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Differential diagnosis of red eye.

This article describes a pediatric clinical case presentation of red eye. In addition, a discussion of the most common differential diagnoses for the presentation of red eye and its treatment is provided. Red eye is the most common eye disorder seen in primary care. For the pediatric health care provider, it can be associated with upper respiratory illness, allergic syndrome, and foreign body.

Subjective Data

CC: A five-year-old African-American female with a complaint of redness and matting in left eye for one week, and complaint of runny nose and cough for two weeks.

HPI: In usual state of good health until two weeks ago when she started having a runny nose, a cough that was worse at night or when lying down, and sneezing. This week, the mother noted redness and clear to now cloudy drainage in the left eye that then spread to right. The child complains that her eyes hurt with exposure to bright light and are matted in the morning, which is relieved with warm wash cloths to loosen crusts. The mother denies the child has had trauma to the eyes or had a fever, and she is giving over-the-counter (OTC) cough medicine (Robitussin[TM]) but states it does not seem to help. The child is eating well. However, the child has not been to school for the past several days. The siblings present with same symptoms following URI x two weeks. The mother thinks her child has pink eye.

ROS: HEENT--Denies headache, dizziness, injury; denies glasses, double or blurred vision, spots, specks, flashes, and pain in eyes. Reports eye redness and drainage bilaterally; denies swelling or lesions around eyes. The client denies decreased hearing, earache, or discharge from ears. There is a positive history of nasal congestion, eye drainage, and cough. The mother states that the child does not have a history of frequent colds, allergies, or nosebleeds. She also denies sore throat or hoarseness and swellings or knots in neck.

RESP: The child reports a non-productive cough when lying down, but there is no history of wheezing, asthma, or difficulty breathing.

PMH: Healthy, full-term newborn with uncomplicated delivery; normal development; no accidents or injuries, hospitalizations, or surgeries. Immunizations: needs Hepatitis B.

FH: Lives with mother and two other siblings. Siblings present with same symptoms following URI x two weeks; siblings have history of asthma--steroid inhalers and nib treatments; otherwise non-contributory.

MEDS: OTC cough medicine (Robitussin[TM]).

ALLERGIES: NKDA (siblings have allergy to sulfonamides).

Objective Data

GEN: African-American female in mild distress.

HEENT: Erythematous left and right conjunctiva without periorbital edema. Mucopurulent (yellow) discharge on lower lids; lids without redness, no lesions present; preauricular lymphadenopathy; left and right orbits soft but tender to palpation; visual fields intact; EOMs intact with occasional beat nystagmus; iris normal color bilaterally; PERRLA; Snellen OD 20/20, OS 20/20 without glasses; positive red reflex bilaterally; cornea and anterior chamber, clear bilaterally; disk margins sharp, well-defined bilaterally; C:D ratio less than 1:2, disk color cream-yellow, background red-orange, A:V = 2:3, vessels non-tortuous bilaterally; overlay 2 disk diameters at 4:00 in OS, OD clear. Macula darker red-orange, avascular near temporal area bilaterally. NOP with clear to cloudy secretions; turbinates moist, pink, and edematous; throat clear; tonsils non-tender to palpation, without drainage or exudate; TMs pearl gray without fluid present bilaterally.

RESP: Bilateral breath sounds equal and clear with good air exchange, smooth symmetrical chest excursion; no use of accessory muscles.

Assessment

Differential Diagnosis

The literature supports several differential diagnoses for the clinical presentation of red eye (Farina, & Mazarin, 2006; Leibowitz, 2000; Porter, Kaplan, Homeier, & Beers, 2005; Shields, 2000; Wagner, 1997a, b; Wirbelauer, 2006). The most common causes associated with the clinical presentation of red eye are acute conjunctivitis caused by bacterial, viral, or allergic pathogens; subconjunctival hemorrhage associated with trauma or foreign body; and blepharitis, an infection of the eyelids. Several other diagnoses that pose serious threats to vision must also be considered with the presentation of red eye and require immediate referral to an ophthalmologist. These include acute angle-closure glaucoma and acute anterior uvitis. Table 1 describes the three most common causes of red eye, giving subjective, objective, and diagnostic data for each.

The most common cause of red eye in children is conjunctivitis. The cause may be bacterial, viral, or allergic. According to Wagner (1997a), the most common causes of bacterial conjunctivitis are Haemophilus influenzae, Streptococcus pneumoniae, and Moraxella catarrhalis, and most often present from January through March. Wagner (1997b) also associates bacterial conjunctivitis with children under six years of age. The illness presents with an acute onset that develops in one eye and then spreads to the other eye within 48 hours. The infection is most often characterized by a mucopurulent discharge, matted eyelids on awaking, dried secretions at the base of the eyelashes, and occasional complaint of photophobia (Leibowitz, 2000; Wagner, 1997a). On physical examination, the eye has diffuse erythema of the conjunctiva with or without preauricular node involvement. Laboratory culture, gram, and giemsa stain of the discharge may be obtained to determine organism and antibiotic sensitivity; however, many diagnoses of conjunctivitis are based on history and physical examination findings (Farina & Mazarin, 2006).

