Ojo Rojo. Evaluación y Gestión - UpToDate

27/4/24, 13:11 Los ojos rojos: Evaluación y gestión - UpToDate
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El ojo rojo: evaluación y gestión

AUTOR: Deborah S Jacobs, MD
EDITOR DE SECCIÓN: Matthew F Gardiner, MD
EDITOR ADJUNTO: Jane Givens, MD, MSCE
Todos los temas se actualizan a medida que hay nueva evidencia disponible y nuestro proceso de revisión por pares se
completa.
Revisión de la literatura vigente hasta: marzo de 2024.

Este tema se actualizó por última vez: 19 de julio de 2022.
INTRODUCCIÓN
Los "ojos rojos" son un síntoma de presentación común en la práctica ambulatoria. Este tema
presenta un enfoque para distinguir a los pacientes con ojos rojos que deben ser remitidos a un
oftalmólogo, como aquellos con glaucoma de ángulo cerrado, de los pacientes que pueden ser
tratados por un médico de atención primaria, como aquellos con conjuntivitis alérgica (
tabla 1 y Tabla 2 ). Algunas características distintivas de las afecciones que se presentan
como ojos rojos se resumen en una tabla ( tabla 3 ).
El diagnóstico y tratamiento específicos de muchos de estos trastornos se analizan por

separado. (Ver "Lesiones de los párpados" y "Conjuntivitis" y "Abrasiones corneales y cuerpos
extraños corneales: Manifestaciones clínicas y diagnóstico" y "Uveítis: Etiología, manifestaciones
clínicas y diagnóstico" y "Glaucoma de ángulo cerrado" y "Fotoqueratitis" y "Blefaritis ". " y
"Lesión conjuntival", sección sobre 'Hemorragia subconjuntival' .)
DESCRIPCIÓN GENERAL
Los "ojos rojos" son un síntoma de presentación común en la práctica ambulatoria. Un pequeño
porcentaje de pacientes con ojo rojo necesitan derivación y tratamiento oftalmológico urgente,
aunque la gran mayoría puede ser tratado por el médico de atención primaria. Hay pocos datos
epidemiológicos sobre el ojo rojo y no hay datos basados en evidencia que nos orienten en el
tratamiento de estos pacientes. La conjuntivitis (alérgica o viral) es probablemente la causa más
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común de ojos rojos en el ámbito comunitario, pero también pueden ocurrir varias afecciones
más graves [ 1,2 ].
EVALUACIÓN DEL PACIENTE
Los antecedentes del paciente, la medición de la agudeza visual y los hallazgos del examen con
linterna son características importantes para determinar la causa y el tratamiento del ojo rojo.
La historia y el examen ocular brindan orientación en la decisión de derivar al paciente para una
evaluación oftalmológica.
Determinar quién necesita ser atendido en persona : muchos pacientes con ojos rojos
llaman para preguntar si necesitan ser atendidos por un médico. Ciertas características
históricas o síntomas de presentación indican la necesidad de un examen médico y
posiblemente de una derivación del paciente. Se deben formular las siguientes preguntas a
todos los pacientes. Muchos casos pueden ser manejados por proveedores de atención
primaria por teléfono o telemedicina (video) o pidiendo al paciente que envíe imágenes por
teléfono.
La pandemia de la enfermedad por coronavirus de 2019 (COVID-19) ha producido informes

sobre el enfoque de la telemedicina para los ojos rojos [ 3 ]. Hay preguntas críticas que
determinan si se justifica una evaluación en persona o la derivación a un oftalmólogo. Cada vez
hay más pruebas de que la consulta virtual para los ojos rojos da como resultado un
diagnóstico preciso y puede reducir la necesidad de visitas en persona [ 4 ].
Si la respuesta a cualquiera de las siguientes preguntas es sí, es más probable que se trate de
un proceso que amenace la vista y se justifica una evaluación en persona o una derivación a un
oftalmólogo:
● ¿Está afectada la visión? – ¿Todavía puedes leer letras impresas normales con el ojo
afectado? Los pacientes con problemas de visión no pueden ser atendidos por teléfono o
telemedicina; requieren un examen médico y, según los hallazgos, pueden requerir
derivación oftalmológica.
● ¿Hay dolor de inicio agudo, progresivo, que no se alivia con analgesia o que interfiere con
el sueño?
● ¿Hay sensación de cuerpo extraño? – ¿Sientes como si hubiera algo en tu ojo que interfiere
con tu capacidad para mantenerlo abierto? La sensación de cuerpo extraño es el síntoma
cardinal de un proceso corneal activo. La evidencia objetiva de sensación de cuerpo

extraño, en la que el paciente es incapaz de abrir el ojo espontáneamente o mantenerlo

