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Diagnosis and Management of Red Eye in Primary Care Reviewed

  • Authors: News Author: Laurie Barclay, MD
    CME Author: Désirée Lie, MD, MSEd
  • CME/CE Released: 1/28/2010
  • Valid for credit through: 1/28/2011
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Target Audience and Goal Statement

This article is intended for primary care clinicians, emergency medicine specialists, ophthalmologists, and other specialists who care for patients presenting with red eye.

The goal of this activity is to provide medical news to primary care clinicians and other healthcare professionals in order to enhance patient care.

Upon completion of this activity, participants will be able to:

  1. Describe the most common causes of red eye.
  2. Describe management strategies for red eye and indications for referral to an ophthalmologist.


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  • Laurie Barclay, MD

    Freelance writer and reviewer, Medscape, LLC


    Disclosure: Laurie Barclay, MD, has disclosed no relevant financial relationships.


  • Brande Nicole Martin

    CME Clinical Editor, Medscape, LLC


    Disclosure: Brande Nicole Martin has disclosed no relevant financial information.

CME Author(s)

  • Désirée Lie, MD, MSEd

    Clinical Professor, Family Medicine, University of California, Irvine, Orange, California; Director of Research and Patient Development, Family Medicine, University of California, Irvine, Medical Center, Rossmoor, California


    Disclosure: Désirée Lie, MD, MSEd, has disclosed the following relevant financial relationship:
    Served as a nonproduct speaker for: "Topics in Health" for Merck Speaker Services

CME Reviewer/Nurse Planner

  • Laurie E. Scudder, MS, NP

    Accreditation Coordinator, Continuing Professional Education Department, Medscape, LLC; Clinical Assistant Professor, School of Nursing and Allied Health, George Washington University, Washington, DC; Nurse Practitioner, School-Based Health Centers, Baltimore City Public Schools, Baltimore, Maryland


    Disclosure: Laurie E. Scudder, MS, NP, has disclosed no relevant financial relationships.

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Diagnosis and Management of Red Eye in Primary Care Reviewed

Authors: News Author: Laurie Barclay, MD CME Author: Désirée Lie, MD, MSEdFaculty and Disclosures

CME/CE Released: 1/28/2010

Valid for credit through: 1/28/2011


January 28, 2010 — Diagnosis and management of red eye in the primary care setting are reviewed in the January 15 issue of the American Family Physician. Eye discharge, redness, pain, photophobia, itching, and visual changes are the characteristic signs and symptoms of red eye.

"Red eye is the cardinal sign of ocular inflammation," write Holly Cronau, MD, Ramana Reddy Kankanala, MD, and Thomas Mauger, MD, from the Ohio State University College of Medicine in Columbus. "The condition is usually benign and can be managed by primary care physicians. Conjunctivitis is the most common cause of red eye."

Both viral and bacterial conjunctivitis are usually self-limiting and rarely lead to serious complications. Most patients with conjunctivitis are typically treated with broad-spectrum antibiotics because, to date, there is no specific diagnostic test to distinguish viral from bacterial conjunctivitis. Allergies or irritants also may cause conjunctivitis.

Other common causes of red eye conjunctivitis include blepharitis, corneal abrasion, foreign body, subconjunctival hemorrhage, keratitis, iritis, glaucoma, chemical burn, and scleritis.

Complete patient history and thorough eye examination are needed to diagnose the cause of red eye. Useful questions to cover in the history include duration of symptoms and whether they are unilateral or bilateral, type and amount of discharge, visual changes, pain severity, photophobia, response to previous treatments, use of contact lenses, and history of allergies or systemic illness.

Ocular examination should include thorough inspection of the eyelids, lacrimal sac, pupil size and reactivity to light, corneal involvement, and the pattern and location of hyperemia, as well as visual acuity and the presence or absence of preauricular lymph node involvement.

