Evaluation and Management of Acute Red Eye in a 4-Year-Old Child
Begin with a focused history and examination to identify red flags requiring urgent ophthalmology referral, while recognizing that most pediatric red eyes are benign conditions manageable in primary care. 1
Initial Assessment: Red Flags Requiring Urgent Referral
Immediately refer to ophthalmology if any of the following are present:
- Severe ocular pain (beyond mild irritation) 2
- Significant photophobia (true light sensitivity, not just squinting) 2
- Decreased visual acuity (≥2 lines difference between eyes or reduced from baseline) 3
- Abnormal or asymmetric red reflex (suggests intraocular pathology) 3, 4
- Abnormal pupillary response or relative afferent pupillary defect 3
- Proptosis (forward displacement of the globe) 5
- Limited or painful extraocular movements 5
- Corneal opacity or haze (suggests keratitis or ulcer) 1
- Hypopyon (layered white cells in anterior chamber) 1
- Associated neurological symptoms with new-onset eye findings 3
Focused History
Obtain specific details about:
- Onset and duration: Sudden versus gradual, unilateral versus bilateral 1
- Discharge characteristics: Watery (viral/allergic), purulent (bacterial), mucoid (allergic) 1, 6
- Pain quality: None (conjunctivitis), foreign body sensation (corneal involvement), deep aching (intraocular) 2
- Vision changes: Any blurring or loss of vision 2
- Trauma history: Even minor trauma can cause serious injury 1
- Contact lens use: Increases risk of bacterial keratitis 2
- Recent illness: Upper respiratory infection suggests viral etiology 1
- Allergic symptoms: Itching, seasonal pattern, bilateral presentation 6
Systematic Examination
Visual Assessment
- Perform monocular visual acuity testing using age-appropriate optotypes (HOTV or LEA SYMBOLS charts), testing each eye separately with the other eye completely occluded 3
- Assess fixation and following behavior if formal acuity testing not possible 4
External Examination
- Red reflex testing (Brückner test) to detect intraocular abnormalities and assess symmetry 3, 4
- Pupillary examination: Size, shape, reactivity, and check for relative afferent pupillary defect 3, 4
- Pattern of redness: Diffuse (conjunctivitis), circumcorneal/ciliary flush (anterior uveitis, keratitis), sectoral (episcleritis) 1
- Eyelid examination: Swelling, erythema, vesicles, foreign body under lid 1
- Corneal clarity: Use penlight tangentially; any opacity requires referral 1
Common Pitfalls to Avoid
- Do not assume bilateral red eye is always benign—bilateral presentation can occur with serious conditions like uveitis 1
- Do not miss examination under the upper eyelid for foreign bodies, especially if unilateral and history of outdoor activity 1
- Do not rely solely on discharge pattern—bacterial and viral conjunctivitis can have overlapping presentations 1
Management Based on Likely Diagnosis
Benign Conditions (No Red Flags Present)
Viral Conjunctivitis (watery discharge, recent URI, often starts unilateral):
- Supportive care with cool compresses 1
- Artificial tears for comfort 1
- Strict hand hygiene to prevent spread 1
- Expected duration 7-14 days 1
Bacterial Conjunctivitis (purulent discharge, matted lashes):
- Topical antibiotic drops (e.g., polymyxin B-trimethoprim or fluoroquinolone) 1
- Expected improvement within 2-3 days 1
Allergic Conjunctivitis (bilateral, itching predominant, clear/stringy discharge):
- Topical antihistamine/mast cell stabilizer combination 6
- Cool compresses 6
- Avoidance of known allergens 6
When Examination is Unsuccessful
Urgent referral for examination under sedation or anesthesia is indicated when there is suspicion of a vision-threatening cause and assessment in clinic is unsuccessful. 1