abierto, sugiere afectación corneal; Con excepción de la presentación inicial por abrasión
corneal o cuerpo extraño, dichos pacientes justifican una derivación urgente o de
emergencia a un oftalmólogo. En comparación, muchos pacientes informan una
"sensación de picazón", "arenilla" o una sensación "como arena en los ojos" con alergia,
conjuntivitis viral u ojos secos. Esta es una sensación subjetiva de cuerpo extraño y no
necesariamente sugiere un problema corneal que requiera derivación.
● ¿Hay fotofobia? – ¿Es usted sensible a la luz brillante? Los pacientes con fotofobia siempre
deben ser examinados por un médico.
Patients with an active corneal process have objective signs of photophobia as well as
objective signs of foreign body sensation. They may present wearing a hat and/or
sunglasses, covering the affected eye with the hand to block out light, or keeping the head
down and turned away from light fixtures or windows. They may request that the
examination room lights be left off while waiting for the provider. Patients with iritis have
objective signs of photophobia but no objective foreign body sensation.
● Was there recent trauma, eye surgery, or contact lens wear? – A history of contact lens
wear in the setting of discharge and a red eye should increase the suspicion of keratitis [5].
(See "Complications of contact lenses", section on 'Infectious keratitis'.)
● Is there new onset of binocular double vision?
Determining severity of condition
General observation — Further history and general observation of the patient can provide
guidance as to whether the problem is likely to be benign and treatable initially by the primary
care clinician or if it requires referral. Although the subjective report of symptoms and threshold
to report symptoms varies among individuals, simple patient observation can provide reliable
clues.
● Is there discharge, other than tears, that continues throughout the day? – Morning
crusting followed by a watery discharge for the remainder of the day is characteristic of
many self-limited processes such as allergy, stye or hordeolum, viral conjunctivitis, allergic
conjunctivitis, and dry eyes. Patients typically interpret morning crusting as "pus."
● Bacterial conjunctivitis and bacterial keratitis cause opaque discharge that persists
throughout the day and requires specific therapy. Bacterial conjunctivitis, which is typically
not associated with a reduction in visual acuity, foreign body sensation, or photophobia,

may be treated by the primary care clinician. Bacterial keratitis, on the other hand, which
may or may not affect vision but typically causes objective foreign body sensation and
photophobia, requires emergency referral. (See 'Bacterial keratitis' below.)
● Lid and conjunctival entities do not cause objective foreign body sensation or
photophobia. The patient will be sitting in the examination room with both eyes open,
unaffected by the ambient lighting. The patient with viral or allergic conjunctivitis may
have signs of rhinorrhea, lymphadenopathy, or other upper respiratory tract symptoms.
● By comparison, the patient suffering from infectious keratitis, iritis, or angle-closure

glaucoma is likely to have objective signs indicating the more serious nature of the
problem. These entities all require ophthalmologic consultation. Signs of these entities
include corneal whitening or opacity, eyeball tenderness on palpation, and ciliary flush,
which is redness localized to the limbus (the transition zone between cornea and sclera).
Ophthalmologic examination
Visual acuity
● Measurement – Vision should be documented for every patient who is seen for an eye
complaint. (An inquiry should be made about a change in vision on every telephone
triage.) Each eye should be tested separately. Snellen acuity is the standard; however, this
test requires using a Snellen chart at 20 feet with best correction or pinhole and is often
difficult to perform.
An alternative in a triage setting is measurement of near vision. Allow the patient to use
his or her usual reading correction if possible and hold a near card or ordinary book,
newspaper, or magazine at a comfortable distance. It is not important to determine
exactly whether the vision is 20/30 or 20/40 at 12 or 14 inches, but rather to document
visual acuity in crude categories: reading vision (small versus large print); form vision only
(hand motions or count fingers); or light perception. This measurement should be made
before lights are shined in the eye or drops of any sort are applied.
● Importance of results – In cases in which a lid disorder, conjunctival process, corneal

abrasion, or foreign body is suspected, the presence of normal acuity can be a source of
reassurance to the primary care clinician that it is reasonable for them to initiate therapy.
On the other hand, if acuity is reduced in the presence of a red eye beyond that which the
patient reports is typical, the clinician should suspect one of the more worrisome
diagnoses: infectious keratitis, iritis, or angle-closure glaucoma. These patients should be
referred for initial therapy.

Penlight examination — The penlight should be used to examine the pupils and anterior
segment. A slit lamp is not required to distinguish those entities that can be treated by the
primary care clinician from those entities that must be referred. It is useful to consider the
following questions during the penlight examination:
● Does the pupil react to light? – The pupil is fixed in mid-dilation in cases of angle-closure
glaucoma. It does not react to light and is typically 4 to 5 mm in diameter.
● Is the pupil very small (1 to 2 mm) in size? – The pupil is pinpoint in cases of corneal
abrasion, infectious keratitis, or iritis. Abrasion is distinguished from iritis by the presence
of a staining defect on fluorescein examination and an objective foreign body sensation,
neither of which are present with iritis. Abrasions are usually caused by focal trauma to the
surface of the eye. Traumatic iritis may occur after blunt trauma, a softball, or a fist, but
there are no corneal findings.
● Is there purulent discharge? – Purulent discharge suggests bacterial conjunctivitis or

bacterial keratitis. In conjunctivitis, there are no opacities by penlight or staining defects
with fluorescein.
● What is the pattern of redness? – Diffuse injection involving both the conjunctiva inside the
lid (the palpebral conjunctiva) and the conjunctiva on the globe (the bulbar conjunctiva)
suggests a primary conjunctival problem such as conjunctivitis. Conjunctivitis may be
bacterial, viral, allergic, toxic, or nonspecific (eg, dry eye syndrome). In these entities, the
entire mucus membrane is equally involved. By comparison, ciliary flush is characteristic of
the more serious entities including infectious keratitis, iritis, or angle closure. With ciliary
flush, injection is most marked at the limbus (where the cornea undergoes transition to
the sclera) and then diminishes toward the equator ( picture 1).
When the redness appears hemorrhagic rather than in a pattern of injection (dilated blood
vessels), the diagnosis of subconjunctival hemorrhage should be considered.
● Is there a white spot, opacity, or foreign body on the cornea? – A white spot or opacity on
the cornea suggests infectious keratitis. This can usually be seen without the aid of
fluorescein. Fluorescein is used at the end of the examination to confirm the absence or
presence of a corneal process. The white spot of a bacterial keratitis and the raised,
grayish branching opacity of herpes simplex keratitis will pick up stain ( picture 2).
Abrasions will also pick up stain; however, these are not characterized by the presence of
corneal opacity. A corneal foreign body will not pick up stain.

