Urgent Care Evaluation and Management of the Red Eye (Infectious Disease and Pharmacology CME)

Table of Contents

 

About This Issue

Chief complaints of “red eyes”—with or without other symptoms—are common in the urgent care setting. Most causes of a red eye can be easily managed in an urgent care setting, but benign and self-limited causes must be differentiated from more serious conditions that can result in vision loss. In this issue, you will learn:

The key aspects of the patient history, physical examination, and eye examination that will help to determine the etiology of a red eye.

The role of topical anesthetics in the evaluation and diagnosis of red eyes.

How to interpret fluorescein staining patterns to assist in red eye diagnosis.

When antibiotic treatment is indicated in various eye conditions.

Which eye conditions require urgent ophthalmology consultation or referral.

CHARTING & CODING: Learn how to select the appropriate level of service for patient encounters for red eye complaints.

1. About This Issue
2. Abstract
3. Case Presentations
4. Introduction
5. Anatomy and Pathophysiology
6. Urgent Care Evaluation
   1. History
   2. Physical Examination
      1. Visual Acuity
      2. External Eye and Face
      3. Topical Anesthesia
      4. Penlight and Pupil Examination
      5. Funduscopy
      6. Slit Lamp
      7. Eyelid Eversion
      8. Fluorescein Staining
      9. Tonometry
7. Diagnosis
8. Treatment
   1. Entropion and Trichiasis
   2. Subconjunctival Hemorrhage
   3. Allergic Conjunctivitis
   4. Infectious Bacterial and Viral Conjunctivitis
   5. Dry Eyes
   6. Episcleritis
   7. Scleritis
   8. Anterior Uveitis
   9. Corneal Abrasion
   10. Keratitis
       1. Noninfectious Keratitis
       2. Viral Keratitis
   11. Acute Angle-Closure Glaucoma
9. KidBits: Special Considerations in Pediatric Patients
10. Disposition
11. Summary
12. 5 Things That Will Change Your Practice
13. Risk Management Pitfalls for Evaluation and Management of the Red Eye in Urgent Care
14. Case Conclusions
15. Coding & Charting: What You Need to Know
    1. Medical Decision Making
       1. Number and Complexity of Problems Addressed
       2. Amount and/or Complexity of Data to be Reviewed and Analyzed
       3. Risk of Morbidity and/or Mortality of Patient Management
    2. Documentation
16. Acknowledgments
17. Clinical Pathway for Diagnostic Evaluation of the Red Eye
18. References

Abstract

Red eyes are a common presenting complaint in urgent care settings, with causes that range from benign to vision-threatening. A thorough and efficient evaluation of red eyes is critical to identify more serious causes and provide prompt referral if needed. A detailed patient history and eye examination, along with the use of diagnostic tools such as visual acuity testing and fluorescein staining, will guide the urgent care clinician in the assessment. This review provides an evidence-based framework for evaluating red eye presentations in urgent care. Recommendations for management are also offered, including indications for consultation or emergent referral to ophthalmology, along with treatment recommendations for conditions that can be managed in urgent care.

Case Presentations

A 23-year-old woman presents with 1 month of mild eye redness and itchiness...

• She has minimal clear discharge involving both eyes that is consistent throughout the day.
• She reports no systemic symptoms other than seasonal allergies.
• The patient says she just needs antibiotic drops for her “pink eye,” but you suspect a different etiology...

A 35-year-old man presents with 48 hours of redness in his left eye...

• He complains of increased tear production and increasing discomfort in the eye.
• He is photophobic to minimal light.
• His pupils are equal in size. On penlight exam, you notice there is significant limbic injection.
• You wonder what additional diagnostic steps should be taken for this patient...

A 69-year-old man presents with acute onset of visual loss and redness in his right eye...

• He complains of discomfort, vision loss, and redness without discharge in the right eye. His left eye is unaffected.
• Symptoms began after he lifted a heavy suitcase into the trunk of his car. He was able to drive home from his vacation, but when his vision did not improve after the drive, he decided to come to the urgent care clinic.
• As part of your focused history, you learn that the patient had lens replacement surgery 3 months ago for cataracts.
• Given the recent eye surgery, you know that an ophthalmology referral will be needed. As you proceed with the eye examination, you consider how urgent that referral will need to be...

How would you manage these patients? Subscribe for evidence-based best practices and to discover the outcomes.

