Red Eye
Cynthia J. Mollen
INTRODUCTION
Red eye may refer to erythema of the ocular adnexa, conjunctiva, sclera, or cornea, or inflammation of deeper structures.
DIFFERENTIAL DIAGNOSIS LISTOcular Adnexa
Infectious Causes
Hordeolum and chalazion
Dacryocystitis
Molluscum contagiosum
Blepharitis
Phthiriasis (louse)
Frontal sinus infection or other sinusitis
Periostitis of orbital bones
Orbital cellulitis, periorbital cellulitis
Dental abscess
Neoplastic Causes
Neuroblastoma
Leukemia
Neurofibroma
Traumatic Causes
Insect bites
Basilar skull fracture
Trauma to eyelid or nose
Miscellaneous Causes
Frequent eye rubbing
Cavernous sinus thrombosis
Prolonged crying
Contact dermatitis
Seborrhea
Conjunctiva
Infectious Causes
Bacteria
Viruses
Fungi
Protozoans
Helminths—onchocerciasis (river blindness)
Toxic Causes
Atropine, scopolamine
Irritants—makeup, smoke, smog, chemicals, contact lenses, caterpillar hair, wind, ultraviolet light, tobacco
Neoplastic Causes
Orbital tumors—retinoblastoma
Traumatic Causes
Foreign body
Entropion, ectropion
Child abuse
Blunt or penetrating trauma
Traumatic glaucoma
Subconjunctival hemorrhage
Immunologic Causes
Allergic/inflammatory conjunctivitis
Keratoconjunctivitis sicca and other dry eye disorders
Nasal inflammation
Sjögren syndrome and other collagen vascular diseases
Kawasaki syndrome
Stevens-Johnson syndrome
Inflammatory bowel disease
Juvenile rheumatoid arthritis
Graves disease
Miscellaneous Causes
Bone marrow transplant
Ectodermal dysplasia
Subconjunctival hemorrhage (secondary to severe cough, bacteremia, blood dyscrasia, or vomiting)
Cornea
Infectious Causes
Keratitis
Syphilis
Traumatic Causes
Contact lenses
Corneal ulcer
Corneal abrasion
Chemical irritant
Uveal Tract
Iridocyclitis
Reiter syndrome
Sclera
Episcleritis
Scleritis
Collagen vascular disease
Pupil
Hyphema
Globe
Glaucoma
DIFFERENTIAL DIAGNOSIS DISCUSSION
Neonatal Conjunctivitis
Etiology
Neonatal conjunctivitis is most often secondary to infection or chemical irritation.
Infection. Causes of infectious conjunctivitis in the neonates include sexually transmitted and nonsexually transmitted organisms. Sexually transmitted agents, in order of decreasing frequency, are Chlamydia trachomatis, Neisseria gonorrhoeae, and herpes simplex virus (HSV), usually type 2. Staphylococcus aureus is the most common nonsexually transmitted infectious pathogen. Other bacterial causes include enteric Gram-negative rods.
Chemical irritation. Silver nitrate is the most common cause of neonatal chemical conjunctivitis, although other antibiotics used for prophylaxis can also cause conjunctivitis.
Clinical Features
Conjunctivitis that presents in the first 24 hours of life is most likely secondary to chemical irritation, unless there was prolonged rupture of membranes before delivery.
Gonococcal conjunctivitis, which presents 2 to 6 days after birth, is an acute to hyperacute infection that causes edema of the eyelids and conjunctiva (chemosis), local pain, and a copious purulent discharge. Swelling and discharge can be so extensive that the orbit is difficult to view. Often there is a palpable preauricular node, a finding otherwise uncommon in bacterial conjunctivitis.
Chlamydial conjunctivitis has a slightly later onset than gonococcal conjunctivitis but can be symptomatic as early as 4 to 5 days after birth. Modest purulent
drainage and mild-to-moderate inflammation are seen. As with gonococcal conjunctivitis, the preauricular lymph node may be tender.
Herpes simplex conjunctivitis is associated with clusters of vesicles on the face, eyelids, and mucous membranes.
HINT: Chlamydial conjunctivitis, in general, is markedly less acute and impressive than gonococcal conjunctivitis.
HINT: Chlamydial pneumonitis occurs in as many as a one-third of infants with chlamydial conjunctivitis, although it presents later, typically at 3 to 16 weeks of age.Evaluation
Bacterial culture, including chocolate agar or Thayer-Martin plates and Gram stain of the purulent material, should be obtained. In up to 95% of cases of gonococcal conjunctivitis, Gram-negative intracellular diplococci are identified by Gram stain.
Chlamydia culture should be obtained on conjunctival scrapings (not purulent material) using a Dacron-tipped swab. Nucleic acid amplification techniques can be used to identify both the organisms in laboratories with these testing capabilities. In patients with suspected herpes simplex conjunctivitis, conjunctival scrapings reveal mononuclear cells and giant multinucleated epithelial cells.
Treatment
Chlamydial conjunctivitis. Hospitalization is not necessary. Treatment consists of 14 days of oral erythromycin combined with topical erythromycin.
Gonococcal conjunctivitis. Hospitalization and consultation with an ophthalmologist are required. The eye should be irrigated every 1 to 2 hours to reduce bacterial load and local irritation. Improperly treated gonococcal conjunctivitis can quickly damage vision. Intravenous therapy for 7 days is indicated for disseminated infection, and up to 14 days for meningitis; one dose is adequate for isolated conjunctivitis. Cefotaxime or ceftriaxone are appropriate until sensitivities are known; use ceftriaxone with caution in patients with hyperbilirubinemia.
Herpes simplex conjunctivitis. Patients must be followed by an ophthalmologist to minimize the chances of permanent scarring and damage to vision.
Infectious Conjunctivitis (Outside the Neonatal Period)
Etiology
The most common bacterial cause of conjunctivitis is S. aureus, which affects all age groups. Haemophilus influenzae and Streptococcus pneumoniae are common causes of conjunctivitis in young children. Adolescents can also present with gonococcal conjunctivitis secondary to sexual contact.
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