● Is there hypopyon or hyphema? – Hypopyon, a layer of white cells in the anterior chamber,
or hyphema, a layer of red cells, each require urgent referral to an ophthalmologist
( picture 3 and picture 4). Hypopyon is associated with sight-threatening infectious
keratitis or endophthalmitis until proven otherwise; these patients must be seen by an
ophthalmologist within hours. Hyphema is a sign of significant blunt or penetrating
trauma to the globe and must also be seen by an ophthalmologist within hours to evaluate
for penetrating eye injury, retinal detachment, and acute glaucoma. (See "Traumatic
hyphema: Clinical features and diagnosis".)
No role for fundus examination — The fundus examination is typically not helpful in the
differential diagnosis of the red eye. In the benign entities such as lid and conjunctival
processes, the fundus examination is easily performed and has no associated pathologic
features. In iritis and keratitis, the pupil will be very small and the patient photophobic, making
the examination difficult to perform. Although the pupil is midsize in angle-closure glaucoma,
the fundus examination becomes increasingly difficult to perform as the attack persists because
of increasing corneal edema from high intraocular pressure. A fundus examination is important
if there is red eye in the presence of swelling or vesicular eruption respecting the midline of
face, proptosis, or nonreactive pupil to characterize optic nerve involvement.
ETIOLOGY AND MANAGEMENT
The differential diagnosis of the red eye includes benign conditions ( table 2) and serious
conditions that require ophthalmologic evaluation ( table 1). Features that can help
distinguish these include history, visual acuity, sensation of a foreign body, photophobia,
discharge, pupil size and reactivity, pruritus or pain, and fluorescein staining ( table 3).
Photographs of specific conditions show typical features of blepharitis ( picture 5 and
picture 6), episcleritis ( picture 7 and picture 8), bacterial conjunctivitis ( picture 9),
allergic conjunctivitis ( picture 10), corneal abrasion ( picture 11), corneal foreign body
( picture 12), anterior uveitis ( picture 13), hyphema ( picture 4), hypopyon ( picture 14
and picture 3), bacterial keratitis endophthalmitis ( picture 15), angle-closure glaucoma
( picture 1), and subconjunctival hemorrhage ( picture 16).
In the section to follow, the conditions that require emergency (same day), or urgent (within two
to three days) ophthalmologic evaluation are summarized ( table 1).
Common benign conditions — The most common entities among the benign conditions are
listed below and in the table ( table 2).

Eyelid lesions — Stye (hordeolum) and chalazion are discussed in detail elsewhere
( figure 1). (See "Eyelid lesions", section on 'Chalazion'.)
Blepharitis — Blepharitis is discussed in detail elsewhere. (See "Blepharitis".)
Conjunctivitis — Conjunctivitis is discussed in detail elsewhere. (See "Conjunctivitis" and

"Allergic conjunctivitis: Clinical manifestations and diagnosis" and "Allergic conjunctivitis:
Management".)
Corneal abrasions — Corneal abrasion or foreign bodies are discussed in detail elsewhere.
(See "Corneal abrasions and corneal foreign bodies: Clinical manifestations and diagnosis".)
Contact lens overwear — Contact lens overwear is discussed elsewhere. (See "Complications
of contact lenses".)
Dry eye syndrome — Dry eye syndrome is discussed elsewhere. (See "Dry eye disease".)
Episcleritis — Episcleritis is a localized ocular redness from inflammation of episcleral vessels.

It is most commonly unilateral and sectoral, although it may also be nodular. The vessels or
nodules are typically quite distinct and are moveable over the scleral surface. Patients describe
an achiness or awareness but typically don’t report pain. Episodes typically last for a few weeks.
Episcleritis can be recurrent and may be associated with underlying autoimmune disease.
Episcleritis is not sight-limiting or sight-threatening; symptoms are typically managed with oral
nonsteroidal antiinflammatory drugs (NSAIDs) by the primary care provider, although
confirmation of diagnosis by an eye care provider at first episode or for frequent recurrence
may be reassuring to both patient and primary care provider.
Subconjunctival hemorrhage — Patients with subconjunctival hemorrhage are generally

asymptomatic. Typically, the patient is unaware of a problem until they look in the mirror or are
informed of it by someone else. The clinical appearance of subconjunctival hemorrhage, with
demarcated areas of extravasated blood just beneath the surface of the eye, is generally both
obvious and diagnostic ( picture 16). However, the appearance can be quite alarming to
patients and others who interact with them. Subconjunctival hemorrhage may occur
spontaneously or with Valsalva associated with coughing, sneezing, straining, or vomiting. The
diagnosis is confirmed by normal acuity and the absence of discharge, photophobia, or foreign
body sensation.
The blood is typically resorbed over one to two weeks, depending on the amount of
extravasated blood. Because the subconjunctival space is loculated, the amount of blood may
seem to increase on the second day, but this typically represents redistribution. No specific

therapy is indicated. If subconjunctival hemorrhage is recurrent or if the patient has a history of

