Red, Watery Eye

Background

Red/watery eye means one of the following:  

• Infection
• Allergy
• Dust
• Chemicals
• Foreign Body

Infection can be either bacterial or viral.  Infectious red eye is called “conjunctivitis”.  Conjunctivitis is inflammation/redness of the sclera and space under the eyelid. Conjunctiva is resistant to mouth and nose bacteria but is very sensitive to skin sources, especially the genital source.  Gonorrhea/Chlamydia causes very serious eye infections.  Cold viruses often cause redness too.  

If both eyes are red consider either viral or allergic etiology.  Bacterial infections are usually unilateral then become bilateral in a few days.    Infection causes itching, burning, and yellow/greenish discharge or a.m. crusts.  Ideal treatment for bacterial conjunctivitis is topical antibiotic ointment that is smeared on the eye and rubbed in every 4 hours.  Blurry vision usually resolves in a few minutes.  Eye drops are more convenient and should be used every 2 hrs ideally.  Total number days of treatment should be about 10 days.

Other things to think about are:  acute iritis, narrow angle glaucoma, corneal abrasion, hyphema, and keratitis.  These are all painful. 

Hyphema		Painful, no vision change, no discharge or pupil change.  Blood in anterior chamber of eye, fluid level noted.  Ask blunt ocular trauma or violent sneezing.  Treatment is eye patch to decrease movement.
Corneal abrasion		Painful with photophobia, no pupil changes; watery discharge, diagnose by fluorescein stain to detect areas of corneal defect; ask about direct trauma to eye (finger, stick) treat with antibiotics, eye patch and exam daily.
Keratitis		Painful, photophobia, tearing. Decreased vision.  Herpes shows classic dendritic branching on fluorescein stain. Pain in anterial chamber is grave sign.  Consider adenovirus, hsv, pseudomonas, S. pneumo, staph,  Ask for Herpes history.  Immediate ophthalomology consult to treat with vidarabine.
Uveitis, iritis		nflammation of the iris, ciliary body +/- choroid; pain, miosis, photophobia; considerIBD, sarcoidosis, CMV, syphilis. Need to diagnose and treat appropriately.

Narrow angle glaucoma

Rapid onset, severe pain, decreased vision, halos, fixed mid-dilated pupil; emergency and iv mannitol and acetazolamide, laser treatment.  Consult with ophthalmology.

Note

With common nonvisual painless tearing; consider emotional states, hypersecretion of tears, and blockage of drainage.   Tear duct occlusion and pain is due to infection and treat with keflex.

Epidemic Keratoconjunctivitis (EKC)

Drug Allergy

Differential diagnosis:

Discharge present

• conjunctivitis
• blepharitis
• contact lens over wear syndrome
• sub conjunctival hemorrhage
• acute allergic reaction

No discharge, but mild-moderately painful:

• dry-eye syndrome
• blepharitis
• conjunctivitis
• episcleritis
• inflamed  pterygium
• foreign body
• corneal disorder
• ultra violet keratitis
• herpes simplex keratitis

No discharge, but moderate to severe pain:  

• corneal abrasion
• corneal erosion
• ulcer
• uveitis
• acute narrow angle glaucoma
• contact lens over wear syndrome  

No discharge, and minimal or no pain

• subconjunctival hemorrhage
• pterygium/pingueculum
• blepharitis
• dry-eye syndrome
• retinal detachment
• corneal opacity

This section provided by CAPT Robert B. North, Jr., MC, USN

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