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Overview of the red eye

Author: Deborah S Jacobs, MD
Section Editor: Jonathan Trobe, MD
Deputy Editor: Jane Givens, MD

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Dec 2019. | This topic last updated: Jun 24, 2019.

INTRODUCTION

"Red eye" is a common presenting complaint in ambulatory practice. A small percentage of patients with
red eye need urgent ophthalmological referral and treatment, although the vast majority can be treated by
the primary care clinician. There are little epidemiologic data on the red eye, and there are no evidence-
based data to guide us in the management of these patients. Conjunctivitis (allergic or viral) is probably
the most common cause of red eye in the community setting, but a number of more serious conditions can
also occur [1,2].

This topic presents an approach for distinguishing patients with red eye who must be referred to an
ophthalmologist, such as those with angle-closure glaucoma, from patients who can be managed by the
primary care clinician, such as those with allergic conjunctivitis (table 1 and table 2). Some distinguishing
features of conditions presenting as a red eye are summarized in a table (table 3). The specific diagnosis
and treatment of these disorders are discussed separately. (See "Eyelid lesions" and "Conjunctivitis" and
"Corneal abrasions and corneal foreign bodies: Clinical manifestations and diagnosis" and "Uveitis:
Etiology, clinical manifestations, and diagnosis" and "Angle-closure glaucoma" and "Photokeratitis" and
"Blepharitis".)

PATIENT EVALUATION

Patient history, measurement of visual acuity, and findings on penlight examination are important features
in determining the cause and management of red eye. The history and ocular examination provide
guidance in the decision about whether to refer the patient for ophthalmologic evaluation. Performance of
the slit lamp examination is discussed separately. (See "Slit lamp examination".)

History — Many patients with a red eye call to inquire whether they need to be seen by a clinician.
Certain historical features or presenting complaints signal the need for clinician examination and possibly
patient referral. The following questions should be asked in all patients:

● Is vision affected? – Can you still read ordinary print with the affected eye? Patients with impaired
vision cannot be managed over the phone; they require a clinician examination and may, depending
upon the findings, require ophthalmological referral.
 ● Is there foreign body sensation? – Does it feel as though there is something in your eye, interfering
with your ability to keep your eye open? A foreign body sensation is the cardinal symptom of an active
corneal process. Objective evidence of foreign body sensation, in which the patient is unable to
spontaneously open the eye or keep it open, suggests corneal involvement; with the exception of the
initial presentation for corneal abrasion or foreign body, such patients warrant emergency or urgent
referral to an ophthalmologist. By comparison, many patients report a "scratchy feeling," "grittiness,"
or a sensation "like sand in my eyes" with allergy, viral conjunctivitis, or dry eyes. This is subjective
foreign body sensation and does not necessarily suggest a corneal problem that requires referral.

● Is there photophobia? – Are you sensitive to bright light? Patients with photophobia should always be
examined by a clinician.

Patients with an active corneal process have objective signs of photophobia as well as objective signs
of foreign body sensation. They may present wearing a hat and/or sunglasses, covering the affected
eye with the hand to block out light, or keeping the head down and turned away from light fixtures or
windows. They may request that the examination room lights be left off while waiting for the provider.
Patients with iritis have objective signs of photophobia but no objective foreign body sensation.

● Was there trauma? – Have you suffered an injury due to a finger poke, a tool, utensil, or other object?
Was there blunt trauma such as a fist or tennis ball?

● Are you a contact lens wearer? – A history of contact lens wear in the setting of discharge and a red
eye should increase the suspicion of keratitis [3]. (See "Complications of contact lenses", section on
'Infectious keratitis'.)

● Is there discharge, other than tears, that continues throughout the day? – Morning crusting followed
by a watery discharge for the remainder of the day is characteristic of many self-limited processes
such as allergy, stye or hordeolum, viral conjunctivitis, allergic conjunctivitis, and dry eyes. Patients
typically interpret morning crusting as "pus."

Bacterial conjunctivitis and bacterial keratitis cause opaque discharge that persists throughout the day and
requires specific therapy. Bacterial conjunctivitis, which is typically not associated with a reduction in
visual acuity, foreign body sensation, or photophobia, may be treated by the primary care clinician.
Bacterial keratitis, on the other hand, which may or may not affect vision but typically causes objective
foreign body sensation and photophobia, requires emergency referral.

General observation — General observation of the patient can provide guidance as to whether the
problem is likely to be benign and treatable initially by the primary care clinician or if it requires referral.
The subjective report of symptoms and threshold to report symptoms varies among individuals.