Clinical Pathway for Diagnostic Evaluation of the Red Eye

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

1. * Narayana S, McGee S. Bedside diagnosis of the 'red eye': a systematic review. Am J Med. 2015;128(11):1220-1224. (Systematic review; 5 studies, 957 patients) DOI: 10.1016/j.amjmed.2015.06.026

5. * Chuck RS, Dunn SP, Flaxel CJ, et al. Comprehensive adult medical eye evaluation Preferred Practice Pattern^®. Ophthalmology. 2021;128(1):P1-P29. (Guidelines) DOI: 10.1016/j.ophtha.2020.10.024

7. Gurnani B, Kim J, Tripathy K, et al. Iritis. In: StatPearls. NCBI Bookshelf version. StatPearls Publishing; 2023. Updated February 27, 2023. Accessed July 10, 2023. (Online textbook chapter)

8. Singh P, Gupta A, Tripathy K. Keratitis. In: StatPearls. NCBI Bookshelf version. StatPearls Publishing; 2023. Updated February 22, 2023. Accessed July 10, 2023. (Online textbook chapter)

10. * Alteveer JG, McCans KM. The red eye, the swollen eye, and acute vision loss: handling non-traumatic eye disorders in the ED. Emerg Med Pract. 2002;4(6):1-28. (Review)

12. * Gilani CJ, Yang A, Yonkers M, et al. Differentiating urgent and emergent causes of acute red eye for the emergency physician. West J Emerg Med. 2017;18(3):509-517. (Review) DOI: 10.5811/westjem.2016.12.31798

21. Gosling D, Meyer JJ. Normal tension glaucoma. In: StatPearls. NCBI Bookshelf version. StatPearls Publishing; 2023. Updated December 12, 2022. Accessed July 10, 2023. (Online textbook chapter)

23. * Leibowitz HM. The red eye. N Engl J Med. 2000;343(5):345-351. (Review) DOI: 10.1056/NEJM200008033430507

25. * Timlin H, Butler L, Wright M. The accuracy of the Edinburgh Red Eye Diagnostic Algorithm. Eye (Lond). 2015;29(5):619-624. (Prospective study; 39 patients) DOI: 10.1038/eye.2015.9

27. Baab S, Le PH, Kinzer EE. Allergic conjunctivitis. In: StatPearls. NCBI Bookshelf version. StatPearls Publishing; 2023. Updated May 23, 2022. Accessed July 10, 2023. (Online textbook chapter)

29. * Johnson D, Liu D, Simel D. Does this patient with acute infectious conjunctivitis have a bacterial infection?: The rational clinical examination systematic review. JAMA. 2022;327(22):2231-2237. (Systematic review and meta-analysis; 32 studies) DOI: 10.1001/jama.2022.7687

30. Pippin MM, Le JK. Bacterial conjunctivitis. In: StatPearls. NCBI Bookshelf version. StatPearls Publishing; 2023. Updated January 23, 2023. Accessed July 10, 2023. (Online textbook chapter)

31. * Jacobs DS. Conjunctivitis. In: Post T, ed. UptoDate. 2020. Updated April 11, 2023. Accessed July 10, 2023. (Online textbook chapter)

33. * Tarff A, Behrens A. Ocular emergencies: red eye. Med Clin North Am. 2017;101(3):615-639. (Review) DOI: 10.1016/j.mcna.2016.12.013

34. Schonberg S, Stokkermans TJ. Episcleritis. In: StatPearls. NCBI Bookshelf version. StatPearls Publishing; 2023. Updated September 25, 2022. Accessed July 10, 2023. (Online textbook chapter)

36. Lagina A, Ramphul K. Scleritis. In: StatPearls. NCBI Bookshelf version. StatPearls Publishing; 2023. Updated June 27, 2022. Accessed July 10, 2023. (Online textbook chapter)

41. Hayden FA. Distinguishing dendrites. ASCRS EyeWorld. March 2012. Accessed July 10, 2023. (Online article)

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Keywords: red eye, conjunctival injection, viral conjunctivitis, bacterial conjunctivitis, allergic conjunctivitis, dry eye, acute angle-closure glaucoma, scleritis, uveitis, iritis, anterior uveitis, herpesvirus, keratitis, corneal abrasion, foreign body, fluorescein, entropion, trichiasis, episcleritis, subconjunctival hemorrhage