For the pediatrician, a child with a red eye can be a significant
challenge; the key decision is whether to refer to a pediatric ophthalmologist.
The diagnosis is often reasonably clear after a careful history
has been obtained. The examination may be challenging without the
availability of an accurate visual acuity test for each eye, appropriate
diagnostic eyedrops, microscopic examination, and the distraction
devices that pediatric ophthalmologists often use. Making an incorrect
diagnosis in a child with a red eye can result in vision loss, and
inappropriate treatment can have vision-threatening side effects.
The pediatrician is occasionally tempted to treat a red eye with
steroid eyedrops, but this should only be prescribed by a physician
able to do a complete eye examination and measure intraocular pressure.
Therefore, in practice, steroids should not be prescribed by pediatricians
or family physicians.1,2
Conjunctivitis is a common problem in childhood. The conjunctiva
becomes red and inflamed in response to a wide range of inciting
agents, such as infections, allergens, chemicals, smoke, trauma,
toxins, and systemic diseases. Red eye is not a common feature of
congenital glaucoma or nasolacrimal duct obstruction. This chapter
focuses on diagnosis and treatment of injected or red conjunctiva.
The differential diagnosis and management of a red eye are outlined
in Tables 588-1, 588-2, 588-3, and 588-4.
These tables do not provide exhaustive lists, but rather present
the scope of problems that may lead to a red eye. History taking
is more likely to lead to the correct diagnosis if this broad range
of possible diagnoses is considered. Figure 588-1 provides
a useful guide to evaluating a child with a red eye.
Table 588-1. Infective Causes
of a Red Eye3-5 ||Download (.pdf)
Table 588-1. Infective Causes
of a Red Eye3-5
|Condition||Etiology||Symptoms and Signs||Diagnosis and Treatment|
|Conjunctivitis of the newborn (neonatal conjunctivitis, ophthalmia neonatorum)3||Gonococcus, Chlamydia trachomatis,Staphylococcus
aureus, herpes simplex, chemical (from silver nitrate prophylaxis),
gram-negative and other bacteria||Purulent discharge, lid swelling (hyperacute, with possible
keratitis, in gonococcal infection), brain and skin involvement
with herpes ||Cultures, polymerase chain reaction (PCR), antibiotics/antivirals,
irrigation (gonococcus); if gonorrhea, must have ophthalmology consultation|
|Viral conjunctivitis (acute follicular conjunctivitis)||Adenovirus, rarely enteroviruses, Coxsackie viruses||Acute, often associated with upper respiratory infection,
may have preauricular or submandibular adenopathy lymphadenopathy;
conjunctival edema, discomfort, mild photophobia, small subconjunctival
hemorrhages. Spreads to second eye over days. May have discrete
corneal infiltrates visible at slit lamp.||Consider viral cultures/PCR, no treatment for mild
|Chlamydia conjunctivitis||Chlamydia trachomatis||Follicular and papillary conjunctivitis, mucopurulent discharge,
sometimes mild ptosis||Culture, PCR|
|Trachoma is the leading cause of preventable blindness
worldwide. It is endemic to North Africa, the Middle East, India,
and Southeast Asia.||Chlamydia trachomatis||Transmission is by direct person-to-person
contact through infected ocular secretions or indirectly though
contact with infected material. Flies can also spread the disease.
Children with trachoma can ...|