Conjunctival disorders and episcleritis*

Allergic or seasonal conjunctivitis

Bilateral, prominent itching, possibly conjunctival bulging (chemosis)

Known allergies or other features of allergies (eg, seasonal recurrences, rhinorrhea)

History and physical examination, including ophthalmic examination if the diagnosis is unclear or vision loss present‡

Chemical (irritant) conjunctivitis

Exposure to potential irritants (eg, dust, smoke, ammonia, chlorine, phosgene)

History and physical examination, including ophthalmic examination if the diagnosis is unclear or vision loss present‡

Episcleritis

Unilateral focal redness, mild irritation, minimal lacrimation

History and physical examination, including ophthalmic examination if the diagnosis is unclear or vision loss present‡

Infectious conjunctivitis

Scratchy sensation, photosensitivity

Sometimes mucopurulent discharge, eyelid edema, or papillae on tarsal conjunctiva

History and physical examination, including ophthalmic examination if the diagnosis is unclear or vision loss present‡

Ensure fastidious hand hygiene and cleaning of examination equipment to prevent cross-contamination

Subconjunctival hemorrhage

Unilateral, asymptomatic focal red patch or confluent redness

Possibly prior trauma or Valsalva maneuver

History and physical examination‡

Vernal conjunctivitis

Intense itching, stringy discharge

Usually preadolescent or adolescent males

Other atopic disorders

Waxing in spring and waning in winter

History and physical examination, including ophthalmic examination if the diagnosis is unclear or vision loss present‡

Corneal disorders†

Contact lens keratitis

Prolonged wearing of contact lenses, lacrimation, corneal edema

History and physical examination, including ophthalmic examination if the diagnosis is unclear or vision loss present‡

Corneal abrasion or foreign body

Onset after injury (but this history may be inapparent in infants and young children)

Foreign body sensation

History and physical examination, including ophthalmic examination if the diagnosis is unclear or vision loss present‡

Corneal ulcer

Often grayish opacity on the cornea, followed by a visible crater

Possibly a history of sleeping with contact lenses

Ophthalmic evaluation‡

Culture of ulcer (scrapings done by an ophthalmologist)

Epidemic keratoconjunctivitis (adenoviral conjunctivitis with keratitis), if moderate or severe

Copious watery discharge

Often eyelid edema, preauricular lymphadenopathy, chemosis (bulging of the conjunctiva)

Occasionally severe temporary loss of vision

History and physical examination, including ophthalmic examination if the diagnosis is unclear or vision loss present‡

Herpes simplex keratitis

Onset after conjunctivitis, blisters on eyelid

Unilateral

Ophthalmic evaluation‡

Viral culture if diagnosis is unclear

Herpes zoster ophthalmicus

Unilateral vesicles and crusts on an erythematous base in a V1 distribution, sometimes affecting the tip of the nose

Eyelid edema

Red eye

May be associated with uveitis

Possibly severe pain

Ophthalmic evaluation‡

Viral culture if diagnosis is unclear

Other disorders

Acute angle-closure glaucoma

Severe ocular ache

Headache, nausea, vomiting, halos around lights

Hazy cornea (caused by edema), marked conjunctival erythema

Decreased visual acuity

Intraocular pressure usually > 40 mm Hg

Tonometry and gonioscopy by ophthalmologist

Anterior uveitis

Ocular ache, photophobia

Ciliary flush (redness most concentrated and often confluent around the cornea)

Often a risk factor (eg, autoimmune disorder, blunt trauma within previous few days)

Possibly decreased visual acuity or pus in anterior chamber (hypopyon)

Cells and flare on slit-lamp examination

Ophthalmic evaluation‡

Scleritis

Severe pain, often described as boring

Photophobia, lacrimation

Red or violaceous patches under bulbar conjunctiva

Scleral edema

Tenderness of globe when palpated

Often history of autoimmune disorder

Ophthalmic evaluation‡

Further testing by or in conjunction with an ophthalmologist