What is the appropriate workup for an 83-year-old female presenting with a red eye?

Workup for Red Eye in an 83-Year-Old Female

The workup for red eye in an 83-year-old female should begin with careful assessment of warning signs that require urgent ophthalmology referral, including severe pain, vision loss, photophobia, and corneal involvement, followed by a targeted history and examination to differentiate between common causes such as conjunctivitis, dry eye, glaucoma, and giant cell arteritis.

Initial Assessment: Red Flag Symptoms

Immediately assess for these warning signs that require urgent ophthalmology referral 1, 2, 3:

• Severe pain (especially if not relieved by topical anesthetics)
• Vision loss or decreased visual acuity
• Significant photophobia
• Pupillary abnormalities or distortion
• History of trauma or recent eye surgery
• Copious purulent discharge
• Corneal involvement (loss of transparency)
• Herpetic features

Focused History

Gather information about:

• Duration and onset of redness (sudden vs. gradual)
• Associated symptoms:
  • Pain characteristics (dull, sharp, throbbing)
  • Discharge (type, amount, consistency)
  • Visual changes
  • Itching or burning sensation
  • Light sensitivity
  • Headache or temporal tenderness (critical in elderly patients)
• Systemic symptoms 1:
  • Temporal headache
  • Jaw claudication
  • Weight loss
  • Proximal myalgia
  • Fever
• Relevant medical history:
  • Cardiovascular disease
  • Diabetes
  • Autoimmune conditions
  • Previous eye conditions
• Medication history (especially those that may cause ocular side effects)

Physical Examination

1. Visual acuity assessment 1

2. External eye examination:

   • Eyelid position and function
   • Presence of swelling, redness, or crusting
   • Discharge characteristics

3. Pupillary assessment for:

   • Size and shape
   • Reactivity to light
   • Relative afferent pupillary defect (RAPD)

4. Slit-lamp biomicroscopy (if available) 1:

   • Conjunctival injection pattern (diffuse vs. localized)
   • Corneal clarity and integrity
   • Anterior chamber assessment for cells and flare
   • Fluorescein staining for epithelial defects

5. Intraocular pressure measurement (especially important in elderly patients)

6. Undilated fundus examination if possible

Differential Diagnosis and Specific Workup

1. Conjunctivitis

• Most common cause of red eye 2
• Look for:
  • Bilateral or unilateral involvement
  • Type of discharge (watery, mucoid, purulent)
  • Itching (suggests allergic etiology)
  • Follicular or papillary reaction
• Management: Consider topical antibiotics for bacterial conjunctivitis 4
  • Moxifloxacin 0.5% one drop TID for 7 days

2. Dry Eye Disease

• Common in elderly patients
• Look for:
  • Burning sensation
  • Foreign body sensation
  • Minimal discharge
  • Tear film instability
• Consider tear breakup time and ocular surface staining

3. Acute Angle Closure Glaucoma

• Ocular emergency requiring immediate referral 5
• Look for:
  • Mid-dilated, non-reactive pupil
  • Hazy cornea
  • Severe pain
  • Nausea/vomiting
  • Elevated intraocular pressure

4. Giant Cell Arteritis (GCA)

• Critical consideration in elderly patients 1
• Look for:
  • Temporal tenderness
  • Jaw claudication
  • Vision loss
  • Optic disc swelling
• Immediate laboratory testing:
  • Erythrocyte sedimentation rate (ESR)
  • C-reactive protein (CRP)
  • Complete blood count with platelets

5. Subconjunctival Hemorrhage

• Benign but alarming appearance
• Look for:
  • Well-demarcated area of blood under conjunctiva
  • No pain
  • No visual changes
  • History of coughing, straining, or blood thinners

6. Keratitis

• Look for:
  • Pain
  • Photophobia
  • Corneal opacity or infiltrate
  • History of contact lens use or trauma

7. Retinal or Ophthalmic Artery Occlusion

• Ocular emergency requiring immediate referral 1
• Look for:
  • Sudden, painless vision loss
  • Cherry-red spot (CRAO)
  • Pale retina
  • History of cardiovascular disease

Laboratory Testing

Based on clinical suspicion:

1. For suspected GCA 1:

   • ESR (elevated in GCA)
   • CRP (elevated in GCA)
   • Complete blood count with platelets

2. For suspected infection:

   • Consider conjunctival swab for culture and sensitivity

Imaging Studies

Based on clinical findings:

1. For suspected retinal or ophthalmic artery occlusion 1:

   • Urgent referral for diffusion-weighted MRI of the brain
   • Carotid imaging

2. For suspected orbital pathology:

   • CT or MRI of orbits

Management Algorithm

1. If red flags present → immediate ophthalmology referral

2. If suspected GCA → immediate ESR/CRP and referral for potential corticosteroid therapy 1

3. If suspected acute angle closure → immediate ophthalmology referral 5

4. If suspected retinal or ophthalmic artery occlusion → immediate referral to stroke center 1

5. If uncomplicated conjunctivitis:

   • Bacterial: Topical antibiotics (e.g., moxifloxacin 0.5% one drop TID for 7 days) 4
   • Allergic: Topical antihistamines (e.g., ketotifen one drop BID) 6
   • Viral: Supportive care with artificial tears

6. If dry eye: Preservative-free artificial tears

Key Pitfalls to Avoid

1. Failing to recognize GCA in elderly patients with headache and vision changes - can lead to permanent blindness if not treated promptly 1

2. Misdiagnosing acute angle closure as conjunctivitis - look for mid-dilated pupil and corneal haziness 5

3. Overlooking retinal artery occlusions - these require immediate referral to a stroke center due to high risk of concurrent stroke (up to 24%) 1

4. Prescribing topical steroids without ophthalmology consultation - can worsen herpetic infections and mask serious conditions 2

5. Failing to remove contact lenses in patients with conjunctivitis 4