What causes redness around both eyes without itching?

Causes of Redness Around Both Eyes Without Itching

The most common causes of redness around both eyes without itching include viral conjunctivitis, bacterial conjunctivitis, and irritative/mechanical causes, with viral conjunctivitis being the most frequent etiology. 1

Common Causes

1. Viral Conjunctivitis

• Presentation:
  • Abrupt onset, often sequentially bilateral
  • Bulbar conjunctival injection (redness)
  • Watery discharge
  • Minimal or no itching
  • May have preauricular lymphadenopathy
• Associated factors:
  • Exposure to infected individuals
  • Recent upper respiratory infection
  • Highly contagious
• Management:
  • Self-limited (5-14 days)
  • Avoid topical antibiotics (ineffective against viral causes) 1
  • Cold compresses for comfort
  • Strict hand hygiene to prevent spread

2. Bacterial Conjunctivitis

• Presentation:
  • Unilateral or bilateral redness
  • Mucopurulent or purulent discharge
  • Eyelid mattering/crusting
  • Minimal itching
• Management:
  • Often self-limiting
  • Topical antibiotics may shorten duration
  • No evidence supporting superiority of any specific antibiotic 1

3. Mechanical/Irritative Causes

• Types:
  • Contact lens-related keratoconjunctivitis
  • Exposure to irritants/chemicals
  • Medication-induced/preservative-induced
  • Floppy eyelid syndrome
• Presentation:
  • Bilateral redness
  • Irritation without significant itching
  • May have foreign body sensation

Less Common Causes

1. Superior Limbic Keratoconjunctivitis

• Associated with thyroid disorders
• Redness predominantly in the superior bulbar conjunctiva

2. Dry Eye Disease

• Bilateral redness
• Burning sensation rather than itching
• Worse with environmental factors (wind, air conditioning)

3. Blepharitis

• Inflammation of eyelid margins
• Associated with rosacea
• Redness along lid margins extending to conjunctiva

4. Systemic Conditions

• Thyroid eye disease
• Vasculitis
• Graft-versus-host disease

5. Neoplastic Processes

• Rarely present as bilateral redness
• Usually unilateral and progressive 2

Distinguishing Features from Allergic Conjunctivitis

Allergic conjunctivitis typically presents with:

• Significant itching (cardinal symptom)
• Bilateral involvement
• Seasonal patterns (in seasonal allergic conjunctivitis)
• Papillary reaction on the tarsal conjunctiva 3

Red Flags Requiring Urgent Referral

• Severe pain not relieved by topical anesthetics
• Vision loss
• Copious purulent discharge (may indicate gonococcal infection)
• Corneal involvement
• Distorted pupil
• Herpes infection 4

Diagnostic Algorithm

1. Assess discharge:

   • Watery discharge → Consider viral etiology
   • Purulent discharge → Consider bacterial etiology
   • Minimal/no discharge → Consider dry eye or irritative causes

2. Evaluate pattern:

   • Bilateral simultaneous onset → Likely viral, allergic, or irritative
   • Sequential bilateral (one eye then the other) → Classic for viral
   • Unilateral → May be bacterial or early viral

3. Associated symptoms:

   • Recent URI or sick contacts → Viral conjunctivitis
   • Contact lens wear → Contact lens-related keratoconjunctivitis
   • Exposure to irritants → Irritative conjunctivitis

Management Principles

1. For viral conjunctivitis:

   • Patient education on contagious nature
   • Strict hand hygiene
   • Avoid sharing towels/pillows
   • Cold compresses
   • Artificial tears for comfort
   • Avoid topical antibiotics (ineffective and may cause toxicity) 1

2. For bacterial conjunctivitis:

   • Consider topical antibiotics for severe cases
   • Erythromycin ophthalmic ointment is commonly used, though may cause minor ocular irritation 5

3. For irritative causes:

   • Remove the offending agent (discontinue contact lens wear, avoid irritants)
   • Preservative-free artificial tears

Remember that indiscriminate use of topical antibiotics or corticosteroids should be avoided. Viral conjunctivitis will not respond to antibacterial agents, and mild bacterial conjunctivitis is likely to be self-limited 1.