Approach Considerations
The key to management is making the correct diagnosis in a timely fashion. Uncomplicated cases of blepharitis, conjunctivitis, foreign bodies, corneal abrasion, and subconjunctival hemorrhage may be managed by the primary care physician. [3, 20, 21, 22, 23] However, other possible causes of red eye require ophthalmologic consultation within an appropriate time period. Corneal ulcers, iritis, endophthalmitis, penetrating foreign bodies, and other conditions must be seen by a specialist promptly. [24]
All patients with acute changes in vision require immediate consultation. Primary care physicians should refrain from treating any patients with corticosteroids without first obtaining an appropriate consultation. Referral to an internist or a family physician should be made as indicated for hypertension or bleeding diathesis. [1, 2]
Cause-Specific Management
All cases of conjunctivitis are treated with antibiotic drops to address the bacterial cause or prevent secondary bacterial infection. The common practice of prescribing a topical antibiotic ointment creates poor compliance owing to patient frustration with ointment application, as well as poor clinical response due to the limited sensitivity spectrum of the most commonly available ophthalmic ointments. Allergic conjunctivitis is treated with topical antihistamines and pulse vasoconstrictors, when indicated, occasionally in conjunction with antibiotic drops. Vasoconstrictors should never be prescribed on a long-term basis owing to the high risk for dependency. Herpes conjunctivitis and keratitis require systemic treatment with acyclovir (800 mg orally 5 times daily) and with 3% acyclovir ophthalmic ointment, topical trifluridine, or topical ganciclovir.
Red eye caused by conjunctivitis may be contagious. Washing hands and avoiding use of contaminated tissues or washcloths helps prevent spread to the other eye or to other individuals.
In blepharitis, cleaning the eyelids with soap eyelid-specific soapy applicators (Avenova, Ocusoft, Oasis brands) several times a day usually leads to symptomatic improvement. Antibiotic drops or pills may also be necessary.
Treatment of episcleritis and scleritis involves administration of nonsteroidal anti-inflammatory drugs (NSAIDS) such as diclofenac 50 mg orally 3 times daily and referral to an ophthalmologist.
Patients with iritis should be promptly (ie, within 1-2 days) referred to an ophthalmologist. Topical steroids are usually initiated by the ophthalmologist, along with cycloplegic agents to prevent synechiae.
For keratitis, the use of antibiotic eye drops or the appropriate topical antiviral agent is indicated, depending on the etiology, along with referral to an ophthalmologist.
Angle-closure glaucoma is a medical emergency that may lead to blindness; therefore, prompt treatment and evaluation by an ophthalmologist are warranted. Temporizing treatment consists of miotic drops (eg, pilocarpine 1% or 2% every 5 minutes up to 1 hour), acetazolamide (500-1000 mg orally or intravenously [IV]), antiemetics, analgesia, and, in some cases, IV mannitol. Peripheral iridotomy, usually performed with a YAG laser, is essentially curative.
In cases of subconjunctival hemorrhage with no history of trauma, no treatment is required. Artificial tears can be used 4 times per day for mild irritation. Elective use of aspirin products or NSAIDs should be discouraged. With time and blood breakdown, the hemorrhage may become green or yellow, like a bruise, spreading around the circumference of the globe. Usually, this disappears within 2 weeks. Patients are told to return if the bruiselike appearance does not fully resolve, if pain ensues, or if the hemorrhage recurs.
Treatment of red eye from a corneal or conjunctival foreign body consists of removal of the foreign body, administration of antibiotic drops, and follow-up with an ophthalmologist to monitor for the development of an infection. An Alger brush or metal rotating burr is often required to remove the painful and cicatrizing residual rust ring seen commonly after iron-containing metallic foreign body removal.
Treatment of red eye caused by dry eye syndrome (DES), or keratoconjunctivitis sicca (KCS), consists of administration of artificial tear drops and referral to an ophthalmologist if symptoms persist.
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Follicular conjunctivitis and subconjunctival hemorrhage.
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Symblepharon secondary to epidemic keratoconjunctivitis.
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Blepharitis. Courtesy of Wikipedia Commons.
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Scleritis. Courtesy of Wikipedia Commons.
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Acute dacryocystitis.
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Canaliculitis of the left lower lid. Courtesy of Peter Rubin, MD, Director, Eye Plastics Service, Massachusetts Eye and Ear Infirmary, Harvard Medical School.
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Corneal abrasion.
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This photograph depicts a child with a bilateral eye condition known as interstitial keratitis (IK), a stigma related to congenital syphilis.
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Conjunctivitis. Courtesy of Wikipedia Commons.
