3-24
Follow-up Actions
Return evaluation: Evacuate ASAP since the greatest potential to improve symptoms exists within the first 90
minutes after onset and significantly decreases after 24 hours.
Evacuation/Consultation Criteria: Immediate consultation if possible. Evacuate as above.
Symptom: Eye Problems: Acute Red Eye Without Trauma
MAJ Thomas Lovas, MC, USA & CAPT Frank Butler, MC, USNIntroduction: The differential diagnosis of non-traumatic acute red eye includes herpes simplex virus
keratitis, corneal erosion, acute angle-closure glaucoma, scleritis, conjunctivitis, blepharitis, ultraviolet keratitis,
episcleritis, conjunctival foreign body, dry eye and contact lens overwear syndrome. If red eye is associated
with trauma, see Eye Injury Section.
Subjective: Symptoms
Fever, eye pain, loss of vision, redness, discharge, foreign-body sensation (especially in chemical injuries),
increased sensitivity to light or photophobia (irritation of cornea or iris), dry eye, nausea and vomiting (if the
intraocular pressure rises suddenly).
Focused History Questions: Quality - Is the pain sharp or dull? (Sharp pain usually indicates a corneal
process; dull pain typically indicates iritis or scleritis) Is your eye sensitive to light? (Photophobia can indicate
many anterior segment diseases form corneal abrasion to iritis). Is there any discharge? (Mucoid discharge
may indicate viral infections, whereas purulent discharge may indicate bacterial infection)
Duration - Was the onset of symptoms sudden or over hours or, days? (Sudden onset is typically corneal;
gradual onset indicates inflammatory processes such as iritis)
Pearl: Does the patient notice a relief with one drop of topical anesthesia? If so, this indicates corneal
or conjunctival disease.
Objective: Signs
Using Basic Tools: Vital signs: Fever may indicate systemic infection.
Inspect extraocular muscles. Have patient look in all directions and note any limitations that may indicate
entrapment of a muscle or palsy.
Pupil exam: Irregular pupil may indicate scarring from iritis or ruptured globe.
Flashlight: Look for injected conjunctival vessels: perilimbal (cornea-sclera junction) injection indicates iritis;
diffuse injection indicates infection or corneal disease. Look for discharge: Mucoid discharge may indicate
viral infections, whereas purulent discharge may indicate bacterial infection
Snellen Chart (if available): Decreased visual acuity to between 20/40 and 20/100. Decreased vision
indicates abnormality in anterior segment (cornea, crystalline lens or iris). If a Snellen chart is not available,
reading the print in a book or other printed material will provide a rough measure of visual acuity.
Using Advanced Tools: Fluorescein Strip and UV light: Observe for stained tissue indicating corneal
abrasion. UV Light intensifies staining from strips.
Topical anesthesia: 1 drop proparacaine or tetracaine 0.5% Pain relief can indicate ocular surface disease
(conjunctivitis, keratitis, etc.).
Assessment:
Differential Diagnosis: Both traumatic causes (see Eye Injuries Section) and non-traumatic causes, such
as:
Herpes simplex virus keratitis - dendritic figure on fluorescein staining; no trauma; often a history of previous
episodes
Corneal erosion - abrasion or ulcer noted on fluorescein exam