Lid and conjunctival entities do not cause objective foreign body sensation or photophobia. The patient will
be sitting in the examination room with both eyes open, unaffected by the ambient lighting. The patient
with viral or allergic conjunctivitis may have signs of or complain of rhinorrhea, lymphadenopathy, or other
upper respiratory tract symptoms.

By comparison, the patient suffering from infectious keratitis, iritis, or angle-closure glaucoma is likely to
have objective signs indicating the more serious nature of the problem. These entities all require
ophthalmologic consultation.
Ophthalmologic examination

Measurement of visual acuity — Vision should be documented for every patient who is seen for an
eye complaint. (An inquiry should be made about a change in vision on every telephone triage.) Each eye
should be tested separately. Snellen acuity is the standard; however, this test requires using a Snellen
chart at 20 feet with best correction or pinhole and is often difficult to perform.

An alternative in a triage setting is measurement of near vision. Allow the patient to use his or her usual
reading correction if possible and hold a near card or ordinary book, newspaper, or magazine at a
comfortable distance. It is not important to determine exactly whether the vision is 20/30 or 20/40 at 12 or
14 inches, but rather to document visual acuity in crude categories: reading vision (small versus large
print); form vision only (hand motions or count fingers); or light perception. This measurement should be
made before lights are shined in the eye or drops of any sort are applied.

In cases in which a lid disorder, conjunctival process, corneal abrasion, or foreign body is suspected, the
presence of normal acuity can be a source of reassurance to the primary care clinician that it is
reasonable for them to initiate therapy. On the other hand, if acuity is reduced in the presence of a red eye
beyond that which the patient reports is typical, the clinician should suspect one of the more worrisome
diagnoses: infectious keratitis, iritis, or angle-closure glaucoma. These patients should be referred for
initial therapy.

Penlight examination — The penlight should be used to examine the pupils and anterior segment. A
slit lamp is not required to distinguish those entities that can be treated by the primary care clinician from
those entities that must be referred. It is useful to consider the following questions during the penlight
examination:

● Does the pupil react to light? – The pupil is fixed in mid-dilation in cases of angle-closure glaucoma. It
does not react to light and is typically 4 to 5 mm in diameter.

● Is the pupil very small (1 to 2 mm) in size? – The pupil is pinpoint in cases of corneal abrasion,
infectious keratitis, or iritis. Abrasion is distinguished from iritis by the presence of a staining defect on
fluorescein examination and an objective foreign body sensation, neither of which are present with
iritis. Abrasions are usually caused by focal trauma to the surface of the eye. Traumatic iritis may
occur after blunt trauma, a softball, or a fist, but there are no corneal findings.

● Is there purulent discharge? – Purulent discharge suggests bacterial conjunctivitis or bacterial

keratitis. In conjunctivitis, there are no opacities by penlight or staining defects with fluorescein.

● What is the pattern of redness? – Diffuse injection involving both the conjunctiva inside the lid (the
palpebral conjunctiva) and the conjunctiva on the globe (the bulbar conjunctiva) suggests a primary
conjunctival problem such as conjunctivitis. Conjunctivitis may be bacterial, viral, allergic, toxic, or
nonspecific (eg, dry eye syndrome). In these entities, the entire mucus membrane is equally involved.
By comparison, ciliary flush is characteristic of the more serious entities including infectious keratitis,
iritis, or angle closure. With ciliary flush, injection is most marked at the limbus (where the cornea
undergoes transition to the sclera) and then diminishes toward the equator.

When the redness appears hemorrhagic rather than in a pattern of injection (dilated blood vessels),
the diagnosis of subconjunctival hemorrhage should be considered.
 ● Is there a white spot, opacity, or foreign body on the cornea? – A white spot or opacity on the cornea
suggests infectious keratitis. This can usually be seen without the aid of fluorescein. Fluorescein is
used at the end of the examination to confirm the absence or presence of a corneal process. The
white spot of a bacterial keratitis and the raised, grayish branching opacity of herpes simplex keratitis
will pick up stain (picture 1). Abrasions will also pick up stain; however, these are not characterized by
the presence of corneal opacity. A corneal foreign body will not pick up stain.

