Red eye (medicine)

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Red eye
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Subconjunctival hemorrhage causing red coloration as result of ruptured blood vessel in the eye
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A red eye is an eye that appears red due to illness or injury. It is usually injection and prominence of the superficial blood vessels of the conjunctiva, which may be caused by disorders of these or adjacent structures. Conjunctivitis and subconjunctival hemorrhage are two of the less serious but more common causes.

Contents

Management includes assessing whether emergency action (including referral) is needed, or whether treatment can be accomplished without additional resources.

Slit lamp examination is invaluable in diagnosis but initial assessment can be performed using a careful history, testing vision (visual acuity), and carrying out a penlight examination.

Diagnosis

Hyphaema - showing blood filling the anterior chamber, causing a horizontal fluid level Hyphema - occupying half of anterior chamber of eye.jpg
Hyphaema – showing blood filling the anterior chamber, causing a horizontal fluid level

Particular signs and symptoms may indicate that the cause is serious and requires immediate attention. [1]

Seven such signs are:

The most useful is a smaller pupil in the red eye than the non-red eye (opposite eye) and sensitivity to bright light. [2]

Reduced visual acuity

A reduction in visual acuity in a 'red eye' is indicative of serious ocular disease, [3] such as keratitis, iridocyclitis, and glaucoma, and never occurs in simple conjunctivitis without accompanying corneal involvement.

Ciliary flush

Ciliary flush is usually present in eyes with corneal inflammation, iridocyclitis or acute glaucoma, though not simple conjunctivitis. A ciliary flush is a ring of red or violet spreading out from around the cornea of the eye.

Corneal abnormalities

The cornea is required to be transparent to transmit light to the retina. Because of injury, infection or inflammation, an area of opacity may develop which can be seen with a penlight or slit lamp. In rare instances, this opacity is congenital. [4] In some, there is a family history of corneal growth disorders which may be progressive with age. Much more commonly, misuse of contact lenses may be a precipitating factor. Whichever, it is always potentially serious and sometimes necessitates urgent treatment and corneal opacities are the fourth leading cause of blindness. Opacities may be keratic, that is, due to the deposition of inflammatory cells, hazy, usually from corneal edema, or they may be localized in the case of corneal ulcer or keratitis.
Corneal epithelial disruptions may be detected with fluorescein staining of the eye, and careful observation with cobalt-blue light. Corneal epithelial disruptions would stain green, which represents some injury of the corneal epithelium. These types of disruptions may be due to corneal inflammations or physical trauma to the cornea, such as a foreign body.

Pupillary abnormalities

In an eye with iridocyclitis, (inflammation of both the iris and ciliary body), the involved pupil will be smaller than the uninvolved, due to reflex muscle spasm of the iris sphincter muscle. Generally, conjunctivitis does not affect the pupils. With acute angle-closure glaucoma, the pupil is generally fixed in mid-position, oval, and responds sluggishly to light, if at all.

Shallow anterior chamber depth may indicate a predisposition to one form of glaucoma (narrow angle) but requires slit-lamp examination or other special techniques to determine it. In the presence of a "red eye", a shallow anterior chamber may indicate acute glaucoma, which requires immediate attention.

Abnormal intraocular pressure

Intraocular pressure should be measured as part of a routine eye examination. It is usually only elevated by iridocyclitis or acute-closure glaucoma, but not by relatively benign conditions. In iritis and traumatic perforating ocular injuries, the intraocular pressure is usually low.

Severe pain

Those with conjunctivitis may report mild irritation or scratchiness, but never extreme pain, which is an indicator of more serious disease such as keratitis, corneal ulceration, iridocyclitis, or acute glaucoma.