bleeding disorder or blood dyscrasia, or is on anticoagulant therapy, referral to a primary care
provider for evaluation of the anticoagulant therapy, or investigation as to whether there is an
underlying hematologic or coagulation abnormality, is warranted. Eyes with subconjunctival
hemorrhage in the setting of blunt trauma must be evaluated for the possibility of ruptured
globe or retrobulbar hemorrhage. (See "Conjunctival injury", section on 'Subconjunctival
hemorrhage'.)
More serious conditions
Angle-closure glaucoma — Acute angle-closure glaucoma is relatively uncommon, but the

incidence increases dramatically with age [6]. Angle closure leads to increased intraocular
pressure ( figure 2A-B). The patient with angle-closure glaucoma typically appears to be in
general distress. They are likely to be slumped over, covering the eye or clutching the frontal or
temporal region of the head with one hand, and complaining of headache and malaise. As
angle closure progresses and the intraocular pressure rises, patients develop nausea and in
some cases vomiting. The pain of angle closure is a dull ache that is more likely reported as
unilateral headache rather than eye pain. Some patients complain of "the worst headache in my
life" and do not attribute their symptoms to the eye. (See "Angle-closure glaucoma".)
Unnecessary neurologic workup and imaging that may critically delay treatment can be avoided
if the red eye is noted and assessed. Acuity becomes increasingly reduced as the duration of the
attack increases. These patients may be photophobic. They do not typically complain of a
foreign body sensation.
Penlight examination reveals a red eye with ciliary flush and no discharge. The pupil is fixed in
mid-dilation and the anterior chamber is shallow. Within hours of symptom onset, the cornea
becomes hazy ( picture 1).
Diagnosis is confirmed with measurement of intraocular pressure. Normal intraocular pressure

is 8 to 22 mmHg; pressures in acute angle closure are often greater than 45 mmHg.
Angle-closure glaucoma is a sight-threatening emergency that must be treated within hours to

avoid irreversible damage to the optic nerve. Typically, pressure-lowering topical and systemic
agents are administered, and definitive treatment in the form of laser iridotomy is performed
that same day by the ophthalmologist. The fellow eye is then treated prophylactically within
days.
Hyphema — Hyphema refers to the finding of red blood cells layered out in the anterior
chamber. This finding warrants same-day evaluation by an ophthalmologist as it can be

associated with significant trauma, inflammation, or pathologic neovascularization. (See

"Traumatic hyphema: Clinical features and diagnosis" and "Traumatic hyphema: Management".)
Hypopyon — Hypopyon refers to the finding of white blood cells layered out in the anterior
chamber. This finding warrants same-day evaluation by an ophthalmologist as it can be
associated with infectious keratitis or endophthalmitis. (See "Bacterial endophthalmitis".)
Iritis — Inflammation of the anterior uveal tract is called iritis or anterior uveitis; when the
adjacent ciliary body is also inflamed, the process is called iridocyclitis. (See "Uveitis: Etiology,
clinical manifestations, and diagnosis".)
Patients with iritis may present in a similar fashion to those with an active corneal process, but
there is no foreign body sensation per se. The patient may choose to keep the eyes closed to
block out light but, in a dimly lit environment, the patient is able to keep the affected eye open
spontaneously. Patients with an active corneal process and iritis will display an aversive
response when the penlight is shined in the affected and in the uninvolved eye.
The cardinal sign of iritis is ciliary flush: injection that gives the appearance of a red ring around
the iris. Typically, there is no discharge and only minimal tearing. The pupil is typically very
small. Corneal abrasion should be ruled out with fluorescein staining, and angle closure should
be ruled out by confirming that the pupil is not fixed in mid-dilation. The diagnosis is
presumptive until presence of inflammatory cells or exudative “flare” is confirmed by slit lamp
examination.
Iritis can be caused by any one of many infections, inflammatory, and infiltrative processes.
These include tuberculosis, sarcoidosis, syphilis, toxoplasma, toxocara, and reactive arthritis.
Many cases are idiopathic.
Patients with iritis should be seen by an ophthalmologist within a matter of days. The
ophthalmologist will initiate treatment, typically with topical steroids, and monitor for side
effects and response to therapy. Cases that are bilateral, recurrent, sight-threatening, or non-
responsive to therapy will require extensive evaluation for etiology.
Infectious keratitis — Infectious keratitis can be caused by bacteria, viruses, fungi, or

parasites [7]. One report estimated that in the United States there are nearly one million visits to
outpatient clinics or emergency departments for keratitis or contact lens disorders annually [8].
(See "Complications of contact lenses", section on 'Infectious keratitis'.)
Bacterial keratitis — Bacterial infectious keratitis warrants evaluation by an

ophthalmologist on the same day. The patient will complain of foreign body sensation and have

trouble keeping the involved eye open, a sign of an active corneal process. Bacterial pathogens
include Staphylococcus aureus, Pseudomonas aeruginosa, coagulase-negative Staphylococcus,
diphtheroids, Streptococcus pneumoniae, and polymicrobial isolates [9].
Improper contact lens wear is the largest risk factor for bacterial keratitis [8]. Overnight wear of
contact lenses is associated with a higher incidence of bacterial keratitis, but the entity can
occur in patients who do not wear contact lenses or who wear them on a daytime-only basis.
Breakdown in local or systemic host defense mechanisms, including dry ocular surfaces, topical
corticosteroid use, and immunosuppression, can predispose to bacterial keratitis.
The diagnostic finding in bacterial keratitis is a corneal opacity or infiltrate (typically a round
white spot) in association with red eye, photophobia, and foreign body sensation. This infiltrate
or ulcer (>0.5 mm in size) can be seen with a penlight and does not require a slit lamp for
identification. It will stain with fluorescein. Mucopurulent discharge is typically present.
Fulminant cases may present with an associated hypopyon (layer of white cells in the anterior
chamber) ( picture 3).
Treatment requires urgent ophthalmological referral and prompt initiation of topical

