acute atraumatic painful red eye(s)

see also:

• ophthalmology
• Eye injuries
• the patient with acute blurred vision or visual loss / blindness

• there are a range of non-traumatic possibilities, some of which are potentially vision threatening such as glaucoma or uveitis
• note that the patient may not be aware of a trauma, hence examination should include looking for foreign body, eye trauma
• bilateral red eyes tend to be more likely due to either conjunctivitis, welder flash burns - UV keratopathy (photo keratitis), or chemical burns
• the patient with an acute red eye (especially if unilateral) requires a complete eye exam as there are important conditions that need urgengt Rx

• visual acuity measurement
  • with glasses on if usually wears them
  • both eyes
  • if severely abnormal, check acuity with pinpoint aperture to exclude a refractive error
• check for herpes zoster (shingles) - a lesion on tip of nose is suggestive of zoster ophthalmicum
• general appearance of the eye looking for:
  • is there an obvious eyelid infection such as a stye
  • pupil size, shape and reaction
    • irregular pupil may suggest a penetrating injury (eg. from a small metal chip from hitting a metal object against a metal object) - or an old injury
    • unilateral fixed dilated pupil raises possibility of acute glaucoma or use of cycloplegic drops (which may also cause acute glaucoma)
  • presence of a hyphaema suggests traumatic injury
  • red injected sclera could suggest:
    • glaucoma
    • episcleritis - especially if sectoral, not severely painful, no photophobia
    • uveitis - especially if mainly surrounds the iris
    • conjunctivitis - especially if bilateral
    • excessive rubbing of eye due to corneal FB, keratitis, etc
• slit lamp examination
  • presence of a corneal FB (may require slit lamp exam)
  • presence of corneal pathology (usually requires slit lamp exam +/- flourescein staining):
    • vertical linear lines suggest a subtarsal FB - evert the upper eyelid to look for one
    • an oblique linear ulcer suggests a corneal abrasion eg. from a leaf on a tree or a baby's fingernail, but could be Herpes simplex virus (HSV)
    • diffuse keratitis sparing upper and lower parts of corneal suggests welding burns from UV exposure - but this is usually bilateral
    • generalised keratitis suggests chemical burn or toxin (eg. “Christmas eye” in NE Victoria), or inadequate lubrication (eg. in Facial palsy)
    • geographic ulcers suggest Herpes simplex virus (HSV) or possibly bacterial or rarely fungal infection
    • a small discrete ulcer suggests possible corneal FB which has now fallen off
  • assess anterior chamber:
    • inflammatory cells in the anterior chamber suggests uveitis
• ocular pressures
  • particularly if any features to suggest glaucoma, uveitis or eye trauma, then check ocular pressures in each eye
    • a low pressure in one eye suggests penetrating injury
    • a high pressure suggests acute glaucoma