What is the likely cause of photophobia with red, burning eyes in bright light and what initial management is recommended?

Red, Burning Eyes with Photophobia: Differential Diagnosis and Management

Red, burning eyes with photophobia most commonly represent either dry eye disease or ocular surface inflammation, but require urgent ophthalmology referral if accompanied by vision loss, severe pain, or corneal involvement to rule out sight-threatening conditions like uveitis, keratitis, or acute glaucoma. 1

Immediate Red Flag Assessment (RAPID Criteria)

Before proceeding with routine management, assess for these urgent features requiring same-day ophthalmology referral: 1

• Redness with vision loss (acuity worse than baseline)
• Acuity loss (any reduction in visual acuity)
• Pain (moderate-to-severe, beyond irritation or foreign body sensation)
• Intolerance to light (photophobia, especially if severe)
• Damage to cornea (fluorescein uptake, ulceration, haze, opacity, or purulent discharge)

Any combination of redness plus one additional red flag mandates emergency ophthalmology consultation within 24 hours. 1

Most Likely Diagnosis: Dry Eye Disease

The combination of burning, redness, and photophobia most commonly indicates dry eye syndrome, which presents with: 1

• Burning, stinging, or foreign body sensation
• Photophobia (light sensitivity)
• Redness and irritation
• Symptoms worsening later in the day
• Exacerbation with wind, low humidity, prolonged screen time, or reading

Tear film instability is the most common mechanism, more frequent than aqueous deficiency alone. 1

Initial Management for Mild-to-Moderate Cases

Start with preservative-free artificial tears 2-4 times daily as first-line therapy. 1

Treatment Ladder for Progressive Management:

1. Mild symptoms: Preservative-free lubricants 2-4 times daily 1

2. Moderate symptoms (if inadequate response after 1-2 weeks): Add olopatadine 0.1% twice daily to preservative-free lubricants 1, 2

3. Severe symptoms or requiring topical tacrolimus: Ophthalmology referral within 4 weeks 1

Critical Differential Diagnoses Requiring Specialist Referral

Uveitis (Anterior Chamber Inflammation)

Photophobia and eye pain persisting beyond 2-3 weeks suggests inflammatory pathology rather than simple conjunctivitis. 3 Uveitis requires:

• Immediate topical prednisolone acetate 1% every 1-2 hours plus cycloplegic agents 3
• Urgent ophthalmology evaluation, as untreated uveitis progresses to vision loss 3

Infectious Keratitis

Risk factors include contact lens wear, ocular surface disease, or recent trauma. Contact ophthalmology immediately if redness, pain, or photophobia worsens. 3

Allergic Conjunctivitis

Distinguished by severe itching and allergen exposure history. 4 Responds to topical antihistamines like olopatadine. 2

History Elements to Elicit

Document these specific factors: 1

• Symptom characteristics: Duration, bilateral vs unilateral, diurnal variation
• Exacerbating factors: Wind, air travel, decreased humidity, prolonged screen time
• Medication history: Topical drops (especially preserved formulations), antihistamines, diuretics, antidepressants, beta-blockers
• Systemic conditions: Sjögren syndrome, rheumatoid arthritis, rosacea, atopic dermatitis
• Contact lens use: Type, wearing schedule, hygiene practices
• Recent ocular surgery: LASIK, cataract surgery

Common Pitfalls to Avoid

Never start topical corticosteroids empirically before ruling out infection—steroids worsen infectious keratitis and prolong viral shedding. 3

Avoid preserved artificial tears with frequent use (>4 times daily), as preservatives cause additional ocular surface toxicity. 1

Do not dismiss unilateral redness—bilateral presentation is typical for dry eye and drug-related conditions, while unilateral suggests infection, trauma, or focal pathology. 1

When to Refer to Ophthalmology

Immediate referral (<24 hours): 1

• Any red flag present (RAPID criteria)
• Vision loss or severe pain
• Suspected corneal involvement
• Unilateral presentation with pain

Routine referral (within 4 weeks): 1

• Symptoms requiring topical tacrolimus
• Severe redness at initial presentation
• Inadequate response to initial treatment ladder
• Children under 7 years (due to visual development plasticity)