OFFICIAL ABP TOPIC:

Evaluate and manage a patient with eye redness

BACKGROUND

Eye redness is one of the most common ophthalmologic complaints in primary care. While most cases are benign and self-limiting, some represent serious conditions requiring urgent intervention. Primary care physicians can effectively manage many cases, but knowing when to refer for ophthalmologic evaluation is crucial for preventing vision loss and other complications.

EVALUATION

PHYSICAL EXAMINATION

Systematic examination should include:

1. Visual Acuity
   • Test each eye separately
   • Use Snellen chart or near card
   • Document before any eye manipulation
2. Penlight Examination
   • Pupil size and reactivity: Fixed/dilated pupil suggests acute glaucoma
   • Pattern of redness: Diffuse vs. localized
   • Corneal appearance: Check for opacity, white spot, foreign body, or ciliary flush (erythema most marked around cornea)
   • Anterior chamber: Look for hypopyon (white blood cells) or hyphema (blood) in the anterior chamber
3. Fluorescein testing if concerns for corneal abrasion
4. Eyelid eversion if concerns for foreign body

DIAGNOSTIC FINDINGS BY CONDITION

BENIGN CONDITIONS (CAN BE MANAGED BY PRIMARY CARE)

• Conjunctivitis
  • Viral: Watery discharge, often bilateral, possible URI symptoms
  • Bacterial: Purulent discharge, crusting, may be unilateral
  • Allergic: Bilateral, intense itching, watery discharge
• Subconjunctival Hemorrhage
  • Well-demarcated, bright red patch on the sclera
  • Normal vision and comfort
  • No discharge
  • IMAGE: www.pbrlinks.com/MOCA2025-SH
• Blepharitis
  • Crusting and matting of eyelashes, causing morning irritation
  • Chronic course
• Chalazion
  • Firm, painless nodule in eyelid
  • Caused by obstructed meibomian gland
• Corneal Abrasion
  • Uptake of fluorescein dye in a linear or geographic pattern
  • History of minor trauma
• Contact Lens Overwear:
  • Redness, discomfort, and foreign body sensation in contact lens wearer
  • Improves with lens removal

• Dry Eye Syndrome:

  • Redness, irritation, and foreign body sensation
  • Worse in dry or windy conditions, with prolonged screen use

• Episcleritis:

  • Localized patch of redness and inflammation on sclera
  • Usually self-limited, may recur

SERIOUS CONDITIONS (REQUIRE OPHTHALMOLOGY REFERRAL)

MANAGEMENT

PRIMARY CARE MANAGEMENT

Viral Conjunctivitis:

• Supportive care (cold compresses, artificial tears)
• Counsel on contagious nature and hand hygiene
• No antibiotics needed unless secondary infection

Bacterial Conjunctivitis:

Immediate antibiotic therapy is recommended for healthcare workers, hospitalized patients, or those in other healthcare settings. It is also advised for individuals with risk factors such as immune compromise, uncontrolled diabetes, contact lens use, dry eye, or recent ocular surgery, as well as for children in schools or daycare centers requiring antibiotics for readmission.

For patients without risk factors: Consider delaying antibiotics if they are well-informed, have access to follow-up care, or prefer to avoid immediate treatment.

• Topical antibiotics may include erythromycin, trimethoprim/polymyxin B, fluoroquinolones, aminoglycosides, azithromycin, or combination products
• 5-7 days of treatment typically sufficient

Allergic Conjunctivitis:

• Topical antihistamines/mast cell stabilizers
• Environmental modification
• Consider oral antihistamines for severe cases

Subconjunctival Hemorrhage:

• Reassurance
• Assess risk factors for bleeding, including anticoagulant use
• No specific treatment needed

Blepharitis:

• Warm compresses, eyelid hygiene
• Topical antibiotics if not improving (e.g., erythromycin, bacitracin, or azithromycin)
• Oral antibiotics for severe or refractory cases

Chalazion:

• Warm compresses
• Referral for incision and drainage if persistent

Corneal Abrasion:

• Topical antibiotics (e.g., erythromycin ointment, trimethoprim/polymyxin B, fluoroquinolones); avoid aminoglycosides
• Pain control with oral analgesics and cycloplegics
• Patching not recommended
• Referral if large or vision affected

Contact Lens Overwear:

• Discontinue lens wear
• Supportive care with artificial tears
• Referral if not improving in 24-48 hours

Dry Eye Syndrome:

• Artificial tears, gels, or ointments
• Punctal plugs
• Topical cyclosporine for inflammation

Episcleritis:

• Artificial tears for comfort
• Oral NSAIDs
• Refer if recurrent or not improving with treatment

REFERRAL GUIDELINES

Emergency Referral to Ophthalmology (same day):

• Vision loss
• Severe eye pain
• Chemical exposure
• Fixed/dilated pupil
• Corneal opacity
• Hypopyon or hyphema
• Acute angle-closure glaucoma
• Bacterial keratitis
• Suspected globe rupture or penetrating injury

Urgent Referral (24-48 hours):

• Photophobia not improving
• Corneal involvement other than minor corneal abrasions
• Moderate eye pain
• History of eye surgery
• Contact lens-related infection
• Iritis/uveitis
• Scleritis
• Herpes simplex keratitis (disciform keratitis)
• Adenoviral keratitis (epidemic keratoconjunctivitis)

Routine Referral:

• Chronic conditions not responding to treatment
• Recurrent episodes
• Diagnostic uncertainty

Conditions that can be managed without referral:

• Minor corneal abrasions (with follow-up in 24-48 hours)
• Corneal foreign body (after removal, with follow-up in 24-48 hours)
• Conjunctivitis (viral, bacterial, or allergic)
• Subconjunctival hemorrhage
• Blepharitis
• Chalazion
• Hordeolum (stye)
• Dry eye syndrome
• Episcleritis

REFERENCES

https://www.uptodate.com/contents/the-red-eye-evaluation-and-management 

https://www.aafp.org/pubs/afp/issues/2010/0115/p137.html