● Is there hypopyon or hyphema? – Hypopyon, a layer of white cells in the anterior chamber, or
hyphema, a layer of red cells, each require urgent referral to an ophthalmologist (picture 2 and picture
3). Hypopyon is associated with sight-threatening infectious keratitis or endophthalmitis until proven
otherwise; these patients must be seen by an ophthalmologist within hours. Hyphema is a sign of
significant blunt or penetrating trauma to the globe and must also be seen by an ophthalmologist
within hours to evaluate for penetrating eye injury, retinal detachment, and acute glaucoma. (See
"Traumatic hyphema: Clinical features and diagnosis".)

Fundus examination — The fundus examination is typically not helpful in the differential diagnosis of
the red eye. In the benign entities such as lid and conjunctival processes, the fundus examination is easily
performed and has no associated pathologic features. In iritis and keratitis, the pupil will be very small and
the patient photophobic, making the examination difficult to perform. Although the pupil is midsize in angle-
closure glaucoma, the fundus examination becomes increasingly difficult to perform as the attack persists
because of increasing corneal edema from high intraocular pressure.

ETIOLOGY AND MANAGEMENT

The differential diagnosis of the red eye includes benign conditions (table 2) and serious conditions that
require ophthalmologic evaluation (table 1). Features that can help distinguish these include history, visual
acuity, sensation of a foreign body, photophobia, discharge, pupil size and reactivity, pruritus or pain, and
fluorescein staining (table 3). Photographs of specific conditions show typical features of blepharitis
(picture 4 and picture 5), episcleritis (picture 6 and picture 7), bacterial conjunctivitis (picture 8), allergic
conjunctivitis (picture 9), corneal abrasion (picture 10), corneal foreign body (picture 11), anterior uveitis
(picture 12), hyphema (picture 3), hypopyon (picture 13 and picture 2), bacterial keratitis endophthalmitis
(picture 14), angle-closure glaucoma (picture 15), and subconjunctival hemorrhage (picture 16).

In the section to follow, the conditions that require urgent or emergency ophthalmologic evaluation are
summarized (table 1). The most common entities among the benign conditions covered in another table
(table 2), conjunctivitis and corneal abrasion, are covered elsewhere. Subconjunctival hemorrhage is
common and is alarming to patients; it is covered here as it does not fall into the other categories. (See
"Conjunctivitis" and "Allergic conjunctivitis: Clinical manifestations and diagnosis" and "Corneal abrasions
and corneal foreign bodies: Clinical manifestations and diagnosis" and "Complications of contact lenses"
and "Conjunctival injury".)

Angle-closure glaucoma — Acute angle-closure glaucoma is relatively uncommon, but the incidence
increases dramatically with age [4]. Angle closure leads to increased intraocular pressure (figure 1A-B).
The patient with angle-closure glaucoma typically appears to be in general distress. He or she is likely to
be slumped over, covering the eye or clutching the frontal or temporal region of the head with one hand,
and complaining of headache and malaise. As angle closure progresses and the intraocular pressure
rises, patients develop nausea and in some cases vomiting. The pain of angle closure is a dull ache that is
more likely reported as unilateral headache rather than eye pain. Some patients complain of "the worst
headache in my life" and do not attribute their symptoms to the eye. (See "Angle-closure glaucoma".)

Unnecessary neurologic workup and imaging that may critically delay treatment can be avoided if the red
eye is noted and assessed. Acuity becomes increasingly reduced as the duration of the attack increases.
These patients may be photophobic. They do not typically complain of a foreign body sensation.

Penlight examination reveals a red eye with ciliary flush and no discharge. The pupil is fixed in mid-dilation
and the anterior chamber is shallow. Within hours of symptom onset, the cornea becomes hazy (picture
15).

Diagnosis is confirmed with measurement of intraocular pressure. Normal intraocular pressure is 8 to 22

mmHg; pressures in acute angle closure are often greater than 45 mmHg.

Angle-closure glaucoma is a sight-threatening emergency that must be treated within hours to avoid
irreversible damage to the optic nerve. Typically, pressure-lowering topical and systemic agents are
administered, and definitive treatment in the form of laser iridotomy is performed that same day by the
ophthalmologist. The fellow eye is then treated prophylactically within days.

Hyphema — Hyphema refers to the finding of red blood cells layered out in the anterior chamber. This
finding warrants same-day evaluation by an ophthalmologist as it can be associated with significant
trauma, inflammation, or pathologic neovascularization. (See "Traumatic hyphema: Clinical features and
diagnosis" and "Traumatic hyphema: Management".)

Hypopyon — Hypopyon refers to the finding of white blood cells layered out in the anterior chamber. This
finding warrants same-day evaluation by an ophthalmologist as it can be associated with infectious
keratitis or endophthalmitis. (See "Bacterial endophthalmitis".)