bactericidal antibiotics (ideally after obtaining cultures). These antibiotics are sometimes
compounded in fortified concentrations, not commercially available. The role of topical
glucocorticoids and topical drug combinations containing topical steroids is controversial and
best left to the discretion of the consulting ophthalmologist [9-12].(See "Complications of
contact lenses", section on 'Infectious keratitis'.)
Viral keratitis — Herpes simplex causes infectious keratitis, characterized by red eye,
photophobia, foreign body sensation, and watery discharge. There may be a faint branching
grey opacity on penlight examination ( picture 17). This branching opacity is best visualized
with application of fluorescein. Although typically a self-limited process, duration of symptoms
is reduced with treatment with topical or oral antiviral agents. (See "Herpes simplex keratitis".)
Patients should be referred to an ophthalmologist within a few days for confirmation of

diagnosis, initiation of therapy, and monitoring for response, sequelae, or recurrence.
Immunocompromised patients may require topical and systemic treatment and longer duration
of therapy. A small percentage of patients develop chronic or recurrent inflammation, or
recurrent viral keratitis, both of which are treated with prophylactic oral antiviral agents. Some
patients also benefit from treatment with topical corticosteroid agents, used in conjunction with
antiviral prophylaxis, under the care of an ophthalmologist.
Adenovirus typically causes conjunctivitis, but some strains in some individuals can cause an
associated keratitis (epidemic keratoconjunctivitis [EKC]). These patients have classic
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manifestations of viral conjunctivitis but within a few days develop symptoms of an active
corneal process (photophobia and objective foreign body sensation). Penlight examination of
cornea is unremarkable, but fluorescein staining reveals multiple punctate staining lesions.
Preauricular lymphadenopathy is often present.
EKC or adenoviral keratitis is typically a self-limited process without sequelae, although patients
are quite miserable during active disease because of photophobia and foreign body sensation.
Referral to an ophthalmologist within days is warranted for confirmation of the diagnosis, for
monitoring for resolution, and for treatment if there is decline in vision from centrally located
viral lesions. (See "Diagnosis, treatment, and prevention of adenovirus infection".)
Scleritis — Scleritis is a painful, destructive, and potentially blinding disorder that may also
involve the cornea, adjacent episclera, and underlying uveal tract. Scleritis has a striking, highly
symptomatic clinical presentation ( picture 18). Scleritis is usually characterized by severe,
constant, boring pain that worsens at night or in the early morning hours and radiates to the
face and periorbital region. Additionally, patients may report headache, watering of the eyes,
ocular redness, and photophobia. If the scleritis is purely posterior there may be no redness.
When there is anterior scleritis, the redness is typically deeper in color or purpuric when
compared with the injected or “bloodshot” appearance of conjunctivitis or episcleritis. Typically,
any congested vessels are deep and not mobile. Symptoms may vary depending upon the
severity and type of scleritis that is present. Patients with suspected scleritis should be referred
to an ophthalmologist for evaluation within a few days. Scleritis is often associated with
systemic disease, including systemic rheumatologic and inflammatory disorders ( table 4).
(See "Clinical manifestations and diagnosis of scleritis".)
INFORMATION FOR PATIENTS
UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics."
The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading
level, and they answer the four or five key questions a patient might have about a given
condition. These articles are best for patients who want a general overview and who prefer
short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more
sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading
level and are best for patients who want in-depth information and are comfortable with some
medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print
or e-mail these topics to your patients. (You can also locate patient education articles on a

variety of subjects by searching on "patient info" and the keyword(s) of interest.)
● Basics topics (see "Patient education: Conjunctivitis (pink eye) (The Basics)" and "Patient
education: Photokeratitis (arc eye) (The Basics)" and "Patient education: Subconjunctival
hemorrhage (The Basics)")
● Beyond the Basics topics (See "Patient education: Conjunctivitis (pink eye) (Beyond the
Basics)".)
SUMMARY
● Overview – "Red eye" is a common presenting complaint in ambulatory practice. A small

percentage of patients with red eye need urgent ophthalmological referral and treatment,
but the vast majority can be treated by the primary care clinician. Conjunctivitis (allergic or
viral) is probably the most common cause of red eye in the community setting. (See
'Overview' above.)
● Patient evaluation – Patient history, measurement of visual acuity, and findings on

penlight examination are important features in determining the cause and management
of red eye ( table 3). The history and ocular examination provide guidance in the
decision about whether to refer the patient for ophthalmologic evaluation. The history
should include whether vision is affected, whether there is a foreign body sensation,
whether there is photophobia, whether there is a history of trauma or contact lens use,
and whether discharge is present. Visual acuity of each eye should be assessed in all
patients using a Snellen chart or alternative means. Penlight examination should include
pupil size and reactivity to light, the presence and nature of discharge, the pattern of
redness, and the presence of corneal opacity, hypopyon, or hyphema. (See 'Patient
evaluation' above.)
● Causes and management – The differential diagnosis of the red eye includes benign
conditions ( table 2) and serious conditions that require ophthalmologic evaluation
( table 1). (See 'Etiology and management' above.)
● Indications for emergency ophthalmic evaluation – In the patient with red eye, if vision
is unaffected, the pupil reacts, there is no objective foreign body sensation or
photophobia, and there is no corneal opacity, hyphema, or hypopyon, it is reasonable for
the primary care clinician to manage the condition. The following are indications for
emergency referral for ophthalmologic evaluation ( table 1):

