Elsevier

The American Journal of Medicine

Volume 128, Issue 11, November 2015, Pages 1220-1224.e1
The American Journal of Medicine

Clinical research study
Bedside Diagnosis of the ‘Red Eye’: A Systematic Review

https://doi.org/10.1016/j.amjmed.2015.06.026Get rights and content

Abstract

Background

In patients with red eye, traditional teachings suggest that photophobia, visual blurring, and eye pain indicate serious eye disease; in patients with presumed conjunctivitis, the finding of purulent drainage traditionally indicates a bacterial cause. The accuracy of these teachings is unknown.

Methods

A MEDLINE search was performed to retrieve articles published between 1966 and April 2014 relevant to the bedside diagnosis of serious eye disease and bacterial conjunctivitis.

Results

In patients with red eye, the most useful findings indicating serious eye disease are anisocoria (with the smaller pupil in the red eye and difference between pupil diameters >1 mm; likelihood ratio [LR], 6.5; 95% confidence interval [CI], 2.6-16.3) and photophobia, elicited by direct illumination (LR, 8.3; 95% CI, 2.7-25.9), indirect illumination (LR, 28.8; 95% CI, 1.8-459), or near synkinesis test (“finger-to-nose convergence test,” LR, 21.4; 95% CI, 12-38.2). In patients with presumed conjunctivitis, complete redness of the conjunctival membrane obscuring tarsal vessels (LR, 4.6; 95% CI, 1.2-17.1), observed purulent discharge (LR, 3.9; 95% CI, 1.7-9.1), and matting of both eyes in the morning (LR, 3.6; 95% CI, 1.9-6.5) increase the probability of a bacterial cause; failure to observe a red eye at 20 feet (LR, 0.2; 95% CI, 0-0.8) and absence of morning gluing of either eye (LR, 0.3; 95% CI, 0.1-0.8) decrease the probability of a bacterial cause.

Conclusions

Several bedside findings accurately distinguish serious from benign eye disease in patients with red eye and, in patients with presumed conjunctivitis, distinguish bacterial from viral or allergic causes.

Section snippets

Materials and Methods

We searched PubMed to identify all English-language studies that evaluated the diagnostic accuracy of the patient interview and physical examination in adult patients presenting with a red eye. The specific search strategy is shown in Appendix E1, (available online).

We included all studies meeting the following 3 criteria: (1) The study enrolled either consecutive unselected adults with red eye, all of whom eventually underwent the diagnostic standard of slit-lamp examination to distinguish

Distinguishing Serious From Benign Eye Disease

Five studies enrolling 957 consecutive patients were included in this review. Four studies recruited patients with red eye,4, 5, 6, 7 and 1 study enrolled patients with “miscellaneous eye complaints.”8 All patients underwent slit-lamp biomicroscopy: Serious disease was found in 4% to 59% (mean, 27%), mostly anterior uveitis (iritis) and corneal disorders (herpes simplex infection, corneal abrasion, and miscellaneous causes of keratitis).

Two findings—anisocoria and the presence of pain during

Discussion

Most ophthalmologic diagnosis depends on empiric observation by specialists using slit-lamp biomicroscopy. However, our results demonstrate that some clinical variables easily observed by primary providers without a slit lamp also accurately diagnose serious eye disease and bacterial conjunctivitis.

Simple observation of the pupil and the patient's response to pupillary constriction provide important clues suggesting serious eye disease. Inflammation of the iris and spasm of the ciliary body are

Conclusions

In patients with the red eye, simple examination of the pupils and response to pupillary constriction accurately identify patients who require immediate referral to an ophthalmologist. All patients with visual blurring and significant eye pain also require immediate referral, although these findings have not been evaluated systematically. In patients with conjunctivitis, a bacterial cause is more likely if there is bilateral matting of the eyes, conjunctival redness obscuring tarsal vessels,

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Cited by (0)

Funding: None.

Conflict of Interest: SM receives royalties from Elsevier for his textbook Evidence-based Physical Diagnosis, 3rd Edition.

Authorship: Both authors had access to the data and played a role in writing this manuscript.

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