Iritis — Inflammation of the anterior uveal tract is called iritis or anterior uveitis; when the adjacent ciliary
body is also inflamed, the process is called iridocyclitis. (See "Uveitis: Etiology, clinical manifestations, and
diagnosis".)

Patients with iritis may present in a similar fashion to those with an active corneal process, but there is no
foreign body sensation per se. The patient may choose to keep the eyes closed to block out light but, in a
dimly lit environment, the patient is able to keep the affected eye open spontaneously. Patients with an
active corneal process and iritis will display an aversive response when the penlight is shined in the
affected and in the uninvolved eye.

The cardinal sign of iritis is ciliary flush: injection that gives the appearance of a red ring around the iris.
Typically, there is no discharge and only minimal tearing. The pupil is typically very small. Corneal
abrasion should be ruled out with fluorescein staining, and angle closure should be ruled out by confirming
that the pupil is not fixed in mid-dilation. The diagnosis is presumptive until presence of inflammatory cells
or exudative “flare” is confirmed by slit lamp examination.

Iritis can be caused by any one of many infections, inflammatory, and infiltrative processes. These include
tuberculosis, sarcoidosis, syphilis, toxoplasma, toxocara, and reactive arthritis. Many cases are idiopathic.
Patients with iritis should be seen by an ophthalmologist within a matter of days. The ophthalmologist will
initiate treatment, typically with topical steroids, and monitor for side effects and response to therapy.
Cases that are bilateral, recurrent, sight-threatening, or non-responsive to therapy will require extensive
evaluation for etiology.

Infectious keratitis — Infectious keratitis can be caused by bacteria, viruses, fungi, or parasites [5]. One
report estimated that in the United States there are nearly one million visits to outpatient clinics or
emergency departments for keratitis or contact lens disorders annually [6]. (See "Complications of contact
lenses", section on 'Infectious keratitis'.)

Bacterial keratitis — Bacterial infectious keratitis warrants evaluation by an ophthalmologist on the

same day. The patient will complain of foreign body sensation and have trouble keeping the involved eye
open, a sign of an active corneal process. Bacterial pathogens include Staphylococcus aureus,
Pseudomonas aeruginosa, coagulase-negative Staphylococcus, diphtheroids, Streptococcus
pneumoniae, and polymicrobial isolates [7].

Improper contact lens wear is the largest risk factor for bacterial keratitis [6]. Overnight wear of contact
lenses is associated with a higher incidence of bacterial keratitis, but the entity can occur in patients who
do not wear contact lenses or who wear them on a daytime-only basis. Breakdown in local or systemic
host defense mechanisms, including dry ocular surfaces, topical corticosteroid use, and
immunosuppression, can predispose to bacterial keratitis. (See "Complications of contact lenses", section
on 'Infectious keratitis'.)

The diagnostic finding in bacterial keratitis is a corneal opacity or infiltrate (typically a round white spot) in
association with red eye, photophobia, and foreign body sensation. This infiltrate or ulcer (>0.5 mm in
size) can be seen with a penlight and does not require a slit lamp for identification. It will stain with
fluorescein. Mucopurulent discharge is typically present. Fulminant cases may present with an associated
hypopyon (layer of white cells in the anterior chamber) (picture 2).

Treatment requires urgent ophthalmological referral and prompt initiation of topical bactericidal antibiotics
(ideally after obtaining cultures). These antibiotics are sometimes compounded in fortified concentrations,
not commercially available. The role of topical glucocorticoids and topical drug combinations containing
topical steroids is controversial and best left to the discretion of the consulting ophthalmologist [7-10].

Viral keratitis — Herpes simplex causes infectious keratitis, characterized by red eye, photophobia,
foreign body sensation, and watery discharge. There may be a faint branching grey opacity on penlight
examination. This branching opacity is best visualized with application of fluorescein. Although typically a
self-limited process, duration of symptoms is reduced with treatment with topical or oral antiviral agents.
(See "Herpes simplex keratitis".)