• Unilateral red eye with pain, nausea, and vomiting (see 'Angle-closure glaucoma' above)
• Hyphema or hypopyon (see 'Hyphema' above and 'Hypopyon' above)
• Visual deficit (see 'Angle-closure glaucoma' above and 'Iritis' above and 'Infectious
keratitis' above)
• Corneal opacity or infiltrate that stains with fluorescein (see 'Infectious keratitis' above)
• Severe ocular pain (see 'Scleritis' above and 'Angle-closure glaucoma' above)
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4. Awad RA, Sesma G, Neyaz SY, et al. Virtual Consultation for Red Eye: Accuracy Assessment
in a Primary Care Center. Middle East Afr J Ophthalmol 2021; 28:180.
5. Liesegang TJ. Contact lens-related microbial keratitis: Part I: Epidemiology. Cornea 1997;
16:125.
6. Teikari J, Raivio I, Nurminen M. Incidence of acute glaucoma in Finland from 1973 to 1982.
Graefes Arch Clin Exp Ophthalmol 1987; 225:357.
7. Forster RK. Conrad Berens Lecture. The management of infectious keratitis as we approach
the 21st century. CLAO J 1998; 24:175.
8. Collier SA, Gronostaj MP, MacGurn AK, et al. Estimated burden of keratitis--United States,
2010. MMWR Morb Mortal Wkly Rep 2014; 63:1027.
9. Hindman HB, Patel SB, Jun AS. Rationale for adjunctive topical corticosteroids in bacterial
keratitis. Arch Ophthalmol 2009; 127:97.
10. Cohen EJ. The case against the use of steroids in the treatment of bacterial keratitis. Arch
Ophthalmol 2009; 127:103.
11. Ray KJ, Srinivasan M, Mascarenhas J, et al. Early addition of topical corticosteroids in the
treatment of bacterial keratitis. JAMA Ophthalmol 2014; 132:737.
12. Herretes S, Wang X, Reyes JM. Topical corticosteroids as adjunctive therapy for bacterial
keratitis. Cochrane Database Syst Rev 2014; :CD005430.
Topic 6900 Version 50.0

GRAPHICS
Emergency versus urgent referral for red eyes
Angle-closure glaucoma Emergency
Hyphema Emergency
Hypopyon Emergency
Iritis Urgent
Infectious keratitis
Bacterial Emergency
Viral Urgent
Scleritis Urgent
Graphic 75654 Version 4.0

Red eyes that may be managed by the primary care clinician
Stye (hordeoleum)
Chalazion
Blepharitis
Subconjunctival hemorrhage
Conjunctivitis
Bacterial
Viral
Allergic
Corneal abrasion (urgent follow-up if not better in 24 to 48 hours)
Corneal foreign body (urgent follow-up if not better in 24 to 48 hours)
Contact lens overwear (urgent follow-up if not better in 24 to 48 hours)
Dry eye syndrome
Episcleritis

Assessment of the red eye
Foreign-
Cardinal
Acuity body Photophobia Discharge T
feature
sensation
Lids/lashes
Stye/hordeoleum Normal - - None Tender T
Chalazion Normal - - None Nontender T
Blepharitis Normal - - Dry crusting Chronic T
Conjunctiva
Conjunctivitis
Bacterial Normal - - Mucopurulent Discharge all T

day
Viral Normal - - Mucoserous None/URI T
Allergic Normal - - Mucoserous Itching T
Nonspecific Normal - - Watery

(toxic or dry
eye
syndrome)
Episcleritis Normal - - None Sectoral T

injection, dull
ache
Subconjunctival Normal - - None Extravasated T

hemorrhage blood
Cornea
Abrasion Normal or + + Watery History/trauma T

decreased defect
revealed by
fluorescein
Contact lens Normal or + + Watery History T

overwear decreased
Foreign body Normal or + + Mucoserous History/trauma T

decreased b
r
i
s
s

a
h
Infectious keratitis
Bacterial Normal or + + Muco- White spot on E

decreased purulent cornea spots r
stains with (
fluorescein
Viral Normal or + + Watery Gray, U

decreased branching r
opacity 2
dendrite;
dendrite
revealed with
fluorescein
Anterior chamber/iris
Iritis Normal or - + None/watery Ciliary flush, U

decreased very small r
pupil 2
Hyphema Normal or - +/- None/watery RBC "level" E

decreased r
(
Hypopyon Normal or - +/- None/purulent WBC "level" E

decreased r
(
Iris/lens
Angle closure Normal or - +/- None/watery Fixed, mid- E

decreased dilated pupil r
(
URI: upper respiratory infection; RBC: red blood cell; WBC: white blood cell.

Acute angle-closure glaucoma
The conjunctival vessels are dilated, especially near the cornea (ciliary flush) and the cornea is slightly
hazy (edematous).
Reproduced with permission from: Trobe JD, Hackel RE. Field Guide to the Eyes. Lippincott Williams & Wilkins, Philadelphia 2002.
Copyright © 2002 Lippincott Williams & Wilkins. www.lww.com.