The treatment for bacterial conjunctivitis is a seven to 10-day course of a broad-spectrum topical antibiotic. The most recommended ophthalmic preparations include sulfacetamide, erythromycin, bacitracin, polymyxin (Polytrim[R], or a combination of trimethoprim and polymyxin B (Leibowitz, 2000; Wagner, 1997a). Aminoglycosides as well as some floroquinolones may also be considered for resistant cases (Wagner, 1997a). For children who present with a combination of otitis media and conjunctivitis, systemic antibiotic therapy should also be considered (Leibowitz, 2000; Wagner, 1997a). Unfortunately, the clinician must also be mindful of other bacterial causes of conjunctivitis, such as Escherichia coli, Chlamydia trachomatis, and Neisseria gonorrhoeae. The latter two require systemic as well as topical treatment of the disease (Leibowitz, 2000).

The most common cause of viral conjunctivitis is adenovirus. Viral conjunctivitis presents with conjunctival erythema and edema, itching, and a watery discharge. The condition spreads from one eye to the other over several days and may be associated with an upper respiratory infection or contact with someone with the disease. The complaint of photophobia is uncommon, and a palpable preauricular node may or may not be present. Laboratory findings may show lymphocytes in the culture, gram, and giemsa stain; however, many infections of the eye are diagnosed without laboratory findings. Viral conjunctivitis is self-limiting and highly contagious; however, the treatment of viral conjunctivitis is controversial. Some sources suggest that the use of broad-spectrum antibiotic, such as trimethoprim and polymyxin B, has been effective in shortening the disease course (Leibowitz, 2000). If the condition does not improve within seven to 10 days or vesicle-appearing lesions are present, one should consider herpes simplex as a possible diagnosis and refer the client to an ophthalmologist (Wagner, 1997a).

Seasonal allergic conjunctivitis is most often associated with a history of seasonal allergy to pollen, mold, dust, or animal dander. The child will complain of itchy or scratchy eyes, rhinorrhea, and sneezing. On physical examination, there is a watery discharge from both eyes, swelling and erythema of the coniunctiva, edematous eyelids, cobblestone appearance, nasal discharge, and swollen or boggy nasal turbinates. The first treatment for allergic conjunctivitis is removal of the allergic trigger or diluting it by the use of artificial tears. Cool compresses can be applied to reduce itching and edema. The use of topical or systemic OTC or prescribed antihistamines help reduce symptoms and itching; however, many are contraindicated in young children. Olopatadine 0.1% ophthalmic solution (Patanol[R]) one to two drops every six to eight hours is approved for children three years of age and older for the relief of allergic conjunctivitis (Wagner, 1997a). Topical mast cell stabilizers, such as lodoxamide tromethamine 0.1% (Alomide[R]) and cromolyn sodium 4% (Crolom[R]), should be reserved for severe conditions (Wagner, 1997b).

In addition to the diagnosis of acute conjunctivitis, there are two other frequent causes of red eye. Subconjunctival hemorrhage may be caused by trauma to the eye, fragile conjunctival vessels, or bleeding disorders, and is a hemorrhage of the conjunctival veins (Leibowitz, 2000). The hemorrhage may be associated with prolonged coughing, vomiting, or straining. On physical examination, the erythema is unilateral, localized, and sharply circumscribed; the underlying sclera is not visible; and the adjacent conjunctiva is free of inflammation (Wagner, 1997b). There is no associated discharge, pain, or affect on vision. No treatment is necessary, and the hemorrhage should resolve gradually within two or three weeks. Failure of the hemorrhage to resolve is cause for referral to an ophthalmologist.

Finally, another common cause of red eye is blepharitis. Blepharitis is an inflammation of the eyelids, most commonly occurring in association with seborrhea, a skin disorder arising from over-activity of the sebaceous glands (Wagner, 1997b). Blepharitis can begin in early childhood, and the disease may occur only once, but more often recurs repeatedly. The presentation is typically bilateral, and the symptom history includes itching, burning, scratchiness, foreign body sensation, excessive tearing and crusty debris around the eyelashes (especially upon waking), and a red eye (Leibowitz, 2000). Physical examination reveals eyelid erythema, crust encircling the eyelashes, missing eyelashes, inturned eyelashes, blocked sebaceous glands, and conjunctival injection. There is often an associated conjunctivitis with papillary hypertrophy of the palpebral conjunctiva (Wagner, 1997b). The condition is alleviated by treating the underlying cause; however, the mainstay of therapy is hygiene. If bacterial or viral infection is suspected, the use of the previously described topical antibiotics sulfacetamide, gentamycin, tobramycin, erythromycin and neomycin, polymyxin B, and bacitracin should be considered (Leibowitz, 2000; Wagner, 1997a). The client that presents with inward or outward rotation of the eyelashes should be referred to an ophthalmologist for surgical intervention.