Patients should be referred to an ophthalmologist within a few days for confirmation of diagnosis, initiation
of therapy, and monitoring for response, sequelae, or recurrence. Immunocompromised patients may
require topical and systemic treatment and longer duration of therapy. A small percentage of patients
develop chronic or recurrent inflammation, or recurrent viral keratitis, both of which are treated with
prophylactic oral antiviral agents. Some patients also benefit from treatment with topical corticosteroid
agents, used in conjunction with antiviral prophylaxis, under the care of an ophthalmologist.
Adenovirus typically causes conjunctivitis, but some strains in some individuals can cause an associated
keratitis (epidemic keratoconjunctivitis [EKC]). These patients have classic manifestations of viral
conjunctivitis but within a few days develop symptoms of an active corneal process (photophobia and
objective foreign body sensation). Penlight examination of cornea is unremarkable, but fluorescein
staining reveals multiple punctate staining lesions. Preauricular lymphadenopathy is often present.

EKC or adenoviral keratitis is typically a self-limited process without sequelae, although patients are quite
miserable during active disease because of photophobia and foreign body sensation. Referral to an
ophthalmologist within days is warranted for confirmation of the diagnosis, for monitoring for resolution,
and for treatment if there is decline in vision from centrally located viral lesions. (See "Diagnosis,
treatment, and prevention of adenovirus infection".)

Episcleritis — Episcleritis is a localized ocular redness from inflammation of episcleral vessels. It is most
commonly unilateral and sectoral, although it may also be nodular. The vessels or nodules are typically
quite distinct and are moveable over the scleral surface. Patients describe an achiness or awareness but
typically don’t report pain. Episodes typically last for a few weeks. Episcleritis can be recurrent and may be
associated with underlying autoimmune disease. Episcleritis is not sight-limiting or sight-threatening;
symptoms are typically managed with oral nonsteroidal antiinflammatory drugs (NSAIDs) by the primary
care provider, although confirmation of diagnosis by an eye care provider at first episode or for frequent
recurrence may be reassuring to both patient and primary care provider.

Scleritis — Scleritis is a painful, destructive, and potentially blinding disorder that may also involve the
cornea, adjacent episclera, and underlying uveal tract. Scleritis has a striking, highly symptomatic clinical
presentation (picture 17). Scleritis is usually characterized by severe, constant, boring pain that worsens
at night or in the early morning hours and radiates to the face and periorbital region. Additionally, patients
may report headache, watering of the eyes, ocular redness, and photophobia. If the scleritis is purely
posterior there may be no redness. When there is anterior scleritis, the redness is typically deeper in color
or purpuric when compared with the injected or “bloodshot” appearance of conjunctivitis or episcleritis.
Typically, any congested vessels are deep and not mobile. Symptoms may vary depending upon the
severity and type of scleritis that is present. Patients with suspected scleritis should be referred to an
ophthalmologist for evaluation. Scleritis is often associated with systemic disease, including systemic
rheumatologic and inflammatory disorders (table 4). (See "Clinical manifestations and diagnosis of
scleritis".)

Subconjunctival hemorrhage — Patients with subconjunctival hemorrhage are generally asymptomatic.

Typically, the patient is unaware of a problem until he or she looks in the mirror or is informed of it by
someone else. The clinical appearance of subconjunctival hemorrhage, with demarcated areas of
extravasated blood just beneath the surface of the eye, is generally both obvious and diagnostic (picture
16). However, the appearance can be quite alarming to patients and their contacts. Subconjunctival
hemorrhage may occur spontaneously or with Valsalva associated with coughing, sneezing, straining, or
vomiting. The diagnosis is confirmed by normal acuity and the absence of discharge, photophobia, or
foreign body sensation.

The blood is typically resorbed over one to two weeks, depending on the amount of extravasated blood.
Because the subconjunctival space is loculated, the amount of blood may seem to increase on the second
day, but this typically represents redistribution. No specific therapy is indicated. If subconjunctival
hemorrhage is recurrent or if the patient has a history of bleeding disorder or blood dyscrasia, or is on
anticoagulant therapy, then an underlying hematologic or coagulation abnormality must be considered.
Eyes with subconjunctival hemorrhage in the setting of blunt trauma must be evaluated for the possibility
of ruptured globe or retrobulbar hemorrhage. (See "Conjunctival injury", section on 'Subconjunctival
hemorrhage'.)

INFORMATION FOR PATIENTS

UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The
Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and
they answer the four or five key questions a patient might have about a given condition. These articles are
best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the
Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are
written at the 10th to 12th grade reading level and are best for patients who want in-depth information and
are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail
these topics to your patients. (You can also locate patient education articles on a variety of subjects by
searching on "patient info" and the keyword(s) of interest.)

● Basics topics (see "Patient education: Conjunctivitis (pink eye) (The Basics)" and "Patient education:
Photokeratitis (arc eye) (The Basics)")

● Beyond the Basics topics (See "Patient education: Conjunctivitis (pink eye) (Beyond the Basics)".)