In viral conjunctivitis, vision, pupil size, and reaction to light are typically normal. Findings may include diffuse conjunctival injections (redness), preauricular lymphadenopathy, and a lymphoid follicle on the undersurface of the eyelid. Pain is usually mild or absent, but there may be occasional gritty discomfort with mild itching and watery to serous discharge. Photophobia is uncommon but, when present, is often unilateral at onset, becoming bilateral within 1 or 2 days. Severe cases may be complicated by subepithelial corneal opacities and pseudomembranes. Adenovirus is the most common cause of viral conjunctivitis, and other causes include enterovirus, coxsackievirus, varicella zoster virus, Epstein-Barr virus, herpes simplex virus, and influenza.

Herpes zoster ophthalmicus is associated with a vesicular rash, keratitis, and uveitis. Rash and conjunctivitis usually precede the pain and tingling sensation in a dermatomal distribution, followed by periocular vesicles. Someone presenting with these symptoms should be referred to an ophthalmologist.

Bacterial conjunctivitis may be hyperacute, acute, or chronic. The most serious form is hyperacute, caused by Neisseria gonorrhoeae, presenting with rapid onset, purulent discharge, pain, and leading to corneal perforation.

Acute and chronic bacterial conjunctivitis are associated with eyelid edema, conjunctival injection, mild to moderate pain with stinging foreign-body sensation, and mild to moderate purulent discharge. Visual acuity is usually preserved, with normal pupil reaction and no corneal involvement. The most predictive factor is the presence of mucopurulent secretions with bilateral glued eyes on awakening. Staphylococcus aureus is the most common pathogen in adults, and Streptococcus pneumoniae and nontypeable Haemophilus influenzae are most common in children.

The underlying cause of red eye determines the appropriate course of treatment. In the primary care management of red eye, a crucial objective is to recognize when emergent referral to an ophthalmologist is required. Conditions mandating referral include severe pain refractory to topical anesthetics, need for topical steroids, vision loss, copious purulent discharge, corneal involvement, traumatic eye injury, recent ocular surgery, distorted pupil, herpes infection, or recurrent ocular infections.

"Red eye is one of the most common ophthalmologic conditions in the primary care setting," the review authors write. "Inflammation of almost any part of the eye, including the lacrimal glands and eyelids, or faulty tear film can lead to red eye. Primary care physicians often effectively manage red eye, although knowing when to refer patients to an ophthalmologist is crucial."

Specific key clinical recommendations for practice, and their accompanying level of evidence rating, are as follows:

  • Meticulous hand washing and other good hygiene practices are keys to reducing transmission of acute viral conjunctivitis (level of evidence, C).
  • For the treatment of acute bacterial conjunctivitis, any ophthalmic antibiotics may be considered because of their similar cure rates (level of evidence, A).
  • An over-the-counter antihistamine/vasoconstrictor agent, or a more effective second-generation topical histamine H1 receptor antagonist, may be used to treat mild allergic conjunctivitis (level of evidence, C).
  • For moderate dry eye, appropriate therapies include anti-inflammatory agents, such as topical corticosteroids, topical cyclosporine, and systemic omega-3 fatty acids (level of evidence, C).
  • An oral tetracycline or doxycycline may be helpful for patients with chronic blepharitis in whom response to eyelid hygiene and topical antibiotics is inadequate.

"To prevent the spread of viral conjunctivitis, patients should be counseled to practice strict hand washing and avoid sharing personal items; food handlers and health care workers should not work until eye discharge ceases; and physicians should clean instruments after every use," the review authors conclude. "Referral to an ophthalmologist is necessary if symptoms do not resolve after seven to 10 days or if there is corneal involvement. Topical corticosteroid therapy for any cause of red eye is used only under direct supervision of an ophthalmologist. Suspected ocular herpetic infection also warrants immediate ophthalmology referral."

The study authors have disclosed no relevant financial relationships.

Am Fam Physician. 2010;81:137-144.

For more information on this topic and materials helpful for patient education, readers are referred to the Mayo Clinic's site entitled Pink eye

Clinical Context

Red eye is the most common ophthalmologic condition in the primary care setting and is the cardinal sign of ocular inflammation, and it is often benign. The most common cause of red eye is conjunctivitis with infectious and allergic causes. Other causes include corneal abrasion, blepharitis, trauma, and subconjunctival hemorrhage. A good detailed history and thorough clinical examination are keys in diagnosis and management.