Eye manifestations of HSV-1 infection
Different eye manifestations of herpes simplex virus-1 infection.
(A) Corneal epithelial disease with damaged epithelial cells observed as "dendrites" after staining with
dyes.
(B) Corneal stromal disease or "disciform keratitis"; this reflects severe damage to infected epithelial cells,
producing stromal edema with corneal clouding.
(C) Necrotizing stromal disease in which infiltration of inflammatory cells and neovascularization results
in destruction of the cornea, glaucoma, and dense scarring.
(D) Keratouveitis in which mononuclear cell clusters, termed "keratic precipitates," can be seen in the
corneal epithelium.
Reprinted from Immunology Today, 18(9), Streilein, JW, Dana, MR, Ksander, BR, HSV-1 Infections: Clinical presentation and
diagnosis, 443-9, 1997, with permission from Elsevier Science.

Hypopyon associated with endophthalmitis
Hazy cornea and hypopyon and markedly inflamed conjunctiva.

Hyphema associated with trauma
A layer of blood at the bottom of the anterior chamber.

Blepharitis
Blepharitis is associated with crusting of the eyelashes, thickening of the eyelids, telangiectatic vessels
along the lid margins, and plugging of the meibomian glands.
Reproduced with permission from: The Wills Eye Hospital Atlas of Clinical Ophthalmology, 2nd ed, Tasman W, Jaeger E (Eds),
Lippincott Williams & Wilkins, Philadelphia 2001. Copyright © 2001 Lippincott Williams & Wilkins.

Blepharitis
Lid margins diffusely and irregularly swollen and red.

Nodular episcleritis
Episcleritis is a localized ocular redness from inflammation of the episcleral vessels. In natural light,
vessels appear salmon pink and are movable over the scleral surface. Usually benign and self-limited,
episcleritis may be nodular, as shown here, or may show only redness and dilated vessels.
Reproduced with permission from: The Wills Eye Hospital Atlas of Clinical Ophthalmology, 2nd ed, Tasman W, Jaeger E (Eds),
Lippincott Williams & Wilkins, Philadelphia 2001. Copyright © 2001 Lippincott Williams & Wilkins.

Episcleritis
Typical form with sectoral injection.
Image created by Christopher J Rapuano, MD. Reproduced with permission from: www.visualdx.com. Copyright VisualDx. All rights
reserved.

Bacterial conjunctivitis
Courtesy of Deborah Jacobs, MD.

Acute seasonal conjunctivitis
Acute seasonal conjunctivitis classically presents with eyelid and conjunctival erythema and swelling. It is
almost always bilateral.

Corneal abrasion
Corneal abrasion unmasked with use of fluorescein dye. Blue light will further enhance visualization of
abraded region where exposed basement membrane picks up the dye. The dye has diffused under the
edge of intact epithelium, making the boundary appear less distinct than it actually is.
reserved.

Corneal foreign body
Corneal foreign body that has been present for several days, resulting in inflammatory reaction to iron in
the foreign body and causing local haze and surface breakdown that picks up stain.
reserved.

Anterior uveitis
The irregular pupil shape is caused by inflammatory adhesion of the iris margin to the anterior lens
surface superiorly.
Reproduced with permission from: Trobe JD. The Physician's Guide to Eye Care, American Academy of Ophthalmology 1993.
Copyright © 1993.

Hypopyon in endophthalmitis
A postoperative eye showing endophthalmitis with conjunctival injection and a hypopyon, the layering of
white blood cells in the anterior chamber.
Reproduced with permission from the department of Ophthalmology and Vision Science, University of Toronto.

Bacterial keratitis
The white corneal opacity suggests purulence necrosis.
Reproduced with permission from: Trobe JD. The Physician's Guide to Eye Care, American Academy of Ophthalmology 1993.
Copyright © 1993.

Subconjunctival hemorrhage
Extravasated blood in the inferior conjunctiva.

Distinguishing hordeolum (stye) from chalazion


Internal hordeolum image: Original photograph used with permission. Copyright © 2022 DermNet NZ. www.dermnetnz.org.

Glaucoma: Angle anatomy of the eye
The angle is the recess formed by the irido-corneal juncture. The scleral spur, trabecular meshwork, and
Schwalbe's line lie within this angle. The trabecular meshwork is a fenestrated structure that transmits
aqueous fluid to Schlemm's canal, from which it drains into the venous system. The normal flow of
aqueous is demonstrated here.
Reproduced with permission from Trobe JD. The Physician's Guide to Eye Care. Foundation of the American Academy of
Ophthalmology, San Francisco, 2001. p.158. Copyright © American Academy of Ophthalmology.

Acute angle-closure glaucoma
El margen pupilar bloquea el paso del humor acuoso desde la cámara posterior a la cámara anterior
(bloqueo pupilar), hinchando el iris hacia adelante (iris bombe), causando que la raíz del iris ocluya la red
trabecular y obstruya completamente el drenaje del líquido acuoso de la cámara anterior. (cierre de
ángulo). La rápida elevación resultante de la presión intraocular requiere una intervención urgente para
evitar la pérdida visual permanente.
Reproducido con permiso de: Trobe JD. La guía del médico para el cuidado de los ojos. Fundación de la Academia Estadounidense
de Oftalmología, San Francisco, 2001. p.158. Copyright © Academia Estadounidense de Oftalmología.
Gráfico 59454 Versión 3.0

Vista con lámpara de hendidura de la queratitis por herpes simple
Vista con lámpara de hendidura de una opacidad ramificada grisácea elevada característica de la
queratitis aguda por herpes simple. Este hallazgo, llamado dendrita, es el equivalente corneal de una
lesión vesicular en la piel.
Reproducido con autorización de Sila Bal, MD, MPH.

escleritis bilateral
Escleritis anterior bilateral en un paciente con síndrome de Cogan, manifestada por dolor ocular y
eritema. (La paciente también tenía vértigo y pérdida auditiva neurosensorial bilateral como
complicación de su síndrome de Cogan).