SUMMARY

● "Red eye" is a common presenting complaint in ambulatory practice. A small percentage of patients
with red eye need urgent ophthalmological referral and treatment, although the vast majority can be
treated by the primary care clinician. (See 'Introduction' above.)

● Patient history, measurement of visual acuity, and findings on penlight examination are important
features in determining the cause and management of red eye (table 3). The history and ocular
examination provide guidance in the decision about whether to refer the patient for ophthalmologic
evaluation. The history should include whether vision is affected, whether there is a foreign body
sensation, whether there is photophobia, whether there is a history of trauma or contact lens use, and
whether discharge is present. Visual acuity of each eye should be assessed in all patients using a
Snellen chart or alternative means. Penlight examination should include pupil size and reactivity to
light, the presence and nature of discharge, the pattern of redness, and the presence of corneal
opacity, hypopyon, or hyphema. (See 'Patient evaluation' above.)

● The differential diagnosis of the red eye includes benign conditions (table 2) and serious conditions
that require ophthalmologic evaluation (table 1). (See 'Etiology and management' above.)

● In the patient with red eye, if vision is unaffected, the pupil reacts, there is no objective foreign body
sensation or photophobia, and there is no corneal opacity, hyphema, or hypopyon, it is reasonable for
 the primary care clinician to manage the condition. The following are indications for emergency
referral for ophthalmologic evaluation:

• Unilateral red eye with pain, nausea, and vomiting (see 'Angle-closure glaucoma' above)
• Hyphema or hypopyon (see 'Hyphema' above and 'Hypopyon' above)
• Visual deficit (see 'Angle-closure glaucoma' above and 'Iritis' above and 'Infectious keratitis'
above)
• Corneal opacity or infiltrate that stains with fluorescein (see 'Infectious keratitis' above)
• Severe ocular pain (see 'Scleritis' above and 'Angle-closure glaucoma' above)

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Topic 6900 Version 38.0

GRAPHICS

Emergency versus urgent referral for red eyes

Angle-closure glaucoma Emergency

Hyphema Emergency

Hypopyon Emergency

Iritis Urgent

Infectious keratitis

◾ Bacterial Emergency

◾ Viral Urgent

Scleritis Urgent

Graphic 75654 Version 4.0

Red eyes that may be managed by the primary care clinician

Stye (hordeoleum)

Chalazion

Blepharitis

Subconjunctival hemorrhage

Conjunctivitis

Bacterial

Viral

Allergic

Corneal abrasion (urgent follow-up if not better in 24 to 48 hours)

Corneal foreign body (urgent follow-up if not better in 24 to 48 hours)

Contect lens overwear (urgent follow-up if not better in 24 to 48 hours)

Dry eye syndrome

Episcleritis

Graphic 56779 Version 2.0

Assessment of the red eye

Foreign-
Cardinal
Acuity body Photophobia Discharge Treat/refer
feature
sensation

Lids/lashes

Stye/hordeoleum Normal - - None Tender Treat

Chalazion Normal - - None Nontender Treat

Blepharitis Normal - - Dry crusting Chronic Treat

Conjunctiva

Conjunctivitis

Bacterial Normal - - Mucopurulent Discharge all day Treat

Viral Mucoserous None/URI Treat

Allergic Mucoserous Itching Treat

Nonspecific Normal - - Watery

(toxic or dry eye
syndrome)

Episcleritis Normal - - None Sectoral Treat

injection, dull
ache

Subconjunctival Normal - - None Extravasated Treat

hemorrhage blood

Cornea

Abrasion Normal or + + Watery History/trauma Treat

decreased defect revealed
by fluorescein

Contact lens Normal or + + Watery History Treat

overwear decreased

Foreign body Normal or + + Mucoserous History/trauma Treat initially by

decreased attempt to
remove by
irrigation or
swab; refer if still
present after 24
hours

Infectious keratitis

Bacterial Normal or + + Muco-purulent White spot on Refer, same

decreased cornea spots day/emergent
stains with
fluorescein

Viral Normal or + + Watery Gray, branching Refer, 1 to 2

decreased opacity dendrite; days/urgent
dendrite revealed
with fluorescein

Anterior chamber/iris

Iritis Normal or - + None/watery Ciliary flush, Refer, 1 to 2

decreased very small pupil days/urgent

Hyphema Normal or - +/- None/watery RBC "level" Refer, same

decreased day/emergent

Hypopyon Normal or - +/- None/purulent WBC "level" Refer, same

decreased day/emergent

Iris/lens

Angle closure Normal or - +/- None/watery Fixed, mid- Refer, same

decreased dilated pupil day/emergent

URI: upper respiratory infection; RBC: red blood cell; WBC: white blood cell.

