Acutely Red And Painful Eye
This is a common reason for an urgent surgery appointment. If a visit request is made, try to negotiate consultation in surgery, where optimal examination conditions and equipment are to hand. Carefully examine to assess acuity, state of the cornea and pupillary reflexes.
Differential diagnosis
Common Diagnoses
- Acute Conjunctivitis (Allergic or Infective)
- Acute Iritis
- Acute Glaucoma
- Keratitis/Corneal Ulcer
- Corneal Abrasion or Superficial Foreign Body (FB)
Occasional Diagnoses
- Episcleritis
- Scleritis
- Keratoconjunctivitis Sicca
- Trauma: Contusion and Penetrating Wound, Burns (Arc Eye and Chemical)
- Orbital Cellulitis
Rare Diagnoses
- Carotico-Cavernous Fistula (Rupture of Carotid Aneurysm)
- Gout (Urate Deposits in Conjunctiva or Sclera)
- Granulomatous Disorders: TB, Sarcoid, Toxoplasmosis
- Onchocerciasis (Transmitted by Simulium Black Fly in Africa)
- Tumour: Primary Eye Tumour, Invasion from Nasopharyngeal Tumour
Ready reckoner
Key distinguishing features of the most common diagnoses
| Conjunctivitis | Iritis | Glaucoma | Keratitis/Ulcer | Abrasion/FB | |
|---|---|---|---|---|---|
| Discharge | Yes | No | No | Possible | Possible |
| Visual Disturbance | No | Yes | Yes | Possible | Possible |
| Circumcorneal Injection | No | Yes | Possible | Possible | No |
| Poor Pupil Reflex | No | Yes | Yes | No | Possible |
| Hazy Cornea | No | Possible | Yes | Possible | No |
Possible investigations
- In practice, the problem is either easily treated by the GP (e.g. conjunctivitis or foreign body) or usually requires urgent referral. The GP’s role in investigating the painful red eye is therefore very limited.
- Swab of discharge for microbiology: Very occasionally helpful in conjunctivitis not settling with usual treatment.
- Blood: Raised WCC and ESR/CRP may support diagnosis of inflammatory disorders. Rheumatoid factor in suspected rheumatoid arthritis (RA); HLA-B27 usually positive in ankylosing spondylitis. The latter investigations would normally be performed at leisure rather than in the acute situation, when an underlying collagen disease is suspected (e.g. iritis).
- Intraocular pressure measurement is essential if acute glaucoma is suspected. Usually done by a specialist.
Top Tips
- If in serious doubt about the diagnosis, refer for urgent assessment – this is one scenario where a delay in treatment can have devastating consequences.
- Don’t rely on the patient’s subjective assessment of blurring of vision – check the visual acuity.
- Remember to evert the upper lid to check for a concealed foreign body.
- Review the patient 24–48 hours after removing a foreign body to ensure that the cornea has healed.
Red Flags
- Never use mydriatics when examining the red eye: You may precipitate acute glaucoma.
- Bilateral red eye is usually caused by conjunctivitis. If unilateral, consider other causes.
- Failure to recognise herpetic corneal ulcer or acute glaucoma may lead to permanent visual loss. If in doubt, refer for urgent specialist opinion.
- Never instil steroid drops unless you are absolutely sure you are managing the problem correctly and have excluded herpetic ulceration.
- Take a careful history when dealing with foreign bodies. Any possibility of a high-speed impact (e.g. grinding metal) requires urgent specialist assessment to exclude intraocular foreign body.
- Contact lens wearers are at risk of a number of significant ocular problems – refer any unilateral red eye in a contact lens wearer for same day specialist assessment.