Red Eye

Author: Michelle Lin, MD
Updated: 1/22/2010

Red Eye

There is significant overlap among conditions that cause a red, painful or red and painful eye. Here are additional cards that may help in your evaluation:


Bacterial conjunctivitis photo


  • IgE mediated, usually associated with itching
  • Treatment: Cold compresses, over-the-counter topical vasoconstrictors, histamine-blocking eyedrops


  • Most common form of infectious conjunctivitis (usually adenovirus)
  • Preauricular lymphadenopathy, global conjunctival injection
  • Watery discharge
  • Follicular reaction of inferior tarsal conjunctiva
  • Treatment: Cold compresses, artificial tears, topicaldecongestants, +/- topical antibiotics, if not able to discern from bacterial etiology

Viral: Epidemic keratoconjunctivitis

Epidemic keratoconjunctivitis photo

  • Adenovirus
  • Symptoms: Eye pain, decreased visual acuity
  • Findings: Corneal subepithelial infiltrates (1-2 mm gray-white crumb-like defects)

Viral: HSV conjunctivitis

  • More prevalent in HIV patients
  • Foreign body sensation in eye (unlike typical viral conjunctivitis)
  • Treatment:
    • If no skin or corneal involvement, topical antivirals (trifluridine or vidarabine) x 10-14 days
    • If corneal involvement (dendrites seen), topical trifluridine and oral acyclovir x 7-10 days. NO STEROIDS.

Viral: HZV ophthalmicus

VZV virus: Reactivation through V1 nerve


  • Hutchinson sign: Herpes pustules at nose tip and is predictive of ocular involvement
  • Dendrites on eye exam
  • Treatment: Systemic vs topical antiviral agents, +/- steroids only with ophthalmology consult


  • Often association with morning crusting
  • Injection more pronounced at fornices
  • Contact lens wearer: Pseudomonas risk
    • Treatment: Topical fluoroquinolone, cycloplegic

Gonorrheal conjunctivitis:

  • Sexually active patients and neonates (from birthcanal)
  • “hyperacute conjunctivitis”, abrupt onset
  • copious purulent discharge
  • Treatment: Topical antibiotics, usually with systemic antibitics because associated with venereal disease

Inclusion or Chlamydial conjunctivitis:

  • Sexually active patients and neonates
  • mucopurulent discharge
  • foreign body sensation
  • Check for concurrent sexually transmitted infections (symptomatic only 1⁄2 patients).
  • Treatment: Topical erythromycin and po azithromycin x 1

Subconjunctival Hemorrhage

  • In setting of trauma and large hemorrhage, consider globe rupture
  • Treatment: Warm compresses, lubrication drops


Episcleritis photo

  • Episclera: Thin membrane over the sclera and beneath conjunctiva
  • Benign self-limited inflammatory cond with focal area of dilated episceral vessels
  • Seen with rheumatoid arthritis, polyarteritis nodosa, lupus, inflam bowel disease, sarcoid, Wegener’s, gout, herpes zoster virus, syphilis
  • Treatment: Oral NSAIDs


Scleritis photo

  • Most common immune cause: Rheumatoid arthritis
  • Most common vasculitis cause: Wegener’s
  • Symptoms: Severe eye pain radiating to ear, scalp, face, and jaw. Dull pain. Photophobia.
  • Exam: Deep episcleral plexus is vascularly engorged – appears blue-violet, vessels non-blanching with vasoconstrictor, scleral edema
  • Treatment:
    • Oral NSAIDs
    • Consider oral steroids, but with ophthalmology consultation


  • Divided into anterior (iris, ciliary body) vs posterior (retinochoroiditis)
  • Etiologies: Inflammatory (50% assoc w/ systemic inflam disease), traumatic, infectious
  • Consider CMV in posterior uveitis in HIV patients
  • Anterior uveitis: Sudden, severe, painful eye; photophobia; perilimbal injection, consensual photophobia from unaffected eye
  • Posterior uveitis: “Floaters”, flashing light – no redness or pain
  • Exam: Inflammatory cells, proteinaceous flare
  • Complications: Cataracts, glaucoma, retinal detachment
  • Treatment:
    • Mydriatic or cycloplegic drops
    • Consider oral steroids, but with ophthalmology consult

Acute Angle Closure Glaucoma

Acute Angle Closure Glaucoma photo

  • Symptoms: Blurred vision, halos around lights, nausea/vomiting, headache
  • Pearl: Consider in all patients with “migraine HA’s” – check pupil reactivity
  • Exam: Corneal edema, mid-dilated NON-reactive pupil
  • Intraocular pressure >30 mmHg requires prompt treatment
  • Treatment:
    • Topicals: Timolol, prednisolone, apraclonidine
    • Oral: Acetazolamide


  • Mahmood AR, Narang AT. Diagnosis and management of the acute red eye. Emerg Med Clin North Am. 2008 Feb;26(1):35-55, vi. [PubMed]