This is a review of the diagnosis and management of red eye in primary care.

Study Highlights

  • Referral to an ophthalmologist for red eye is always indicated when topical corticosteroids or surgery is needed.
  • Conjunctivitis is likely to be viral or bacterial.
  • Adenovirus is the most common cause of viral conjunctivitis; other causes include enterovirus, herpes simplex virus, and influenza.
  • Spread may be from respiratory secretions or by direct contact.
  • Treatment is symptomatic with cold compresses, ocular decongestants, and artificial tears; antibiotics are rarely given.
  • Referral is only necessary if there is corneal involvement or if symptoms do not resolve in 7 to 10 days.
  • Suspected ocular herpetic infection requires immediate ophthalmologic referral.
  • Bacterial conjunctivitis may be hyperacute, acute, or chronic.
  • The most serious form is hyperacute, caused by N gonorrhoeae, presenting with rapid onset, purulent discharge, pain, and leading to corneal perforation.
  • Acute bacterial conjunctivitis is the most common form, with Staphylococcus aureus causing adult forms and Streptococcus pneumoniae and nontypeable H influenzae causing pediatric forms.
  • Laboratory testing for culture and sensitivity is only indicated in severe cases, in those with immunocompromise, neonates, and after initial treatment failure.
  • Topical antibiotics are indicated because they are linked with better cure rates and outcomes.
  • 65% of bacterial conjunctivitis resolves after 2 to 5 days even without treatment, and severe complications are rare.
  • Bacterial pathogens are isolated in only 50% of cases.
  • Chlamydial conjunctivitis should be suspected in sexually active persons who do not respond to antibiotic treatment and who present with follicular conjunctivitis.
  • Sexual partners should also be treated.
  • Polymerase chain reaction testing of conjunctival scrapings is diagnostic but not usually needed.
  • Antibiotic choice should be made according to cost-effectiveness and local bacterial resistance patterns, as no one antibiotic has been shown to be superior.
  • Treatment options are generally topical erythromycin ointment and oral therapy with azithromycin single 1-g dose or doxycycline 100 mg twice daily for 14 days to clear the genital infection.
  • Allergic conjunctivitis is associated with atopy, and ocular allergies affect 25% of the US population.
  • Treatment approaches include avoidance of allergens and second-generation topical histamine H1 receptor antagonists.
  • Dry eye is common and is caused by poor tear quality, associated with increasing age, female sex, and medications such as anticholinergics.
  • Tear osmolarity is the best diagnostic test.
  • Treatment is by frequent applications of artificial tears, lubricant eye ointments and humidification, and well-fitting eyeglasses.
  • Topical cyclosporine may be used but may take several months for improvement.
  • Systemic omega-3 fatty acids have been shown to be helpful, and topical corticosteroids are effective for inflammation associated with dry eye, to prevent scarring and perforation.
  • Blepharitis is a chronic inflammatory condition of the eyelid margins associated with scalp or facial skin flaking, facial flushing, and rosacea of the nose or cheeks.
  • Topical erythromycin or bacitracin ophthalmic ointment to the eyelids and azithromycin eye drops may be used.
  • In severe cases, prolonged oral antibiotics and topical corticosteroids are indicated.
  • Corneal abrasions require supportive care, cycloplegics, pain control, and anti-inflammatory drugs.
  • Topical antibiotics do not have proven benefit, and eye patches do not improve comfort.
  • Topical aminoglycosides should be avoided, and steroids are contraindicated.
  • Referral is indicated if symptoms do not improve in 48 hours.

Clinical Implications

  • Causes of red eye include conjunctivitis (viral, bacterial, and allergic), corneal abrasion, dry eye, blepharitis, trauma, and subconjunctival hemorrhage.
  • Treatments that involve topical corticosteroids or surgery require ophthalmologic referral.

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