Red Eye: A Merck Manual of Patient Symptoms podcast
Red eye refers to a red appearance of the opened eye, reflecting dilation of the superficial ocular vessels.
Dilation of superficial ocular vessels can result from
Several ocular components may be involved, most commonly the conjunctiva, but also the uveal tract, episclera, and sclera.
The most common causes of red eye include
Corneal abrasions and foreign bodies are common causes (see Table 11: Symptoms of Ophthalmologic Disorders: Some Causes of Red Eye). Although the eye is red, patients usually present with a complaint of injury, eye pain, or both. However, in young children and infants, this information may be unavailable.
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Most disorders can be diagnosed by a general health care practitioner.
History of present illness should note the onset and duration of redness and presence of any change in vision, itching, scratchy sensation, pain, or discharge. Nature and severity of pain, including whether pain is worsened by light (photophobia), are noted. The clinician should determine whether discharge is watery or purulent. Other questions assess history of injury, including exposure to irritants and use of contact lenses (eg, possible overuse, such as wearing them while sleeping). Prior episodes of eye pain or redness and their time patterns are elicited.
Review of systems should seek symptoms suggesting possible causes, including headache, nausea, vomiting, and halos around lights (acute angle-closure glaucoma); runny nose and sneezing (allergies, URI); and cough, sore throat, and malaise (URI).
Past medical history includes questions about known allergies and autoimmune disorders. Drug history should specifically ask about recent use of topical ophthalmic drugs (including OTC drugs), which might be sensitizing.
General examination should include head and neck examination for signs of associated disorders (eg, URI, allergic rhinitis, zoster rash).
Eye examination involves a formal measure of visual acuity and usually requires a penlight, fluorescein stain, and slit lamp.
Best corrected visual acuity is measured. Pupillary size and reactivity to light are assessed. True photophobia (sometimes called consensual photophobia) is present if shining light into an unaffected eye causes pain in the affected eye when the affected eye is shut. Extraocular movements are assessed, and the eye and periorbital tissues are inspected for lesions and swelling. The tarsal surface is inspected for follicles. The corneas are stained with fluorescein and examined with magnification. If a corneal abrasion is found, the eyelid is everted and examined for hidden foreign bodies. Inspection of the ocular structures and cornea is best done using a slit lamp. A slit lamp is also used to examine the anterior chamber for cells, flare, and pus (hypopyon). Ocular pressure is measured using tonometry, although it may be permissible to omit this test if there are no symptoms or signs suggesting a disorder other than conjunctivitis.
The following findings are of particular concern:
Interpretation of findings
Conjunctival disorders and episcleritis are differentiated from other causes of red eye by the absence of pain, photophobia, and corneal staining. Among these disorders, episcleritis is differentiated by its focality, and subconjunctival hemorrhage is usually differentiated by the absence of lacrimation, itching, and photosensitivity. Clinical criteria do not accurately differentiate viral from bacterial conjunctivitis.
Corneal disorders are differentiated from other causes of red eye (and usually from each other) by fluorescein staining. These disorders also tend to be characterized by pain and photophobia. If instillation of an ocular anesthetic drop (eg, proparacaine 0.5%), which is done before tonometry and ideally before fluorescein instillation, completely relieves pain, the cause is probably limited to the cornea. If pain is present and is not relieved by an ocular anesthetic, the cause may be anterior uveitis, glaucoma, or scleritis. Because patients may have anterior uveitis secondary to corneal lesions, persistence of pain after instillation of the anesthetic does not exclude a corneal lesion.
Anterior uveitis, glaucoma, acute angle-closure glaucoma, and scleritis can usually be differentiated from other causes of red eye by the presence of pain and the absence of corneal staining. Anterior uveitis is likely in patients with pain, true photophobia, absence of corneal fluorescein staining, and normal intraocular pressure; it is definitively diagnosed based on the presence of cells and flare in the anterior chamber. However, these findings may be difficult for general health care practitioners to discern. Acute angle-closure glaucoma can usually be recognized by the sudden onset of its severe and characteristic symptoms, but tonometry is definitive.
Instillation of phenylephrine 2.5% causes blanching in a red eye unless the cause is scleritis. Phenylephrine is instilled to dilate the pupil in patients needing a thorough retinal examination. However, it should not be used in patients who have the following:
Testing is usually unnecessary. Viral cultures may help if herpes simplex or herpes zoster is suspected and the diagnosis is not clear clinically. Corneal ulcers are cultured by an ophthalmologist. Gonioscopy is done in patients with glaucoma. Testing for autoimmune disorders may be worthwhile in patients with uveitis and no obvious cause (eg, trauma). Patients with scleritis undergo further testing as directed by an ophthalmologist.
The cause is treated. Red eye itself does not require treatment. Topical vasoconstrictors are not recommended.
Last full review/revision November 2012 by Kathryn Colby, MD, PhD