Graphic 77807 Version 3.0

Eye manifestations of HSV-1 infection

Different eye manifestations of herpes simplex virus-1 infection.

(A) Corneal epithelial disease with damaged epithelial cells observed as "dendrites" after staining with dyes.
(B) Corneal stromal disease or "disciform keratitis"; this reflects severe damage to infected epithelial cells, producing stromal
edema with corneal clouding.
(C) Necrotizing stromal disease in which infiltration of inflammatory cells and neovascularization results in destruction of the
cornea, glaucoma, and dense scarring.
(D) Keratouveitis in which mononuclear cell clusters, termed "keratic precipitates," can be seen in the corneal epithelium.

Reprinted from Immunology Today, 18(9), Streilein, JW, Dana, MR, Ksander, BR, HSV-1 Infections: Clinical presentation and diagnosis,
443-9, 1997, with permission from Elsevier Science.

Graphic 54460 Version 3.0

Hypopyon associated with endophthalmitis

Hazy cornea and hypopyon and markedly inflamed conjunctiva.

Reproduced with permission from: Trobe JD, Hackel RE. Field Guide to the Eyes.
Lippincott Williams & Wilkins, Philadelphia 2002. Copyright © 2002 Lippincott
Williams & Wilkins. www.lww.com.

Graphic 51972 Version 9.0

Hyphema associated with trauma

A layer of blood at the bottom of the anterior chamber.

Reproduced with permission from: Trobe JD, Hackel RE. Field Guide to the Eyes.
Lippincott Williams & Wilkins, Philadelphia 2002. Copyright © 2002 Lippincott
Williams & Wilkins. www.lww.com.

Graphic 62031 Version 11.0

Blepharitis

Blepharitis is associated with crusting of the eyelashes, thickening of the eyelids, telangiectatic
vessels along the lid margins, and plugging of the meibomian glands.

Reproduced with permission from: The Wills Eye Hospital Atlas of Clinical Ophthalmology, 2nd ed,
Tasman W, Jaeger E (Eds), Lippincott Williams & Wilkins, Philadelphia 2001. Copyright © 2001
Lippincott Williams & Wilkins.

Graphic 85896 Version 1.0

Blepharitis

Lid margins diffusely and irregularly swollen and red.

Reproduced with permission from: Trobe JD, Hackel RE. Field Guide to the Eyes. Lippincott Williams &
Wilkins, Philadelphia 2002. Copyright © 2002 Lippincott Williams & Wilkins. www.lww.com.

Graphic 85900 Version 6.0

Nodular episcleritis

Episcleritis is a localized ocular redness from inflammation of the episcleral vessels. In natural
light, vessels appear salmon pink and are movable over the scleral surface. Usually benign and
self-limited, episcleritis may be nodular, as shown here, or may show only redness and dilated
vessels.

Reproduced with permission from: The Wills Eye Hospital Atlas of Clinical Ophthalmology, 2nd ed,
Tasman W, Jaeger E (Eds), Lippincott Williams & Wilkins, Philadelphia 2001. Copyright © 2001
Lippincott Williams & Wilkins.

Graphic 85898 Version 1.0

Episcleritis

Typical form with sectoral injection.

Image created by Christopher J Rapuano, MD. Reproduced with permission from: www.visualdx.com.
Copyright VisualDx. All rights reserved.

Graphic 87224 Version 4.0

Bacterial conjunctivitis

The discharge of bacterial conjunctivitis is thick and globular; it may be yellow,

white, or green.

Reproduced with permission from: Trobe, JD. The Eyes Have It: An interactive
teaching and assessment program on vision care. WK Kellog Eye Center, University of
Michigan. Copyright © Jonathan D Trobe, MD.

Graphic 55606 Version 1.0

Acute seasonal conjunctivitis

Acute seasonal conjunctivitis classically presents with eyelid and conjunctival

erythema and swelling. It is almost always bilateral.

Graphic 57240 Version 2.0

Corneal abrasion

Corneal abrasion unmasked with use of fluorescein dye. Blue light will further enhance
visualization of abraded region where exposed basement membrane picks up the dye. The dye
has diffused under the edge of intact epithelium, making the boundary appear less distinct than
it actually is.

