Red Eye

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A red eye is one of the  cardinal signs of ocular inflammation, which can result from many conditions. Subconjunctival hemorrhage (see the image below), defined as blood between the conjunctiva and the sclera, is usually not secondary to inflammation. ^{[1, 2]} Most cases of subconjunctival hemorrhage are benign and can be effectively managed by the primary care provider. ^[3] The key to management is recognizing cases with underlying disease that require ophthalmologic consultation.

For patient education resources, see the Eye and Vision Center and the Glaucoma Center, as well as Anatomy of the Eye, Pinkeye, Iritis, Subconjunctival Hemorrhage (Bleeding in Eye), Black Eye, and Glaucoma Overview.

A red eye most often results from dilation of blood vessels in the anterior portion of the eye. Diagnosis may be aided by the differentiation between ciliary and conjunctival injection. Ciliary injection involves branches of the anterior ciliary arteries and indicates inflammation of the cornea, iris, or ciliary body. Conjunctival injection mainly affects the posterior conjunctival blood vessels. Because these vessels are more superficial than the ciliary arteries, they produce more redness, move with the conjunctiva, and constrict with the application of topical vasoconstrictors. ^[4]

Numerous conditions may be associated with red eye, including conjunctivitis, blepharitis, canaliculitis, corneal injury, dacryocystitis, episcleritis, scleritis, iritis, keratitis, dry eye syndrome (DES; also referred to as keratoconjunctivitis sicca [KCS]), glaucoma, subconjunctival hemorrhage, bacterial or viral infection, or trauma.

Conjunctivitis, the most common cause of red eye, is characterized by vascular dilation of the superficial conjunctival blood vessels, cellular infiltration, and exudation; it must be differentiated on the basis of etiology (viral, bacterial, or allergic).

Blepharitis is an inflammation of the eyelids, usually involving the lid margins. It may be seborrheic or may be caused by staphylococcal infection.

Canaliculitis often is caused by Actinomyces israelii, but Candida or Aspergillus species also may be involved.

Numerous causes or corneal injury exist, which can be grouped into infective, toxic, degenerative, traumatic and allergic conditions.

Dacryocystitis is inflammation of the lacrimal sac caused by obstruction of the nasolacrimal duct. In infants, this results from failure of the canalization that normally occurs by the end of the first month. In adults, acute forms are due to Staphylococcus aureus or beta-hemolytic Streptococcus. Acute cases in children are due to Haemophilus influenzae.

The episclera is the layer between the conjunctiva and the sclera. Episcleritis is an inflammation of the episcleral vessels, usually of autoimmune origin; it can be caused by virtually any inflammatory systemic condition affecting the body, such as rheumatoid arthritis, Sjögren syndrome, coccidioidomycosis, syphilis, zoster, or tuberculosis. Most often, no specific cause can be determined even after these inflammatory conditions have been tested for.

Iritis is an inflammation of the anterior uveal tract. In most cases, the cause cannot be determined. Like episcleritis, however, iritis can be caused by any systemic inflammatory disease. More than 50% of patients have human leukocyte antigen (HLA) B27 (HLA-B27) or HLA-B8 and the many diseases associated with them. Trauma is a common cause.

Keratitis is an inflammation of the cornea and can be of bacterial, viral, fungal, or parasitic origin.

DES may result from any disease that is associated with deficiency of tear film components and lid surface or epithelial abnormalities. In particular, KCS may be associated with rheumatoid arthritis and other autoimmune diseases (Sjögren syndrome).

Narrow-angle glaucoma occurs in patients with preexisting narrowing of the anterior chamber angle. Far-sighted patients and older patients are at increased risk when there has been enlargement of the lens.

Associated systemic disease (eg, rheumatoid arthritis, herpes zoster ophthalmicus, or gout) is found in 40% of all patients with scleritis (anterior).

Subconjunctival hemorrhage results from bleeding of the conjunctival or episcleral blood vessels into the subconjunctival space. It may be spontaneous, traumatic, or related to systemic illness. ^{[5, 6, 7, 8]} The classic presentation involves a patient without eye pain or visual disturbance who discovers the red eye in the mirror or from a concerned friend or family member. Occasionally, the subconjunctival hematoma may be more extensive, thereby elevating the overlying conjunctival tissue and leading to excessive discomfort and surface irritation due to exposure or blinking. In rare cases, the elevated redundant conjunctiva becomes trapped and compressed between the lids, creating even more discomfort and superficial punctate conjunctival staining or frank conjunctival abrasions. Persistent elevated limbal conjunctiva may cause a dellen, which may cause other clinical complications. Causes of a subconjunctival hematoma include the following: ^{[9, 10]}

Bacterial pathogens in keratitis and corneal ulcers include Pseudomonas aeruginosa, S aureus, Streptococcus pneumoniae, and coagulase-negative Staphylococcus. Viral pathogens include herpes simplex and adenovirus.