Differential diagnosis

Of the many causes, conjunctivitis is the most common. [1] Others include:

Usually nonurgent

  • airborne eye irritants
  • blepharitis [5] – a usually chronic inflammation of the eyelids with scaling, sometimes resolving spontaneously
  • drugs: medications or recreational drug use
  • dry eye syndrome – caused by either decreased tear production or increased tear film evaporation which may lead to irritation and redness [8]
    Acute glaucoma, angle closure type Acute Angle Closure-glaucoma.jpg
    Acute glaucoma, angle closure type
  • subconjunctival hemorrhage [1] – a sometimes dramatic, but usually harmless, bleeding underneath the conjunctiva most often from spontaneous rupture of the small, fragile blood vessels, commonly from a cough or sneeze
  • inflamed pterygium [9] – a benign, triangular, horizontal growth of the conjunctiva, arising from the inner side, at the level of contact of the upper and lower eyelids, associated with exposure to sunlight, low humidity and dust. It may be more common in occupations such as farming and welding.
  • inflamed pinguecula [10] – a yellow-white deposit close to the junction between the cornea and sclera, on the conjunctiva. It is most prevalent in tropical climates with much UV exposure. Although harmless, it can occasionally become inflamed.
  • tiredness
  • episcleritis [11] – most often a mild, inflammatory disorder of the 'white' of the eye unassociated with eye complications in contrast to scleritis, and responding to topical medications such as anti-inflammatory drops.

Usually urgent

  • acute closed-angle glaucoma [12] – implies injury to the optic nerve with the potential for irreversible vision loss which may be permanent unless treated quickly, as a result of increased pressure within the eyeball. Not all forms of glaucoma are acute, and not all are associated with increased intraocular pressure.
  • eye injury
  • keratitis [12] – a potentially serious inflammation or injury to the cornea (window), often associated with significant pain, light intolerance, and deterioration in vision. Numerous causes include virus infection. Injury from contact lenses can lead to keratitis.
Eye with iritis showing ciliary flush Clare-314.jpg
Eye with iritis showing ciliary flush
  • iritis [1] – together with the ciliary body and choroid, the iris makes up the uvea, part of the middle, pigmented, structures of the eye. Inflammation of this layer (uveitis) requires urgent control and is estimated to be responsible for 10% of blindness in the United States.
  • scleritis [13] – a serious inflammatory condition, often painful, that can result in permanent vision loss, and without an identifiable cause in half of those presenting with it. About 30–40% have an underlying systemic autoimmune condition.
  • tick-borne illnesses like Rocky Mountain spotted fever [14] – the eye is not primarily involved, but the presence of conjunctivitis, along with fever and rash, may help with the diagnosis in appropriate circumstances.

See also

Related Research Articles

<span class="mw-page-title-main">Conjunctivitis</span> Inflammation of the eye

Conjunctivitis, also known as pink eye, is inflammation of the outermost layer of the white part of the eye and the inner surface of the eyelid. It makes the eye appear pink or reddish. Pain, burning, scratchiness, or itchiness may occur. The affected eye may have increased tears or be "stuck shut" in the morning. Swelling of the white part of the eye may also occur. Itching is more common in cases due to allergies. Conjunctivitis can affect one or both eyes.

<span class="mw-page-title-main">Glaucoma</span> Group of eye diseases

Glaucoma is a group of eye diseases that lead to damage of the optic nerve, which transmits visual information from the eye to the brain. Glaucoma may cause vision loss if left untreated. It has been called the "silent thief of sight" because the loss of vision usually occurs slowly over a long period of time. A major risk factor for glaucoma is increased pressure within the eye, known as intraocular pressure (IOP). It is associated with old age, a family history of glaucoma, and certain medical conditions or medications. The word glaucoma comes from the Ancient Greek word γλαυκός, meaning 'gleaming, blue-green, gray'.

<span class="mw-page-title-main">Keratitis</span> Medical condition

Keratitis is a condition in which the eye's cornea, the clear dome on the front surface of the eye, becomes inflamed. The condition is often marked by moderate to intense pain and usually involves any of the following symptoms: pain, impaired eyesight, photophobia, red eye and a 'gritty' sensation. Diagnosis of infectious keratitis is usually made clinically based on the signs and symptoms as well as eye examination, but corneal scrapings may be obtained and evaluated using microbiological culture or other testing to identify the causative pathogen.