Enfermedades sistémicas asociadas con la escleritis.
Enfermedades del tejido conectivo
Artritis reumatoide
Artritis reactiva
Lupus eritematoso sistémico
Policondritis recurrente
vasculitis sistémicas
Granulomatosis con poliangeítis
Poliangeítis microscópica
Granulomatosis eosinofílica con poliangeítis (Churg-Strauss)
Poliarteritis nudosa
síndrome de cogan
síndrome de behcet
vasculitis urticaria
Infecciones
Sífilis
Tuberculosis
enfermedad de Lyme
Infección de herpes
aspergilis
Otro
sarcoidosis
Enfermedad inflamatoria intestinal

Divulgaciones del colaborador

Deborah S Jacobs, MD Consultores/Consejos asesores: Cloudbreak [Oftalmología/pterigión]; Dompé
[Oftalmología/queratitis neurotrófica]. Todas las relaciones financieras relevantes enumeradas han sido
mitigadas. Matthew F Gardiner, MD Consultores/Consejos asesores: Productos farmacéuticos genéricos
[degeneración macular]. Otro interés financiero: Alcon [Alimentos y bebidas – Curso de cataratas]. Todas
las relaciones financieras relevantes enumeradas han sido mitigadas. Jane Givens, MD, MSCE No hay
relaciones financieras relevantes con empresas no elegibles para revelar.
El grupo editorial revisa las divulgaciones de los contribuyentes para detectar conflictos de intereses.
Cuando se encuentran, estos se abordan mediante un proceso de revisión de varios niveles y mediante
requisitos de referencias que se deben proporcionar para respaldar el contenido. Se requiere que todos
los autores tengan contenido con las referencias adecuadas y deben cumplir con los estándares de
evidencia de UpToDate.
Política de conflicto de intereses

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27/4/24, 13:11 Los ojos rojos: Evaluación y gestión - UpToDate

Reimpresión oficial de UpToDate ®

El ojo rojo: evaluación y gestión

Revisión de la literatura vigente hasta: marzo de 2024.

El diagnóstico y tratamiento específicos de muchos de estos trastornos se analizan por

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EVALUACIÓN DEL PACIENTE

La pandemia de la enfermedad por coronavirus de 2019 (COVID-19) ha producido informes

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extraño, en la que el paciente es incapaz de abrir el ojo espontáneamente o mantenerlo

● Is there new onset of binocular double vision?

Determining severity of condition

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● By comparison, the patient suffering from infectious keratitis, iritis, or angle-closure

● Importance of results – In cases in which a lid disorder, conjunctival process, corneal

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● Is there purulent discharge? – Purulent discharge suggests bacterial conjunctivitis or

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ETIOLOGY AND MANAGEMENT

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Blepharitis — Blepharitis is discussed in detail elsewhere. (See "Blepharitis".)

Conjunctivitis — Conjunctivitis is discussed in detail elsewhere. (See "Conjunctivitis" and

Episcleritis — Episcleritis is a localized ocular redness from inflammation of episcleral vessels.

Subconjunctival hemorrhage — Patients with subconjunctival hemorrhage are generally

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therapy is indicated. If subconjunctival hemorrhage is recurrent or if the patient has a history of

More serious conditions

Angle-closure glaucoma — Acute angle-closure glaucoma is relatively uncommon, but the

Diagnosis is confirmed with measurement of intraocular pressure. Normal intraocular pressure

Angle-closure glaucoma is a sight-threatening emergency that must be treated within hours to

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associated with significant trauma, inflammation, or pathologic neovascularization. (See

Infectious keratitis — Infectious keratitis can be caused by bacteria, viruses, fungi, or

Bacterial keratitis — Bacterial infectious keratitis warrants evaluation by an

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Treatment requires urgent ophthalmological referral and prompt initiation of topical

Patients should be referred to an ophthalmologist within a few days for confirmation of

INFORMATION FOR PATIENTS

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variety of subjects by searching on "patient info" and the keyword(s) of interest.)

● Overview – "Red eye" is a common presenting complaint in ambulatory practice. A small

● Patient evaluation – Patient history, measurement of visual acuity, and findings on

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Use of UpToDate is subject to the Terms of Use.

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Emergency versus urgent referral for red eyes

Angle-closure glaucoma Emergency

Graphic 75654 Version 4.0

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Red eyes that may be managed by the primary care clinician

Corneal abrasion (urgent follow-up if not better in 24 to 48 hours)

Corneal foreign body (urgent follow-up if not better in 24 to 48 hours)

Contact lens overwear (urgent follow-up if not better in 24 to 48 hours)

Dry eye syndrome

Graphic 56779 Version 3.0

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Assessment of the red eye

Stye/hordeoleum Normal - - None Tender T

Chalazion Normal - - None Nontender T