Red and Painful Eye

Symptoms

When the presenting complaint is pain, the first step is to characterize it: itching, burning, dull pain, sharp pain, diffuse, or localized. Two factors of the history are particularly important: suddenness of onset and perception of a foreign body. A foreign-body sensation, particularly when it can be localized, is a strong indicator of corneal origin to the pain (foreign body, corneal abrasion, ulcer, or viral or ultraviolet keratitis). Itching is more often due to irritation by blepharitis, conjunctivitis, or dry eye syndrome. Burning is associated with these conditions and with other superficial problems, such as irritation of a pterygium or pinguecula, episcleritis, or limbic keratoconjunctivitis. Sharp pain generally results from abnormalities of the anterior eye, such as the cornea and uvea. Dull pain, which may be severe, is usually generalized throughout the eye (and may be reported as “headache”). It is typically a manifestation of increased intraocular pressure (IOP) (such as with narrow angle glaucoma), vitreous infection (e.g., endophthalmitis), or referred pain from an extra-orbital process (such as sinusitis, migraine headache, or temporal arteritis). Acute orbital compartment syndrome, caused by retro-orbital hematoma, presents with intense pain and progressive visual loss. These patients often present with head trauma that precludes them from reporting pain, emphasizing the importance of physical examination.

Rarely is there a chief complaint of redness that is not accompanied by pain, itching, irritation, or foreign body sensation. Completely asymptomatic “red eye” is almost always a spontaneous subconjunctival hemorrhage, which is benign but often alarming to the patient. Spontaneous subconjunctival hemorrhage may follow coughing or straining, but it most often occurs without any identifiable precipitating event and is simply noticed by the patient when looking in a mirror.

Symptomatic red eye commonly causes bulbar or limbal injection of the conjunctiva. Free blood noted behind the bulbar conjunctiva (i.e., subconjunctival hemorrhage) or in the anterior chamber (i.e., hyphema) may be spontaneous or post-traumatic. Spontaneous subconjunctival hemorrhage is painless, and the presence of pain raises concern for a more serious cause of the hemorrhage, such as direct globe injury or a retrobulbar process. Hyphema of sufficient size to be noted by the patient or bystander usually presents with pain and blurred vision.

Other symptoms include lid swelling, tearing, discharge, crusting, discomfort on blinking, or sensitivity to light. Lid swelling can be caused by inflammatory and noninflammatory processes. Concurrent erythema and tenderness of the lid favors the former. In the absence of trauma or other external irritant (e.g., contact dermatitis from eye makeup), inflammatory processes include primary lid problems, such as hordeolum (i.e., stye) or blepharitis, as well as extension from concomitant conjunctivitis or cellulitis in orbital or periorbital structures. When pain is present, tearing is usually secondary. Discharge and crusting are most commonly associated with conjunctivitis, whether allergic, chemical, viral, or bacterial. Blepharitis, dacryocystitis, and canaliculitis are other inflammatory processes that may create a discharge and subsequent crusting.

There is considerable debate within the published literature about the importance of eyelid matting as a predictor of a bacterial conjunctivitis. While some studies show that morning eyelid matting is predictive of positive bacterial cultures of ocular discharge, the clinical significance of these cultures are unclear. The hazards of equating lid sticking with bacterial infection are underscored by the fact that viral conjunctivitis, particularly caused by subtypes of adenovirus, can cause dramatic symptoms with mucopurulent discharge, lid sticking, keratitis symptoms, and lid inflammation. There is a decreased likelihood of positive bacterial cultures if the redness is not observed at 20 feet, absence of morning eyelid matting, or presentation during the summer. Even in the setting of a presumed bacterial conjunctivitis, most ophthalmology literature does not support the use of antibiotics in acute, mild conjunctivitis in patients who do not wear contact lenses, have a traumatic injury, and are immunocompetent. Additional past ocular history questions are listed in Box 18.2 .

Signs

A complete eye examination includes eight components, although many patients require only a limited or directed eye examination, depending on the presentation. The mnemonic VVEEPP (pronounced “veep”) plus slit-lamp and funduscopic examinations represent these components ( Box 18.3 ). We recommend slit-lamp examination for any complaint involving trauma, foreign-body sensation, or alteration of vision. Funduscopic examination is pursued if there is vision loss, visual alteration including clouding of vision, or suggestion of serious systemic pathology in the history and initial physical examination. A thorough physical examination can be conducted in the following order: V isual acuity, v isual field testing, e xternal examination, e xtraocular muscle movement, p upillary evaluation, and p ressure determination.

Visual Acuity

A patient’s initial visual acuity provides a baseline from which deterioration or improvement may be followed. It is also predictive of functional outcome after ocular trauma. Visual acuity is quantitatively assessed by use of a Snellen chart at a distance of 20 feet (6 m) or a Rosenbaum chart at a distance of 14 inches. Young patients who cannot yet read letters and numbers should be tested with an Allen chart that depicts easily recognizable shapes. Each eye is tested separately with the opposite eye carefully covered. Patients who present without their prescribed corrective lenses are evaluated by having them view the chart through a pinhole eye cover, which improves most refractive errors in vision.

If the patient cannot distinguish letters or shapes on a chart, visual acuity must be determined qualitatively. Any printed material suffices. The result may be recorded as, for example, “patient able to read newsprint at 3 feet.” If this is not possible, visual acuity is recorded as:

• Unable/able to count fingers (CF)

• Unable/able to perceive hand motion (HM)

• Unable/able to perceive light (LP)