What is the best course of treatment for a patient with a red sclera due to an eye injury?

Management of Eye Injury with Red Sclera

For any eye injury causing scleral redness, immediately start topical moxifloxacin 0.5% four times daily and arrange urgent ophthalmology evaluation within 24 hours to rule out globe perforation, intraocular foreign body, or infection risk. 1

Immediate Assessment Priorities

When evaluating traumatic scleral redness, you must rapidly distinguish between superficial injury and vision-threatening pathology:

• Severe ocular pain, significant photophobia, decreased vision, or history of penetrating trauma are red flags demanding immediate ophthalmology consultation 2, 3
• Check for globe perforation, which occurs in 0.08-5.1% of eye injuries and places patients at higher risk for retinal detachment, vitreous hemorrhage, and endophthalmitis 4
• Assess for hypotony (low intraocular pressure), which suggests full-thickness injury requiring surgical intervention 4

First-Line Medical Management

Antibiotic Coverage (Start Immediately)

• Moxifloxacin 0.5% four times daily is the preferred topical antibiotic for scleral trauma, particularly when corneal epithelial compromise is present or suspected 1
• Alternative fluoroquinolones (levofloxacin, gatifloxacin, or ciprofloxacin) can be substituted if moxifloxacin is unavailable 1
• Prophylactic topical antibiotics must be started within 24 hours of injury to prevent progression to bacterial keratitis or endophthalmitis 1

Supportive Therapy

• Apply preservative-free hyaluronate or carmellose drops every 2 hours during the acute phase to protect the corneal surface and promote epithelial healing 1
• Preservative-free formulations are essential to avoid additional ocular surface toxicity in already compromised tissue 1

Cycloplegic Agents (If Anterior Chamber Inflammation Present)

• Add cyclopentolate 1% or atropine 0.5-1% if significant anterior chamber inflammation or pain is present to prevent synechiae formation and reduce ciliary spasm 1

Anti-Inflammatory Therapy (Delayed, Not Initial)

Consider nonpreserved dexamethasone 0.1% twice daily only after 48-72 hours if significant inflammation develops, but only after infection has been ruled out or adequately controlled 1. Alternatively, prednisolone acetate 1% can be instilled 1-2 drops into the conjunctival sac 2-4 times daily, with frequency increased during the initial 24-48 hours if necessary 5.

Critical caveat: Topical corticosteroids should never be used initially in bacterial conjunctivitis or suspected infection, as they can potentiate bacterial growth and worsen outcomes 1, 5. Care should be taken not to discontinue therapy prematurely, and if signs and symptoms fail to improve after 2 days, the patient must be re-evaluated 5.

When to Suspect Scleritis vs. Simple Trauma

If the sclera appears muddy or discolored rather than bright red, consider inflammatory scleritis rather than simple traumatic injection:

• Urgent ophthalmology consultation is required for patients with muddy or discolored appearance of the sclera to confirm diagnosis and classify the subtype 6
• For non-necrotizing anterior scleritis, start oral NSAIDs as initial therapy, adding oral corticosteroids if NSAIDs fail after 1-2 weeks or if disease is moderate-to-severe at presentation 6
• For necrotizing scleritis or refractory cases, immediate systemic corticosteroids plus disease-modifying anti-rheumatic drugs (DMARDs) are required, with high-dose oral prednisone (1 mg/kg/day) or IV methylprednisolone for severe cases 6

Serious Complications Requiring Active Surveillance

Beyond simple conjunctival injection, watch for these vision-threatening complications:

• Endophthalmitis (1 in 30,000 to 1 in 185,000 cases), presenting with worsening pain, vision loss, increased redness, or purulent discharge 4
• Subconjunctival abscess or preseptal/orbital cellulitis (1 in 1,100 to 1 in 1,900 cases) 4
• Surgically induced necrotizing scleritis (1 in 4,000 cases, more likely in adults) 4
• Retinal detachment (1 in 10,000 to 1 in 40,000 cases) 4

Follow-Up Protocol

• Daily ophthalmology review is necessary during the acute phase to monitor for infection, inflammation, and healing 1
• Patients must return immediately for worsening pain, vision loss, increased redness, or purulent discharge, as these indicate possible progression to endophthalmitis requiring emergency intervention 1
• All pediatric scleral injuries require urgent ophthalmology evaluation within 24 hours to assess for full-thickness perforation, intraocular foreign body, or vitreous involvement 1

Common Pitfalls to Avoid

Do not assume simple "red eye" is benign conjunctivitis in the setting of trauma 7, 2. The duration and laterality of symptoms, intensity of pain, and presence of vision changes are the main criteria differentiating non-critical changes from eye emergencies requiring urgent ophthalmic surgery 7. When diagnosis is in doubt, refer to ophthalmology immediately 7.