopyon (pus in the eye) Conjunctiva can be red with foreign body sensation |
Fluorescein staining Topical antibiotic Emergent referral Discontinue contacts (and save contacts and case for Cx) |
|
Hypopyon (pus in anterior chamber) |
Sign of severe anterior uveitis Causes: corneal ulcers, endophthalmitis, medication toxicity, Behcets |
White exudate in lower anterior chamber of eye Blurred vision, photophobia |
Treat underlying cause Emergent referral |
|
Traumatic Iritis or Uveitis (vs non-traumatic= non-emergent) |
Trauma |
Sxs start within 3 days of trauma Normal or decreased acuity Tearing, photophobia Dull, aching/throbbing pain Asymmetric pupil size |
Emergent referral |
|
Scleritis
Types: Sectoral Diffuse Nodular Necrotizing (severe) |
50% have associated systemic disease (connective tissue disorders, zoster, syphilis, gout, etc.) |
Moderate/severe deep pain with radiation to temple/jaw Photophobia, tearing, tenderness Normal or reduced acuity Scleral edema with engorged deep scleral vessels |
Phenylephrine test as above Relevant PEx and w/u to evaluate for autoimmune or infectious etiologies Urgent referral Oral NSAIDs and refer to ophtho for tx with steroids/ antimetabolites |
*Ophthalmology referral (emergent is immediately, urgent is 24-48 hours, routine is weeks to months).
General principles of management
-Manage pain cycloplegic and/or oral NSAIDs/opiates. (But not in the setting of acute angle closure glaucoma)
-Optimize lubrication with artificial tears 4x/day PRN for irritation.
-Check visual acuity
-Fluorescein exam on all unilateral cases of conjunctivitis to rule out abrasion/ulcer/foreign body and in all contact lens wearers (to r/o ulcer caused by pseudomonas).
When to refer (Most abnormalities are appropriate for referral, so have a low threshold!)
- Blurred vision or reduced visual acuity, photophobia, proptosis, or severe pain
- Colored halos around lights
- Pupillary abnormalities
- Ciliary flush (injection of limbal blood)
- Suspicion of increased intraocular pressure
- Corneal opacification detected by direct illumination with penlight or ophthalmoscope (includes corneal precipitates, diffuse haze, or localized opacities)
- Presence of rust ring or unable to remove foreign body with cotton tip moistened swab.
- Facial zoster extending into the eye, or dendritic pattern (herpes) on fluorescein exam
- Ocular or orbital trauma or chemical injury
References
Bradford CA (2004). Chapter 4: The Red Eye in Basic Ophthalmology. 8th Edition. American Academy of Ophthalmology. 75-97.
Ehlers JP and Shah CP (2008). The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease. 5th Edition. Lippincott Williams & Wilkins.
Leibowitz HM. The red eye. N Eng J Med 2000;343:345-351.
Palay DA and Krachmer JH (2005). Chapter 3: The Red Eye in Primary Care Ophthalmology. 2nd Edition. Elsevier Mosby. 39-65.
Riordan-Eva P and Whitcher JP (2011). Vaughan & Asbury’s General Ophthalmology. 17th Edition. McGraw Hill Lange.
Wirbelauer C. Management of the red eye for the primary care physician. Am J Med 2006;119:302-306.
Stone CK, Humphries RL. Current diagnosis and treatment: emergency medicine, 7th ed. Chapter 31: Eye emergencies. McGraw-Hill 2011.