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Approach to the red eye for medical students

Written by Prof. Khalil Al-Salem M.D FRCS FICO

I am writing this comprehensive article to help medical students approach patients with red eye in a more meaningful way and informative. The article will be devided to history and physical examination part.

History taking; red eye for medical students

General Overview: Red eye is a common complaint in primary care settings, indicating ocular inflammation. While many cases are benign and can be treated by primary care providers, some can be emergent, requiring immediate referral to an ophthalmologist.

What are the common causes of red eye that medical students has to be aware of?

The first cause that comes to the care give mind is Conjunctivitis, this can be caused by a chemical, trauma, allergic, infectious, or automimmune casue.

In addition, you will be focusing on questions that will role out blepharitis, corneal abrasion, foreign body in the eye, subconjunctival hemorrhage, keratitis, iritis, glaucoma, chemical burn, and scleritis. Symptoms include discharge, redness, pain, photophobia, itching, and visual changes. Viral and bacterial conjunctivitis are often self-limiting, and broad-spectrum antibiotics are commonly used for treatment. Red eye can result from inflammation of any part of the eye, including the lacrimal glands and eyelids, or from faulty tear film.

red eye for medical students
Red eye, endophthalmitis

How should a red eye be managed by the primary care giver

Primary acute angle closure glaucoma, acute iritis, dry eye, blepharitis, and conjunctivitis are key conditions leading to red eye. It’s important to classify red eye as either sight-threatening or non-sight-threatening. Painless red eye with normal vision usually recovers well, but red eye accompanied by pain, photophobia, watering, and blurred vision can be sight-threatening and requires urgent attention. Accurate early diagnosis and understanding when to refer to an ophthalmologist are critical.

What Approach to Sight-Threatening Causes of Red Eye

Approaching sight-threatening causes of red eye involves a structured assessment to identify serious conditions promptly. Here’s an overview:

History Taking: Gather detailed information about symptom onset, duration, severity, associated pain, photophobia, vision changes, discharge type, and history of trauma or contact lens use.

Symptom Evaluation: Pay attention to symptoms like severe pain, photophobia, significant visual loss, or history of chemical exposure, as these may indicate a more serious condition.

Common Sight-Threatening Conditions

Acute Angle-Closure Glaucoma: Characterized by severe pain, blurred vision, halos around lights, nausea, and a mid-dilated pupil. The eye is often red, especially around the cornea.

Scleritis: Presents with deep, boring eye pain, often radiating to the head and worsening with eye movements. Visual loss can occur if left untreated.

Keratitis: Caused by infection, injury, or wearing contact lenses. Symptoms include intense pain, photophobia, blurred vision, and discharge. The cornea appears cloudy on examination.

Iritis or Uveitis: Manifests as deep aching pain, photophobia, and blurred vision. The pupil may be irregular, and there’s often an absence of discharge.

Orbital Cellulitis: An infection marked by eyelid swelling, pain, fever, impaired eye movement, and possibly vision loss. Prompt treatment is essential to prevent serious complications.

Endophthalmitis: A severe infection inside the eye, often following surgery or penetrating injury. Symptoms include pain, redness, and significant vision loss.

Examination of a patient with red eye and poor visual acuity

Visual Acuity Test: A significant reduction in visual acuity can be a red flag for sight-threatening conditions.

Slit Lamp Examination: Allows for detailed examination of the anterior and posterior segments of the eye.

Tonometry: Measures intraocular pressure, essential for diagnosing glaucoma.

Fundoscopy: Examines the back of the eye, crucial for detecting signs of uveitis, retinal detachment, or other posterior eye diseases.

Management and Referral

Immediate Referral: Any patient with a suspected sight-threatening condition should be referred urgently to an ophthalmologist.

Pain Management: Provide pain relief while awaiting specialist assessment.

Preventive Advice: Educate patients about the importance of protective eyewear and proper contact lens hygiene.

Early recognition and prompt referral are key in managing sight-threatening red eye conditions. A thorough history, careful examination, and understanding of key symptoms can guide general practitioners in identifying these conditions and ensuring timely intervention.

Approach to Red Eyes with Normal Vision

Symptom Onset and Duration: Note the time of onset and duration of redness.

Associated Symptoms: Ask about itching, discharge, exposure to allergens or irritants, contact lens use, and any recent eye injuries or surgeries.

Pain Level: Determine if there’s any discomfort or pain, which might indicate more serious conditions despite normal vision.

Environmental or Occupational Factors: Exposure to chemicals, dust, or prolonged screen use can contribute to red eye.

2. Common Non-Sight-Threatening Causes

Conjunctivitis: Viral or allergic conjunctivitis often presents with red, itchy, watery eyes. Bacterial conjunctivitis may involve purulent discharge.

Dry Eye Syndrome: Characterized by red, dry, and gritty-feeling eyes, often exacerbated by prolonged screen use or dry environments.

Subconjunctival Hemorrhage: Appears as a bright red patch on the white of the eye, usually harmless and resolves on its own.

Blepharitis: Inflammation of the eyelid margins, causing redness, itching, and flaking.

Allergic Reactions: Often presents with bilateral redness, itching, and tearing.

3. Examination Techniques

Visual Acuity Test: Confirm that vision is indeed normal.

External Inspection: Look for eyelid swelling, discharge, or foreign bodies.

Slit Lamp Examination: For a more detailed assessment of the anterior eye structures.

Fluorescein Staining: Helps in detecting corneal abrasions or ulcers.


For Conjunctivitis: Depending on the cause, treatment may involve lubricating eye drops, antihistamines for allergies, or antibiotics for bacterial infections.

Dry Eye Management: Artificial tears, avoiding dry or smoky environments, and taking breaks during prolonged screen use.

For Blepharitis: Regular eyelid cleaning and warm compresses.

Allergic Reactions: Identifying and avoiding allergens, and using antihistamine eye drops.

5. Patient Education and Follow-up

Advise on proper eye hygiene, especially for contact lens users.

Educate about the importance of taking breaks during prolonged screen use.

Schedule a follow-up if symptoms persist or worsen.

When to Refer

Referral to an ophthalmologist is warranted if there’s no improvement with initial treatment, if symptoms worsen, or if there’s any doubt about the diagnosis.

In cases of red eyes with normal vision, the primary focus is on identifying the underlying cause through a detailed history and examination, followed by appropriate treatment and patient education. Most cases are benign and can be managed effectively in primary care, but knowing when to refer is also crucial.

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