3. “MY EYE HURTS AND IS RED”
Patients with painful, red eyes are at risk for a variety of sight-threatening conditions, including iritis (anterior uveitis), keratitis, and acute angle closure glaucoma, as well as eye trauma (see Table).1,2,4,12,15-27 Decreased visual acuity in a patient with painful, red eyes warrants an urgent or emergent ophthalmologic referral.
When to suspect iritis
Patients with iritis will complain of vision loss, pain, photophobia, and redness. An eye exam will reveal injection of the conjunctiva around the cornea. Visual acuity is often decreased. Pupillary reaction may be sluggish, and the pupil may be smaller or larger than the other eye,4 but a normal pupil size does not exclude iritis in a patient with unilateral eye pain and ciliary injection.15
Iritis is often idiopathic, but risk factors include chronic inflammatory conditions such as ankylosing spondylitis, ulcerative colitis, and Crohn’s disease.16
Treatment with topical steroids is recommended.16 Urgent referral for long-term management of iritis is needed.17
Keratitis has varied causes
Patients with keratitis present with eye pain or foreign body sensation, redness, blurred vision, and photophobia. Examination of the eye will show injection of the conjunctiva surrounding the cornea, and possible corneal defects or opacities; visual acuity may be normal or decreased. The cause varies, based on whether keratitis is bacterial, viral, or noninfectious.
Risk factors for bacterial keratitis include extended wear of contact lenses, eye trauma, eye surgery, and systemic disease such as diabetes, while viral keratitis often follows a case of viral conjunctivitis and herpes simplex keratitis often involves reactivation of the virus. Causes of noninfectious keratitis include flash burns, dry eye or blepharitis, snow blindness, and sunburn.18
Treatment with topical antibiotics is effective for bacterial keratitis, but follow-up referral is needed because the infection could lead to loss of sight.19 Herpes simplex keratitis, which may appear as a mild corneal ulcer (a slit lamp examination will show the classic branching dendritic lesion), can be managed with topical antiviral medications,20 but here, too, an ophthalmologic referral is recommended to look for deeper corneal infiltrates that could lead to vision loss.20,21 Topical numbing medications should not be prescribed for patients with eye problems, as their extended use can lead to infection, corneal thinning, or even perforation of the cornea.22
Blurred vision, pain suggest acute angle
closure glaucoma
Patients with acute angle closure glaucoma present with blurred vision, deep eye pain or brow ache, and frequently, nausea and vomiting.23 Some patients report seeing halos around lights, as well.
Risk factors for acute angle closure glaucoma include older age, Asian descent, farsightedness, family history, and female sex. Attacks are commonly idiopathic, but some are associated with routine pupillary dilation during eye exams.24
On examination, the cornea will be cloudy due to edema and the pupil will be mid-dilated and fixed.12 Typically, intraocular pressure in the affected eye will be elevated, an indication that the nausea and vomiting are associated with this disorder rather than a gastrointestinal condition.23 Emergent referral is needed to preserve vision.25
Eye trauma: What you’ll see, when to act
Hyphema. In patients with a hyphema—typically the result of eye trauma—you’ll usually see a meniscus of blood in front of the iris in the anterior chamber (see Figure 3). If the patient was supine before the evaluation, however, you’ll see red discoloration of the iris. Hyphemas can be a threat to vision, mostly due to potential elevated pressure. Because they are often associated with more extensive ocular injuries that are not always immediately evident, urgent referral is required.26
More significant blunt trauma can cause globe rupture, resulting in both eye pain and loss of vision. Flooding the eye with fluorescein before examining it may make it possible to see a dark or green stream from the ruptured globe.
If you suspect a globe rupture, immediately stop your exam. Do not touch the eye. Instead, protect the eye—with a metal or plastic shield and an antiemetic to prevent pressure and Valsalva strain—and obtain an emergency ophthalmology consult.2,4
Chemical burns. Patients who incur chemical burns of the eye should irrigate the injured eye right away. The physical exam should be delayed until irrigation reaches an endpoint of neutral pH, as measured with Nitrazine paper.4,27 Alkali burns are particularly destructive to the eye and require longer irrigation.27
An emergent ophthalmology referral is needed for all alkali burns of the eye, as well as for any patient whose visual acuity does not return to baseline after irrigation. Slit lamp examination showing a deep corneal injury is also reason for an ophthalmology referral.1,2
4. “MY EYE IS RED” (BUT PAIN FREE)
When a patient seeks care for a red eye that’s not painful, the history and physical will help you determine whether the condition is benign or emergent. Orbital cellulitis, which we’ll discuss shortly, is the most dangerous condition related to this presentation,4,9,28-32 requiring inpatient management and ophthalmology referral (see Table).