Image created by Christopher J Rapuano, MD. Reproduced with permission from: www.visualdx.com.
Copyright VisualDx. All rights reserved.

Graphic 87225 Version 4.0

Corneal foreign body

Corneal foreign body that has been present for several days, resulting in inflammatory
reaction to iron in the foreign body and causing local haze and surface breakdown that
picks up stain.

Image created by Christopher J Rapuano, MD. Reproduced with permission from:

www.visualdx.com. Copyright VisualDx. All rights reserved.

Graphic 87226 Version 4.0

Anterior uveitis

The irregular pupil shape is caused by inflammatory adhesion of the iris margin to the anterior
lens surface superiorly.

Reproduced with permission from: Trobe JD. The Physician's Guide to Eye Care, American Academy of
Ophthalmology 1993. Copyright © 1993.

Graphic 85904 Version 1.0

Hypopyon in endophthalmitis

A postoperative eye showing endophthalmitis with conjunctival injection and a hypopyon, the
layering of white blood cells in the anterior chamber.

Reproduced with permission from the department of Ophthalmology and Vision Science, University of
Toronto.

Graphic 59911 Version 4.0

Bacterial keratitis

The white corneal opacity suggests purulence necrosis.

Reproduced with permission from: Trobe JD. The Physician's Guide to Eye Care, American Academy of
Ophthalmology 1993. Copyright © 1993.

Graphic 85905 Version 1.0

Acute angle-closure glaucoma

The conjunctival vessels are dilated, especially near the cornea (ciliary flush)
and the cornea is slightly hazy (edematous).

Reproduced with permission from: Trobe JD, Hackel RE. Field Guide to the Eyes.
Lippincott Williams & Wilkins, Philadelphia 2002. Copyright © 2002 Lippincott
Williams & Wilkins. www.lww.com.

Graphic 80395 Version 14.0

Subconjunctival hemorrhage

Extravasated blood in the inferior conjunctiva.

Reproduced with permission from: Trobe JD, Hackel RE. Field Guide to the Eyes.
Lippincott Williams & Wilkins, Philadelphia 2002. Copyright © 2002 Lippincott
Williams & Wilkins. www.lww.com.

Graphic 51578 Version 10.0

Glaucoma: Angle anatomy of the eye

The angle is the recess formed by the irido-corneal juncture. The scleral spur,
trabecular meshwork, and Schwalbe's line lie within this angle. The trabecular
meshwork is a fenestrated structure that transmits aqueous fluid to Schlemm's
canal, from which it drains into the venous system. The normal flow of aqueous is
demonstrated here.

Reproduced with permission from Trobe JD. The Physician's Guide to Eye Care. Foundation
of the American Academy of Ophthalmology, San Francisco, 2001. p.158. Copyright ©
American Academy of Ophthalmology.

Graphic 71234 Version 3.0

Acute angle-closure glaucoma

The pupillary margin blocks the passage of aqueous from the posterior chamber
to the anterior chamber (pupillary block), ballooning the iris forward (iris
bombe), causing the iris root to occlude the trabecular meshwork and
completely obstruct drainage of aqueous fluid from the anterior chamber (angle
closure). The resulting rapid elevation of intraocular pressure requires urgent
intervention to prevent permanent visual loss.

Reproduced with permission from: Trobe JD. The Physician's Guide to Eye Care.
Foundation of the American Academy of Ophthalmology, San Francisco, 2001. p.158.
Copyright © American Academy of Ophthalmology.

Graphic 59454 Version 3.0

Bilateral scleritis

Bilateral anterior scleritis in a patient with Cogan's syndrome, manifested by

ocular pain and erythema. (The patient also had vertigo and bilateral
sensorineural hearing loss as a complication of her Cogan's syndrome.)

Graphic 81098 Version 2.0

Systemic diseases associated with scleritis

Connective tissue diseases

Rheumatoid arthritis

Reactive arthritis

Systemic lupus erythematosus

Relapsing polychondritis

Systemic vasculitides
Granulomatosis with polyangiitis

Microscopic polyangiitis

Eosinophilic granulomatosis with polyangiitis (Churg-Strauss)

Polyarteritis nodosa

Cogan's syndrome

Behçet syndrome

Urticarial vasculitis

Infections
Syphilis

Tuberculosis

Lyme disease

Herpes zoster

Aspergillis

Other
Sarcoidosis

Inflammatory bowel disease

Graphic 77619 Version 5.0