Acute red eye

PIC Endorsed

Key points

Conjunctivitis is the most common cause of acute red eyes
Adequate analgesia will aid examination and procedural sedation may be required in the younger child to allow the clinician to differentiate benign from serious conditions
Key features of sight-threatening conditions are severe eye pain, photophobia, decreased visual acuity or a history of possible penetrating eye trauma; these conditions require specialist ophthalmological assessment

Background

Common causes of red eye include conjunctivitis (viral, bacterial, allergic or chemical), foreign body, corneal ulceration and subconjunctival haemorrhage
Uncommon but serious conditions include infectious keratitis, scleritis, uveitis, Penetrating eye injury, endophthalmitis and acute angle closure glaucoma

Assessment

History

Time course of the redness
Eye pain
Vision impairment
Eye trauma
Photophobia
Sensation of foreign body (corneal process)
Itch
Discharge
Contact lens wear
Fever (see Periorbital cellulitis)
Systemic features of inflammation (eg suggestive of Kawasaki disease, PIMS-TS)

Other factors to consider

In a neonate, consider birth history and history of maternal STI
Vomiting/coughing
Rheumatological/autoimmune conditions or family history
Anticoagulant/antiplatelet treatment

Examination

See Eye Examination for detailed approach to examination

Signs and symptoms	Diagnoses to consider
Pain, photophobia, watery discharge	Foreign body Traumatic corneal ulcer Herpetic ulcer Acute angle closure glaucoma Corneal abrasion
Purulent discharge	Bacterial conjunctivitis Infectious keratitis Endophthalmitis
Itchiness, eyelid swelling and redness, watery discharge	Allergic conjunctivitis Viral conjunctivitis
Dull, aching eye pain	Iritis Scleritis
Subconjunctival haemorrhage	Trauma Vigorous coughing or vomiting
Focal conjunctival injection	Trauma Episcleritis

Management

Conjunctivitis
Infectious, or non-infectious inflammation of the bulbar and/or palpebral conjunctivae

Use caution when diagnosing unilateral conjunctivitis

Bacterial	Viral	Allergic
Presents with purulent discharge, conjunctival inflammation, not pruritic and cornea is clear with no infiltrates Treat with eye toilet, topical chloramphenicol 0.5% eye drops 4–6 times per day for 5–7 days. Advise parents of infection control measures (eg washing hands before and after touching eyes) If hypersensitivity to chloramphenicol drops stop treatment and consult ophthalmology Reproduced with permission from The Royal Australian College of General Practitioners from: Lu SJ, Lee GA, Gole GA. Acute red eye in children: A practical approach. Aust J Gen Pract 2020;49(12):815–22 doi: 10.31128/AJGP-02-20-5240. Available at https://www1.racgp.org.au/ajgp/2020/december/acute-red-eye-in-children	Most common type of conjunctivitis Presents with watery discharge, burning sensation, bilateral conjunctival inflammation and/or chemosis, and/or eyelid swelling Often associated with URTI or gastrointestinal symptoms Self-resolving over 1–3 weeks. Symptom control with eye toilet, topical lubricants and cool compresses. Infection control measures. Contagious until eye stops tearing Suspect herpes simplex infection if lid vesicles and/or reduced vision and/or photophobia: Swab for HSV PCR Likely to require treatment with aciclovir Seek specialist advice (ophthalmology, general paediatrics, infectious diseases) If suspected in a neonate, likely to require septic work up. See neonatal conjunctivitis below	Presents with bilateral watery discharge with burning or itchy sensation and eyelid swelling, especially in an atopic child Consider treating with antihistamines (oral or topical) and artificial tears