Conjunctivitis. The entire conjunctiva will be red and discharge will be present, but visual acuity will be normal. Conjunctivitis can be viral or bacterial; office-based testing is now available for viral conjunctivitis caused by adenovirus. Treating bacterial conjunctivitis with antibiotic drops or ointment speeds recovery (see Figure 4).29 When the cause is viral, standard treatment is supportive, with emphasis on preventing viral spread. Some antiviral preparations are being investigated as potential treatments for adenovirus conjunctivitis.28
Periorbital and orbital cellulitis. Redness surrounding the eye can be caused by preseptal (commonly called periorbital) or orbital cellulitis. The clinical presentation of these two conditions is similar, including redness, lid edema, and tenderness. However, periorbital cellulitis is more commonly seen after minor trauma to the eyelid skin or related to a stye or chalazion. Orbital cellulitis, which is considerably more serious, is typically associated with sinus disease or abscess.30
Patients with orbital cellulitis will present with restricted eye movements, decreased visual acuity, proptosis, and possibly an RAPD. These patients will often have pain as well. A fine-cut CT of the orbits aids in diagnosis.31
Care for each is different. Oral antibiotics are usually sufficient for patients with periorbital cellulitis. But for orbital cellulitis, a same-day ophthalmology referral and hospitalization for treatment with parenteral antibiotics is required.9,32
Subconjunctival hemorrhage—dramatic but harmless
While dramatic in appearance, subconjunctival hemorrhage generally does not affect vision. It may be the result of trauma to the globe but can also occur spontaneously.
On physical exam, you’ll see bleeding into the conjunctiva that stops at the edge of the cornea. Visual acuity will be normal, as will the remainder of the eye examination. Abnormal vision, pain, or significant or recurrent bleeding should prompt a search for an alternative diagnosis. No treatment is needed for a simple subconjunctival hemorrhage.4
5. “MY EYE HURTS”
Patients complaining of eye pain with or without vision changes—and without redness—usually have a medical history that leads to the diagnosis (see Table).1,2,4,33-38 Physical exam findings are compatible with the history.
Optic neuritis. Patients with optic neuritis have acute to subacute vision loss, usually in one eye but sometimes bilaterally, lasting hours to days (see Figure 5). Optic neuritis is more common in women and in those ages 15 to 45, with an incidence of five in 100,000 among Caucasians.33 Pain with eye movement is present in more than 90% of adults with optic neuritis34 and is also common in children.35
In addition to vision loss, patients will report decreased detection of light and color,6 and examination will reveal an RAPD.1,2 Vision returns without treatment to the same extent as with treatment, but treatment will speed recovery.36 Patients with optic neuritis require an urgent referral to an ophthalmologist or neurologist to evaluate for multiple sclerosis, which develops in about 30% of those with optic neuritis.4,33
Corneal abrasion. Pain, localized to the surface of the eye, will be the primary complaint of patients with a corneal abrasion, who may or may not have loss of vision. Larger and deeper abrasions are extremely painful, while smaller corneal abrasions may be experienced as a foreign body sensation. The typical patient with a corneal abrasion is likely to have had trauma to the eye.37
Fluorescein is used to examine the patient with a suspected abrasion to highlight the epithelial defect.1 Visual acuity needs to be tested and checked using a pinhole if it is below baseline.37 Treatment protocols range from artificial tears to antibiotic drops or ointments. Topical steroids should be given to patients only by an ophthalmologist.4
Is patching necessary? In a systematic review comparing outcomes based on the use of patching versus not patching on the first day of injury, patients who were not given patches fared the same or better than those whose eyes were patched, both in terms of healing time and pain relief. Primary care providers can treat most corneal abrasions, and symptoms typically resolve in two days.38
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