What are the treatment options for a red eye with no discharge?

Red Eye Without Discharge: Diagnostic Approach and Treatment

For a red eye without discharge, the most critical first step is to identify red flag features—severe pain, vision loss, photophobia, or corneal involvement—which require urgent ophthalmology referral within 24 hours; otherwise, most cases can be managed with preservative-free lubricants and observation while investigating for underlying causes. 1, 2

Initial Assessment: Red Flags Requiring Urgent Referral

The absence of discharge narrows your differential significantly but does not eliminate serious pathology. You must immediately assess for:

• Severe ocular pain (beyond mild irritation or foreign body sensation) suggests corneal involvement, acute angle-closure glaucoma, iritis, or scleritis requiring same-day ophthalmology evaluation 1, 2
• Vision loss or decreased visual acuity indicates potential sight-threatening conditions demanding urgent referral 1, 3
• Photophobia (significant light sensitivity) suggests corneal disease, iritis, or keratitis requiring specialist assessment 1, 2
• Loss of corneal transparency or absent specular reflex on examination indicates corneal pathology requiring immediate ophthalmology consultation 4
• Unilateral presentation is more concerning than bilateral and warrants closer scrutiny for serious pathology 3

Common Causes of Red Eye Without Discharge

Subconjunctival Hemorrhage

• Presents with bright red blood under the conjunctiva without pain, discharge, or vision changes 5
• Management is observation only—artificial tears for comfort, with spontaneous resolution in 1-2 weeks 5
• Recurrent cases require investigation for hypertension, diabetes, bleeding disorders, anticoagulation therapy, and rarely ocular malignancies 5
• Look for salmon-pink lesions suggesting lymphoma in recurrent cases 5

Dry Eye Syndrome

• A commonly misdiagnosed cause of persistent red eye that fails to respond to initial treatment 6
• May represent primary pathology or secondary to medications, with important systemic implications including Sjögren's syndrome 6
• Treatment requires preservative-free artificial tears applied frequently (4 times daily minimum), avoiding preserved drops that worsen the condition 7, 6

Allergic Conjunctivitis (Minimal Discharge Variant)

• Can present with predominantly redness and minimal watery discharge 7
• Initial management includes cold compresses, refrigerated preservative-free artificial tears, and topical antihistamine/mast cell stabilizers 7
• Avoid eye rubbing and environmental allergens 7

Episcleritis/Scleritis

• Presents with sectoral or diffuse redness without discharge 2
• Scleritis causes severe pain not relieved by topical anesthetics and requires urgent referral 1

Treatment Algorithm for Non-Urgent Cases

First-Line Management

• Apply preservative-free artificial tears 4 times daily for lubrication and comfort 7, 6
• Cold compresses for 20-30 minutes using ice and water in a bag with barrier protection to prevent cold injury 5
• Avoid eye rubbing which can worsen inflammation 7

When to Escalate

• If symptoms fail to improve within a few days of lubricant therapy, refer to ophthalmology for comprehensive evaluation 4
• Any development of pain, vision changes, or photophobia during observation requires immediate ophthalmology consultation 1, 2

Critical Pitfalls to Avoid

• Never prescribe topical corticosteroids without ophthalmology consultation—they can worsen herpes simplex infections and prolong viral infections 7
• Do not use topical antibiotics indiscriminately for red eye without discharge, as they cause toxicity without addressing the underlying cause 7
• Chronic vasoconstrictor use causes rebound vasodilation and should be avoided 7
• In patients on anticoagulation with subconjunctival hemorrhage, do not discontinue anticoagulation as these are minor bleeding events 5

Special Considerations

Systemic Disease Screening

• Red eye may be the presenting sign of systemic conditions including hypertension, diabetes, bleeding disorders, or autoimmune disease 5, 6
• For recurrent presentations, investigate underlying systemic conditions through appropriate laboratory workup and specialist consultation 5

Medication Review

• Dry eye syndrome may be medication-induced, requiring review of systemic medications 6
• Multiple topical eye medications can cause preservative-induced keratoconjunctivitis 7