While this article discusses the most common causes of red eye, the primary care provider should be aware of eye emergencies that also present with red eye. Symptoms of acute angle closure glaucoma include ocular and facial pain, unilateral blurring of vision or significantly reduced visual acuity, haloes around lights, and occasional nausea and vomiting (Leibowitz, 2000). Physical examination findings suggestive of acute angle-closure glaucoma include significantly elevated intraocular pressure noted by a firm or hard orbit, and a fixed, mid-dilated pupil (Leibowitz, 2000; Wagner, 1997a). The typical presentation of anterior uveitis involves pain, photophobia, and excessive tearing (Leibowitz, 2000). Clients report a deep, dull aching of the involved eye and surrounding orbit. Physical inspection may reveal mild to moderate congestion of the lids, and inflammatory cells and protein flares in the anterior chamber of the affected eye (Leibowitz, 2000). Both acute angle-closed glaucoma and anterior uveitis need to be referred immediately to an ophthalmologist.

Clinical Diagnosis

Based on the client's history of present illness, review of symptoms, physical examination findings, and after a review of the literature on red eye, the case presented earlier was diagnosed with bacterial conjunctivitis.

Plan

Diagnostic: None; may consider culture, sensitivity, and gram stain for persistent cases.

Treatment: Ilotycin ophthalmic ointment, half-inch ribbon to OU q 4h for 10 days.

Education: Hand washing to prevent contamination and spread to others, instill medication in the inner aspect of lower eyelids.

Follow-up: To clinic in two days if no improvement, one week for Hepatitis B #1, two weeks for reexamination of eyes unless clear at one week.

References

Farina, G.A., & Mazarin, G.I. (2006). Redeye evaluation: Follow-up. Retrieved from http://emedicine.medscape.com/ article/1216540-overview

Leibowitz, H.M. (2000). Primary care: The red eye. The New England Journal of Medicine, 343(5), 345-351.

Porter, R.S., Kaplan, J.L., Homeier, B.P., & Beers, M.H. (Eds). (2005). Red eye (pink eye). The Merck manual's online medical library. Whitehouse Station, NJ: Merck & Co., Inc. Retrieved from http://www.merck.com/mmpe/sec09/ ch098/ch098j.html#CACBGIHG.

Shields, S.R. (2000). Managing eye disease in primary care. Part 2. How to recognize and treat common eye problems. Postgraduate Medicine, 108(5), 83-86, 91-96.

Wagner, R.S. (1997a). Pediatric concerns of ocular inflammation. Immunology and Allergy Clinics of North America, 17(1), 161-172.

Wagner, R.S. (1997b). Eye infections and abnormalities: Issues for the pediatrician. Contemporary Pediatrics, 14(6), 137-153.

Wirbelauer, C. (2006). Management of the red eye for the primary care physician. The American Journal of Medicine, 119(4), 302-306.

Glenda Smith, PhD, RNC, is an Assistant Professor, University of Alabama School of Nursing, Birmingham, AL.
Table 1.
Most Common Differential Diagnoses for Red Eye

                     Acute Bacterial Conjunctivitis
Subjective Data      Eyes matted in morning, history
                     of prolonged URI with
                     rhinorrhea, age of client,
                     afebrile, no trauma, no pain,
                     mild photophobia

Objective Data       Abrupt onset, Diffuse redness of
                     conjunctiva, spreads to
                     unaffected eye within 2 days,
                     mucopurulent drainage,
                     lymphadenopathy

Laboratory/          May consider C & S, gram stain,
Diagnostic Data      giemsa stain

                     Subconjunctival Hemorrhage

Subjective Data      History of prolonged coughing,
                     vomiting or straining; trauma to
                     eye; no pain or discharge

Objective Data       Unilateral redness, localized and
                     sharply circumscribed,
                     underlying sclera not visible

Laboratory/          None
Diagnostic Data

                     Blepharitis

Subjective Data      Itching, burning, scratchiness,
                     foreign body sensation,
                     excessive tearing and crusty
                     debris around the eyelashes

Objective Data       Inflammation an redness of the
                     eyelid, misdirection or loss of
                     eyelashes, drying of the corneal
                     surfaces, redness of conjunctiva

Laboratory/          May consider C & S, gram stain,
Diagnostic Data      giemsa stain if infection is
                     present

Note: C & S = culture and sensitivity.
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Title Annotation:Pediatric Management Problems
Author:Smith, Glenda
Publication:Pediatric Nursing
Article Type:Clinical report
Geographic Code:1USA
Date:Jul 1, 2010
Words:2215
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