<span class="mw-page-title-main">Eye surgery</span> Surgery performed on the eye or its adnexa

Eye surgery, also known as ophthalmic surgery or ocular surgery, is surgery performed on the eye or its adnexa. Eye surgery is part of ophthalmology and is performed by an ophthalmologist or eye surgeon. The eye is a fragile organ, and requires due care before, during, and after a surgical procedure to minimize or prevent further damage. An eye surgeon is responsible for selecting the appropriate surgical procedure for the patient, and for taking the necessary safety precautions. Mentions of eye surgery can be found in several ancient texts dating back as early as 1800 BC, with cataract treatment starting in the fifth century BC. It continues to be a widely practiced class of surgery, with various techniques having been developed for treating eye problems.

<span class="mw-page-title-main">Prednisolone</span> Corticosteroid medication

Prednisolone is a corticosteroid, a steroid hormone used to treat certain types of allergies, inflammatory conditions, autoimmune disorders, and cancers. Some of these conditions include adrenocortical insufficiency, high blood calcium, rheumatoid arthritis, dermatitis, eye inflammation, asthma, and multiple sclerosis. It can be taken by mouth, injected into a vein, used topically as a skin cream, or as eye drops. It differs from the similarly named prednisone in having a hydroxyl at the 11th carbon instead of a ketone.

This is a partial list of human eye diseases and disorders.

<span class="mw-page-title-main">Uveitis</span> Inflammation of the uvea of the eye

Uveitis is inflammation of the uvea, the pigmented layer of the eye between the inner retina and the outer fibrous layer composed of the sclera and cornea. The uvea consists of the middle layer of pigmented vascular structures of the eye and includes the iris, ciliary body, and choroid. Uveitis is described anatomically, by the part of the eye affected, as anterior, intermediate or posterior, or panuveitic if all parts are involved. Anterior uveitis (iridocyclitis) is the most common, with the incidence of uveitis overall affecting approximately 1:4500, most commonly those between the ages of 20–60. Symptoms include eye pain, eye redness, floaters and blurred vision, and ophthalmic examination may show dilated ciliary blood vessels and the presence of cells in the anterior chamber. Uveitis may arise spontaneously, have a genetic component, or be associated with an autoimmune disease or infection. While the eye is a relatively protected environment, its immune mechanisms may be overcome resulting in inflammation and tissue destruction associated with T-cell activation.

<span class="mw-page-title-main">Eye injury</span> Physical or chemical injuries of the eye

Physical or chemical injuries of the eye can be a serious threat to vision if not treated appropriately and in a timely fashion. The most obvious presentation of ocular (eye) injuries is redness and pain of the affected eyes. This is not, however, universally true, as tiny metallic projectiles may cause neither symptom. Tiny metallic projectiles should be suspected when a patient reports metal on metal contact, such as with hammering a metal surface. Corneal foreign bodies are one of the most common preventable occupational hazards. Intraocular foreign bodies do not cause pain because of the lack of nerve endings in the vitreous humour and retina that can transmit pain sensations. As such, general or emergency department doctors should refer cases involving the posterior segment of the eye or intraocular foreign bodies to an ophthalmologist. Ideally, ointment would not be used when referring to an ophthalmologist, since it diminishes the ability to carry out a thorough eye examination.

<span class="mw-page-title-main">Fuchs' dystrophy</span> Medical condition

Fuchs dystrophy, also referred to as Fuchs endothelial corneal dystrophy (FECD) and Fuchs endothelial dystrophy (FED), is a slowly progressing corneal dystrophy that usually affects both eyes and is slightly more common in women than in men. Although early signs of Fuchs dystrophy are sometimes seen in people in their 30s and 40s, the disease rarely affects vision until people reach their 50s and 60s.

<span class="mw-page-title-main">Scleritis</span> Medical condition

Scleritis is a serious inflammatory disease that affects the white outer coating of the eye, known as the sclera. The disease is often contracted through association with other diseases of the body, such as granulomatosis with polyangiitis or rheumatoid arthritis. There are three types of scleritis: diffuse scleritis, nodular scleritis, and necrotizing scleritis. Scleritis may be the first symptom of onset of connective tissue disease.

<span class="mw-page-title-main">Corneal ulcers in animals</span> Veterinary inflammatory condition of the cornea

A corneal ulcer, or ulcerative keratitis, is an inflammatory condition of the cornea involving loss of its outer layer. It is very common in dogs and is sometimes seen in cats. In veterinary medicine, the term corneal ulcer is a generic name for any condition involving the loss of the outer layer of the cornea, and as such is used to describe conditions with both inflammatory and traumatic causes.