Specific Conditions

Condition	Management
Neonatal conjunctivitis Pathogens include staphylococcus, haemophilus, streptococcus, chlamydia, gonococcus and herpes simplex Consider gonococcal conjunctivitis if severe purulent discharge with conjunctival and lid oedema Gonococcal ophthalmia neonatorum with swelling, purulent discharge, injection of the conjunctiva and chemosis	Obtain conjunctival swabs for gram stain, giemsa stain and cultures, and gonococcal and chlamydia PCR if clinical suspicion Gonococcus, chlamydia and herpes simplex can cause invasive disease and may require septic work up. Seek specialist advice (eg neonatology, infectious diseases, general paediatrics, ophthalmology). See Recognition of the seriously unwell neonate Treat chlamydial conjunctivitis with oral azithromycin 20mg/kg once daily for 3 days and eye toilet Treat gonococcal conjunctivitis with a stat dose of ceftriaxone 25-50mg/kg. Where possible, ceftriaxone should be avoided in neonates <41 weeks gestation, particularly if jaundiced or receiving calcium containing solutions. See Antimicrobial guidelines Herpes simplex infection and/or keratitis is likely to require septic work up and treatment with IV aciclovir. Seek specialist advice Treat other organisms with topical chloramphenicol 0.5% eye drops 4–6 times per day for 5–7 days
Subconjunctival haemorrhage Painless and no discharge Associated with activities that increase intraocular pressure; coughing, sneezing, vomiting, valsalva, strangulation Potential sign of penetrating eye injuryif history of trauma. If the posterior extent of the haemorrhage cannot be visualised consider an orbital or base of skull fracture In infants, subconjunctival haemorrhage may be a sign of non-accidental injury Extensive bilateral subconjunctival haemorrhages from excessive vomiting Subconjunctival haemorrhage of temporal bulbar conjunctiva	Observe. If isolated, usually resolves spontaneously within 1 – 3 weeks If recurrent, investigate cause (eg bleeding disorder). Consider non-accidental injury
Foreign body Presents with watery discharge and/or sensation of foreign body Reproduced with permission from The Royal Australian College of General Practitioners from: Lu SJ, Lee GA, Gole GA. Acute red eye in children: A practical approach. Aust J Gen Pract 2020;49(12):815–22 doi: 10.31128/AJGP-02-20-5240. Available at https://www1.racgp.org.au/ajgp/2020/december/acute-red-eye-in-children	See Acute eye injury
Corneal abrasion Presents with watery discharge and pain that is normally severe initially and then subsides over 24 – 48 hours Reproduced with permission from The Royal Australian College of General Practitioners from: Lu SJ, Lee GA, Gole GA. Acute red eye in children: A practical approach. Aust J Gen Pract 2020;49(12):815–22 doi: 10.31128/AJGP-02-20-5240. Available at https://www1.racgp.org.au/ajgp/2020/december/acute-red-eye-in-children	See Acute eye injury
Chemical/thermal burns Presents with pain, watery discharge, conjunctival inflammation or pallor in more severe burns and/or corneal epithelial defect and/or corneal opacity Reproduced with permission from The Royal Australian College of General Practitioners from: Lu SJ, Lee GA, Gole GA. Acute red eye in children: A practical approach. Aust J Gen Pract 2020;49(12):815–22 doi: 10.31128/AJGP-02-20-5240. Available at https://www1.racgp.org.au/ajgp/2020/december/acute-red-eye-in-children	See Acute eye injury Requires urgent, copious irrigation, after local anaesthetic. Sedation or urgent GA may be required
Infectious keratitis Presents with purulent discharge, severe pain, vision loss, intense inflammation of the conjunctiva and corneal opacity (round white spot), or ulcer (dendritic in herpes and varicella) visible after fluorescein staining Can be caused by bacteria, viruses, or fungi Often associated with contact lens wear Reproduced with permission from The Royal Australian College of General Practitioners from: Lu SJ, Lee GA, Gole GA. Acute red eye in children: A practical approach. Aust J Gen Pract 2020;49(12):815–22 doi: 10.31128/AJGP-02-20-5240. Available at https://www1.racgp.org.au/ajgp/2020/december/acute-red-eye-in-children	Contact ophthalmology urgently Keep contact lens if possible for culture
Endophthalmitis Presents with severe pain, purulent discharge, vision loss, intense inflammation of conjunctiva and hypopyon Risk factors: recent eye surgery, penetrating eye injury, keratitis Reproduced with permission from The Royal Australian College of General Practitioners from: Lu SJ, Lee GA, Gole GA. Acute red eye in children: A practical approach. Aust J Gen Pract 2020;49(12):815–22 doi: 10.31128/AJGP-02-20-5240. Available at https://www1.racgp.org.au/ajgp/2020/december/acute-red-eye-in-children	Contact ophthalmology urgently Likely to require broad spectrum IV antibiotics: ceftazidime 50mg/kg (maximum 2g) 8 hourly and vancomycin 15mg/kg (maximum 750mg) 6 hourly
Episcleritis and scleritis Episcleritis presents with eye irritation/mild ocular tenderness, sectoral congestion of episcleral vessels and lacrimation Scleritis presents with watery discharge, severe pain, vision loss and intense inflammation of sclera, episcleral and conjunctiva Both associated with systemic inflammatory disease	Contact ophthalmology (urgent for scleritis) Consider systemic inflammatory disease/autoimmune disease
Iritis/Uveitis Inflammation of the iris (iritis), ciliary body (cyclitis), or choroid (choroiditis) Presents with pain, photophobia, blepharospasm and lacrimation Pupil may be small, irregular and poorly reactive Causes are autoimmune, infection, and trauma	Contact ophthalmology
Acute angle closure glaucoma Presents with severe eye pain, watery discharge, decreased visual acuity (cloudy vision), cloudy cornea and fixed mildly dilated pupil May also have associated headache and vomiting (from raised pressure)	Contact ophthalmology urgently

Consider consultation with local paediatric team when

Any child with suspected child abuse, suspected STI-related conjunctivitis, or possible systemic illness

Consider consultation with ophthalmology when:

A child with a condition present in the table above, or concerns for serious sight-threatening condition
If required to facilitate a complete examination particularly in distressed child

Consider transfer when

A child with a sight threatening condition and/or management is beyond the capacity of the local team
To facilitate ophthalmological assessment

For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services

Consider discharge when

Sight-threatening conditions have been excluded AND
Appropriate treatment has been initiated as per diagnosis or referral made AND
Planned follow up, or clear instructions regarding when early review is indicated has been provided to the child and family

Parent information

Conjunctivitis Kids Health fact sheet

Last updated October 2022

Reference List

Gilani, C. Differentiating urgent and emergent causes of acute red eye for the emergency physician. Western Journal of Emergency Medicine. 2017. 18(3), p509-517.

Jacobs, D. Overview of the red eye. UpToDate (viewed 20 April 2022).

Lu, S et al. Acute red eye in children: A practical approach. Australian Journal of General Practice. 2020. 49(12), p815–22. doi: 10.31128/AJGP-02-20-5240. Retrieved from https://www1.racgp.org.au/ajgp/2020/december/acute-red-eye-in-children.

Mahmood, A. Diagnosis and management of the acute red eye. Emergency medicine clinics of North America. 2008. 26(1), p35 – 55.

NSW ACI, Ophthalmology Network, Sehu, W et al. Eye Emergency Manual App. https://aci.health.nsw.gov.au/networks/ophthalmology/about/eem (viewed 19 April 2022).

The Royal Children's Hospital Melbourne

Clinical Practice Guidelines