Red eye resident survival guide (pediatrics)

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Eman Alademi, M.D.[2]

Synonyms and keywords: Approach to red eye in children, Red-eye work-up in kids, Red-eye management in children

Red eye resident survival guide (pediatrics) Microchapters


Red eye is one of the most common ophthalmologic conditions in the primary care setting in children. Inflammation of almost any part of the eye, including the lacrimal glands and eyelids, or faulty tear film can lead to red eye. Primary care physicians often effectively manage red eye, although knowing when to refer patients to an ophthalmologist is crucial, baseline ophthalmological tests, and accompanying manifestations can narrow down the differential diagnosis. The duration and laterality of symptoms (unilateral- vs. bilateral) and the intensity of pain are the main criteria allowing the differentiation of non-critical changes that can be cared for a general practitioner from diseases calling for an elective referral to an ophthalmologist and eye emergencies requiring urgent ophthalmic surgery.[1]


Life Threatening Causes

Life-threatening causes include conditions that could lead to death or permanent disability within 24 hours if left untreated.[2]

Common Causes[3][4][5][6][7]



FIRE: Focused Initial Rapid Evaluation

Patients with the primary symptom of a red eye are commonly seen in pediatric primary care clinics. The differential diagnoses of a red eye are broad, but with a succinct history and physical examination, the diagnosis can be readily identified in many patients. Identifying conditions that threaten vision and understanding the urgency of referral to an ophthalmologist is paramount. Some systemic diseases such as leukemia, sarcoidosis, and juvenile idiopathic arthritis can present with the chief symptom of a red eye. Finally, trauma, ranging from mild to severe, often precipitates an office visit with a red eye, and thus understanding the signs that raise concern for a ruptured globe is essential . In the primary care setting, with a focused history, a few simple examination techniques, and an appreciation of the differential diagnosis, one can feel confident in managing patients with acute red eyes.[9][10][11][12][13][14][15][16][17][18][19][20][21][22][23], or eye emergencies requiring urgent ophthalmic surgery.[24][25]

History & Physical examination
Systemic disease
Main symptom of red eye
Urgent ophthalmologic evaluation
Rupture of globe
Office visit
Office visit

Complete Diagnostic Approach

Red eye in pediatrics cab be divided into Localized, diffused and peri keratic injection. [26]

Shown below is an algorithm summarizing the diagnosis of red eye according to the Nelson Essentials of Pediatrics guidelines. [27]

Age group
Infants and toddlers
School age children
School age children and adolescent
24 hours
<1 week
1-2 weeks
1-5 years
Viral conjunctivitis
Allergic conjunctivitis
Chemical conjunctivitis
Neisseria Ghonorrhea
Chlamydia Trachomatis
Herpes Simplex
Varicella Zoster
Without otitis
With otitis
Haemophilus Influenzae
Streptoccoccus Penumoniae
H. Influenzae


Shown below is an algorithm summarizing the treatment of Red eye according to the American journal of medicine. [6]

Patient with red eye
Acute conjunctivitis
Chronic blepharitis
Urgent ophthalmic surgery
Eyelid hygiene
Topical antibiotics
•Oral tetracycline or doxycycline
Over the counter
Vasocontricter agent or with more effective second generation topical histamine H1 receptor antagonist
Antiinflammatory agents (eg. topical cyclosporine)
Topical corticosteroids
Systemic omega 3 fatty acids
Hand washing and meticulous hygiene or normal saline spray
Ophthalmic antibiotic such as gentamycin





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