<span class="mw-page-title-main">Corneal neovascularization</span> Medical condition

Corneal neovascularization (CNV) is the in-growth of new blood vessels from the pericorneal plexus into avascular corneal tissue as a result of oxygen deprivation. Maintaining avascularity of the corneal stroma is an important aspect of healthy corneal physiology as it is required for corneal transparency and optimal vision. A decrease in corneal transparency causes visual acuity deterioration. Corneal tissue is avascular in nature and the presence of vascularization, which can be deep or superficial, is always pathologically related.

<span class="mw-page-title-main">Corneal ulcer</span> Medical condition of the eye

Corneal ulcer, also called keratitis, is an inflammatory or, more seriously, infective condition of the cornea involving disruption of its epithelial layer with involvement of the corneal stroma. It is a common condition in humans particularly in the tropics and in farming. In developing countries, children afflicted by vitamin A deficiency are at high risk for corneal ulcer and may become blind in both eyes persisting throughout life. In ophthalmology, a corneal ulcer usually refers to having an infection, while the term corneal abrasion refers more to a scratch injury.

<span class="mw-page-title-main">Herpes simplex keratitis</span> Medical condition

Herpetic simplex keratitis is a form of keratitis caused by recurrent herpes simplex virus (HSV) infection in the cornea.

<span class="mw-page-title-main">Herpes zoster ophthalmicus</span> Shingles in the human eye

Herpes zoster ophthalmicus (HZO), also known as ophthalmic zoster, is shingles involving the eye or the surrounding area. Common signs include a rash of the forehead with swelling of the eyelid. There may also be eye pain and redness, inflammation of the conjunctiva, cornea or uvea, and sensitivity to light. Fever and tingling of the skin and allodynia near the eye may precede the rash. Complications may include visual impairment, increased pressure within the eye, chronic pain, and stroke.

Neurotrophic keratitis (NK) is a degenerative disease of the cornea caused by damage of the trigeminal nerve, which results in impairment of corneal sensitivity, spontaneous corneal epithelium breakdown, poor corneal healing and development of corneal ulceration, melting and perforation. This is because, in addition to the primary sensory role, the nerve also plays a role maintaining the integrity of the cornea by supplying it with trophic factors and regulating tissue metabolism.

Keratoendotheliitis fugax hereditaria is an autosomal dominantly inherited disease of the cornea, caused by a point mutation in cryopyrin that in humans is encoded by the NLRP3 gene located on the long arm of chromosome 1.

<span class="mw-page-title-main">Corneal opacity</span> Medical condition

Corneal opacification is a term used when the human cornea loses its transparency. The term corneal opacity is used particularly for the loss of transparency of cornea due to scarring. Transparency of the cornea is dependent on the uniform diameter and the regular spacing and arrangement of the collagen fibrils within the stroma. Alterations in the spacing of collagen fibrils in a variety of conditions including corneal edema, scars, and macular corneal dystrophy is clinically manifested as corneal opacity. The term corneal blindness is commonly used to describe blindness due to corneal opacity.

Peripheral Ulcerative Keratitis (PUK) is a group of destructive inflammatory diseases involving the peripheral cornea in human eyes. The symptoms of PUK include pain, redness of the eyeball, photophobia, and decreased vision accompanied by distinctive signs of crescent-shaped damage of the cornea. The causes of this disease are broad, ranging from injuries, contamination of contact lenses, to association with other systemic conditions. PUK is associated with different ocular and systemic diseases. Mooren's ulcer is a common form of PUK. The majority of PUK is mediated by local or systemic immunological processes, which can lead to inflammation and eventually tissue damage. Standard PUK diagnostic test involves reviewing the medical history and a completing physical examinations. Two major treatments are the use of medications such as corticosteroids or other immunosuppressive agents and surgical resection of the conjunctiva. The prognosis of PUK is unclear with one study providing potential complications. PUK is a rare condition with an estimated incidence of 3 per million annually.

