Red eye for the internist: When to treat, when to refer
ABSTRACTWhen a patient presents with redness in the eye, the cause needs to be diagnosed quickly. Some of the diseases that cause redness in the eye can be initially managed by an internist, but others call for quick referral to an ophthalmologist. This article reviews the spectrum of conditions manifesting as a red eye, emphasizing how to differentiate between the benign and the vision-threatening.
KEY POINTS
- Blepharitis, conjunctivitis, corneal abrasion, dry eye, and subconjunctival hemorrhage are benign and can usually be managed initially by an internist, although referral is usually indicated if symptoms persist or progress.
- Patients with corneal bacterial infection, uveitis, scleritis, or acute narrow-angle glaucoma need immediate referral to an ophthalmologist, as do most patients with a red eye who use contact lenses, who have had trauma to the eye, or who have vision changes, severe pain, nausea, vomiting, severe headache, marked purulent discharge, or abnormalities in the cornea or anterior segment.
- Because it is difficult to distinguish between infectious and noninfectious conditions, and because treating infections with corticosteroids alone can have grave consequences, we recommend that internists generally not use topical corticosteroids to treat eye symptoms.
Keratoconjunctivitis sicca (dry eye)
Dryness can cause mild eye redness. Patients typically report a foreign body sensation, burning, and paradoxically, watering. Symptoms often worsen as the day progresses and are most prominent at night.
Dryness can be due to:
- Local disturbances in the tear film such as aqueous deficiency
- An abnormal eyelid position
- Systemic autoimmune conditions such as Sjögren syndrome
- Hormonal changes (eg, in menopause)
- Excessively dry environments (eg, winter)
- Medications, including anticholinergics, antihistamines, antidepressants (eg, tricyclics), and antihypertensives (eg, beta-blockers).
Staining the cornea with fluorescein highlights small epithelial defects; rose bengal highlights devitalized cells.
Treat initially with artificial tears (eg, Refresh Tears, GenTeal, Systane, Bion Tears) and ointments (eg, Refresh Liquigel, Lacri-Lube). Dry eye has an inflammatory component; cyclosporine ophthalmic 0.05% (Restasis) may increase tear production and improve symptoms.4
Refer patients with symptoms that do not respond to therapy. An ophthalmologist can place silicone plugs in the canaliculi, a procedure with a 75% success rate for improving dry-eye symptoms.5 Plugs must be carefully fitted: loose ones can spontaneously dislodge, and tight ones can irritate the eye.
Eyelid malposition
Entropion (in-turning of the eyelid) causes eyelashes to rub on the cornea. Ectropion (outward turning of the eyelid) results in tear-film abnormalities and corneal exposure. Both conditions are most commonly caused by aging but may be secondary to scarring or to mechanical, paralytic, or congenital conditions. Definitive treatment involves surgery to restore the normal eyelid position. Several techniques have high success rates.1
Lagophthalmos (inability to fully close the eyes) is caused by orbicularis muscle dysfunction, which may be secondary to Bell palsy, stroke, or neurosurgical procedures that disrupt the facial nerve. The exposed cornea is prone to dryness and irritation. Treatments include artificial tears, lubricating ointments, and surgery—gold weight placement or suturing the eyelid margins (tarsorrhaphy).
Floppy eyelid syndrome refers to a lax upper eyelid that may evert during contact with the pillow during sleep, resulting in irritation and inflammation of the upper palpebral conjunctiva. Signs and symptoms are unilateral eye irritation, burning, and a ropy mucous discharge, which is usually worse in the morning. The upper eyelid is lax and easily everted when pulled toward the eyebrow. Most patients are obese, have obstructive sleep apnea, and sleep on the affected side.
Tell the patient to tape the affected eyelid shut or wear a protective eye shield in bed to prevent rubbing the eye on the pillow. Definitive treatment is surgery to tighten the lax upper eyelid.6
