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Chapter 27: Differential Diagnosis of the Red Eye

Heidi S. Chumley; Richard P. Usatine

PATIENT STORY

A 41-year-old man wakes up with eyes that are reddened bilaterally (Figure 27-1). He has some burning and itching in the eyes, but no pain. He describes minimal crusting on his eyelashes. Examination shows no loss of vision, no foreign bodies, and pupils that are equal, round, and reactive to light. He is diagnosed with viral conjunctivitis, which does not require antibiotic treatment. He is advised about methods to prevent spreading conjunctivitis to others and is asked to notify the physician immediately if he experiences eye pain or loss of vision. He recovers spontaneously without complications after a few days.

FIGURE 27-1

Bilateral viral conjunctivitis in a 41-year-old man. (Reproduced with permission from Richard P. Usatine, MD.)

A photo shows redness in the conjunctiva of both eyes.
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INTRODUCTION

A red eye signifies ocular inflammation. The differential diagnosis includes both benign and sight-threatening conditions. The pattern of redness; presence/absence of eye pain or photophobia, vision loss, or eye discharge; involvement of cornea; and visual acuity are helpful in differentiating among causes (see Table 27-1). Although most red eyes seen in the primary care setting are a result of viral conjunctivitis, several causes of red eye require urgent referral.

TABLE 27-1Clinical Features in the Diagnosis of Red Eye
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TABLE 27-1 Clinical Features in the Diagnosis of Red Eye
  Conjunctivitis Episcleritis Scleritis Uveitis Keratitis Closed-Angle Glaucoma Subconjunctival Hemorrhage Ocular Rosacea
Redness Diffuse Segmental; pink Segmental or diffuse; dark red, purple, or blue 360-Degree perilimbal (worse at limbus) Diffuse, ciliary injection Diffuse, scleral Blotchy, outside vessels Diffuse
Eye pain No Mild, may be tender to touch Severe, boring Sometimes Usually Yes No, unless caused by trauma No
Vision loss No No Sometimes Sometimes Maybe, depending on location Yes No In severe cases
Discharge Usually No No No Maybe No No No
Photophobia* No No Yes Yes, if anterior Yes Yes No Sometimes
Pupil Normal Normal Normal Constricted Normal to constricted Mild dilation, less responsive Normal; unless affected by trauma Normal
Cornea Clear Clear Clear Clear to hazy Hazy Usually hazy Clear Clear or neovascularization, cloudy
Associated diseases URI, allergy, exposure Occasional systemic disease Systemic disease Systemic disease, idiopathic Contact lenses, HSV or varicella, rosacea Causes headaches, nausea, vomiting, GI symptoms HTN, trauma, Valsalva, cough, blood thinners Acne rosacea (can exist without also), blepharitis

HSV, herpes simplex virus; HTN, hypertension; URI, upper respiratory infection.

*For identifying serious causes of red eye, the presence of photophobia elicited with a penlight in a general practice had a positive predictive value of 60% and a negative predictive value of 90%.5

EPIDEMIOLOGY

  • An acute red eye or eyes is a common presentation in ambulatory and emergency departments.

  • Conjunctivitis is the most common cause of a nontraumatic red eye in primary ...

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