References

  1. 1 2 3 4 Cronau, H; Kankanala, RR; Mauger, T (Jan 15, 2010). "Diagnosis and management of red eye in primary care". American Family Physician. 81 (2): 137–44. PMID   20082509.
  2. ↑ Narayana, S; McGee, S (November 2015). "Bedside Diagnosis of the 'Red Eye': A Systematic Review". The American Journal of Medicine. 128 (11): 1220–1224.e1. doi: 10.1016/j.amjmed.2015.06.026 . PMID   26169885.
  3. ↑ Leibowitz HM (2000). "The red eye". N Engl J Med. 343 (5): 345–51. doi:10.1056/nejm200008033430507. PMID   10922425.
  4. ↑ Rezende RA, Uchoa UB, Uchoa R, Rapuano CJ, Laibson PR, Cohen EJ (2004). "Congenital corneal opacities in a cornea referral practice". Cornea. 23 (6): 565–70. doi:10.1097/01.ico.0000126317.90271.d8. PMID   15256994. S2CID   9031282.
  5. ↑ Jackson WB (April 2008). "Blepharitis: current strategies for diagnosis and management". Can J Ophthalmol. 43 (2): 170–79. doi:10.3129/i08-016. PMID   18347619.
  6. ↑ Yazulla, S (September 2008). "Endocannabinoids in the retina: from marijuana to neuroprotection". Progress in Retinal and Eye Research. 27 (5): 501–26. doi:10.1016/j.preteyeres.2008.07.002. PMC   2584875 . PMID   18725316.
  7. ↑ American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Washington DC: American Psychiatric Association; 2000.
  8. ↑ "Keratoconjunctivitis, Sicca". eMedicine . WebMD, Inc. January 27, 2010. Archived from the original on March 7, 2010. Retrieved September 3, 2010.
  9. ↑ Bradley JC, Yang W, Bradley RH, Reid TW, Schwab IR (July 2010). "The science of pterygia". Br J Ophthalmol. 94 (7): 815–20. doi:10.1136/bjo.2008.151852. PMID   19515643. S2CID   15507689.
  10. ↑ Sutphin, John, ed. 2007–2008 Basic and Clinical Science Course Section 8: External Disease and Cornea. American Academy Ophthalmology. p. 365. ISBN   1-56055-814-8.
  11. ↑ Jabs DA, Mudun A, Dunn JP, Marsh MJ (October 2000). "Episcleritis and scleritis: clinical features and treatment results". Am J Ophthalmol. 130 (4): 469–76. doi:10.1016/S0002-9394(00)00710-8. PMID   11024419.
  12. 1 2 Dargin JM, Lowenstein RA (February 2008). "The painful eye". Emerg Med Clin North Am. 26 (1): 199–216. doi:10.1016/j.emc.2007.10.001. PMID   18249263.
  13. ↑ Sims, J (December 2012). "Scleritis: presentations, disease associations and management". Postgrad Med J. 88 (1046): 713–18. doi: 10.1136/postgradmedj-2011-130282 . PMID   22977282. S2CID   37084152.
  14. ↑ Chapman, Alice S.; Bakken, Johan S.; Folk, Scott M.; Paddock, Christopher D.; Bloch, Karen C.; Krusell, Allan; Sexton, Daniel J.; Buckingham, Steven C.; Marshall, Gary S.; Storch, Gregory A.; Dasch, Gregory A.; McQuiston, Jennifer H.; Swerdlow, David L.; Dumler, Stephen J.; Nicholson, William L.; Walker, David H.; Eremeeva, Marina E.; Ohl, Christopher A.; Tickborne Rickettsial Diseases Working Group; CDC (2006-03-31). "Diagnosis and management of tickborne rickettsial diseases: Rocky Mountain spotted fever, ehrlichioses, and anaplasmosis--United States: a practical guide for physicians and other health-care and public health professionals" (PDF). MMWR. Recommendations and Reports: Morbidity and Mortality Weekly Report. Recommendations and Reports. 55 (RR-4): 1–27. ISSN   1545-8601. PMID   16572105. Archived (PDF) from the original on 2019-02-13. Retrieved 2017-09-10.
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