Pediatric emergency medicine trisk 145

TABLE 27.1
COMMON CAUSES OF RED EYE a
Conjunctivitis
Infectious: viral (including herpes), bacterial, chlamydial
Allergic or seasonal
Chemical (or other physical agents such as smoke)
Systemic disease (Table 27.3 )
Trauma
Corneal or conjunctival abrasion
Iritis
Foreign body
Subconjunctival hemorrhage
Dry eye syndromes
Abnormalities of the lids and/or lashes
Blepharitis
Trichiasis due to epiblepharon
Stye or chalazion (external or internal hordeolum)
Molluscum of lid margin
Periorbital or orbital cellulitis
Contact lens–related problems
Infectious keratitis (corneal ulcer)
Allergic conjunctivitis
Corneal abrasion
Poor fit
Overwear
a Not

listed in order of frequency. List not complete.

Direct ocular trauma may result in a red eye due to corneal or conjunctival
abrasion, hyphema, iritis, or rarely, traumatic glaucoma (see Chapter 114 Ocular

Trauma ). If there is no fluorescein staining of the conjunctiva or cornea and there
is no evidence of severe intraocular injury such as hyphema or ruptured globe, the
examiner should consider the possibility of noxious material coming in contact
with the eyeball at the time of trauma. Both acidic and alkaline substances may
cause a red eye (see Chapter 123 Ophthalmic Emergencies ). Likewise, a foreign
body may cause ocular pain and inflammation. Foreign bodies often can be
difficult to see on brief, superficial examination, especially if the foreign body is
smaller than what the naked eye can see. All the recesses and redundant folds of


the conjunctiva must be inspected. The upper eyelid should be everted (see
Chapter 114 Ocular Trauma ). The lower eyelid should be pulled down from the
globe as the patient looks upward so the inferior fornix can be inspected. The
patient should be asked to adduct the affected eye when the lateral canthus is
stretched laterally to allow inspection of the lateral fornix. There is no analogous
medial fornix. In addition to direct trauma, head injury can rarely cause the
development of an intracranial arteriovenous fistula that may present with
proptosis, chemosis, red eye, corkscrew conjunctival blood vessels, and decreased
vision.
TABLE 27.2
LIFE-THREATENING CAUSES OF RED EYE a
Systemic disease (Table 27.3 )
Child abuse
Blunt trauma
Covert instillation of noxious substances (medical child abuse [Munchausen
syndrome by proxy])
Traumatic intracranial arteriovenous fistula (very rare)
a List

not meant to be complete.

TABLE 27.3
SYSTEMIC CONDITIONS THAT MAY BE ASSOCIATED WITH RED
EYE a
Collagen vascular disorders
Juvenile idiopathic arthritis
Infectious diseases
HSV, varicella zoster, measles, otitis media
Kawasaki disease
Inflammatory bowel disease
Cystic fibrosis
Vitamin A deficiency
Cystinosis
Leukemia
Ectodermal dysplasia
Trisomy 21
Cornelia de Lange syndrome
History of radiation therapy, including ocular field
History of bone marrow transplantation or graft-versus-host disease
Stevens–Johnson syndrome
a Not

a complete list: intended to demonstrate multiorgan representation.

The position of the eyelashes should be inspected before performing lid
eversion and examining the conjunctival fornices. Eyelashes that turn against the
ocular surface (trichiasis) may cause a red eye that is accompanied by pain or
foreign body sensation in the absence of lid swelling. Corneal fluorescein staining
from the lashes abrading the corneal epithelium may be so mild that it can only be

detected by slit-lamp biomicroscopy, even in symptomatic patients. Trichiasis is
particularly common in patients who have had prior injury or surgery to the
eyelid and in patients of Asian background. In the latter case, a prominent fold of
skin (epiblepharon) may be found medially just below the eyelid margin, causing
the lower lid medial eyelashes, and less commonly the upper lid lashes, to rotate
toward the eyeball.


FIGURE 27.1 Pseudomembrane on lower lid palpebral conjunctiva and extending into the
inferior fornix in patient with epidemic keratoconjunctivitis (adenovirus).