Red eye is very common, and conjunctivitis is the most frequent cause. Subconjunctival hemorrhage also occurs frequently, but, because it is a self-limited disorder, exact figures are not available since many asymptomatic individuals do not seek medical care. Subconjunctival hemorrhage can occur at all ages, but it is more common with increasing age; no sex-based or racial predilection has been noted.

The prognosis depends on the cause of the red eye. For example, subconjunctival hemorrhage is a self-limited condition when not associated with systemic illness or significant trauma; thus, the prognosis is excellent. Complications also depend on the cause of the red eye.

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Mimura T, Yamagami S, Mori M, Funatsu H, Usui T, Noma H, et al. Contact lens-induced subconjunctival hemorrhage. Am J Ophthalmol. 2010 Nov. 150(5):656-665.e1. [Medline].

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A V P, Patil SS, Koti SV, J S A, Garag SS, Hegde JS. Clinico-bacteriological study of chronic dacryocystitis cases in northern karnataka, India. J Clin Diagn Res. 2013 Nov. 7 (11):2502-4. [Medline].

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Mimura T, Yamagami S, Usui T, Funatsu H, Noma H, Honda N, et al. Location and extent of subconjunctival hemorrhage. Ophthalmologica. 2010. 224(2):90-5. [Medline].

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Robert H Graham, MD Consultant, Department of Ophthalmology, Mayo Clinic, Scottsdale, Arizona

Robert H Graham, MD is a member of the following medical societies: American Academy of Ophthalmology, Arizona Ophthalmological Society, American Medical Association

Disclosure: Partner received salary from Medscape/WebMD for employment.

Vivian Monsanto, MD 

Vivian Monsanto, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Ophthalmology

Disclosure: Nothing to disclose.

Norvin Perez, MD Medical Director, Juneau Urgent and Family Care

Norvin Perez, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Andrew A Dahl, MD, FACS Assistant Professor of Surgery (Ophthalmology), New York College of Medicine (NYCOM); Director of Residency Ophthalmology Training, The Institute for Family Health and Mid-Hudson Family Practice Residency Program; Staff Ophthalmologist, Telluride Medical Center

Andrew A Dahl, MD, FACS is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, American Intraocular Lens Society, American Medical Association, American Society of Cataract and Refractive Surgery, Contact Lens Association of Ophthalmologists, Medical Society of the State of New York, New York State Ophthalmological Society, Outpatient Ophthalmic Surgery Society

Disclosure: Nothing to disclose.

Gino A Farina, MD Program Director, Associate Professor of Clinical Emergency Medicine, Department of Emergency Medicine, Long Island Jewish Medical Center, Albert Einstein College of Medicine

Gino A Farina, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Judith Flaherty-Arnoux, MD Resident Physician, Department of Emergency Medicine, Long Island Jewish Medical Center

Disclosure: Nothing to disclose.

Kilbourn Gordon III, MD, FACEP Urgent Care Physician

Kilbourn Gordon III, MD, FACEP is a member of the following medical societies: American Academy of Ophthalmology and Wilderness Medical Society

Disclosure: Nothing to disclose.

Simon K Law, MD, PharmD Assistant Professor of Ophthalmology, Jules Stein Eye Institute; Chief of Section of Ophthalmology Surgical Services, Department of Veterans Affairs Healthcare Center, West Los Angeles

Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology

Disclosure: Nothing to disclose.

Gregory I Mazarin, MD Assistant Professor, Department of Emergency Medicine, Department of Emergency Medicine, Montefiore Medical Center, Albert Einstein College of Medicine; Consulting Staff, St Vincent’s Midtown, North Shore University Hospital

Gregory I Mazarin, MD is a member of the following medical societies: Alpha Omega Alpha

Disclosure: Nothing to disclose.

J James Rowsey, MD Former Director of Corneal Services, St Luke’s Cataract and Laser Institute

J James Rowsey, MD is a member of the following medical societies: American Academy of Ophthalmology, American Association for the Advancement of Science, American Medical Association, Association for Research in Vision and Ophthalmology, Florida Medical Association, Pan-American Association of Ophthalmology, Sigma Xi, and Southern Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Red Eye

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