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Not Every Red Eye is Pinkeye

Conjunctivitis Can be Hard to Distinguish from Other Eye Disorders

Dec 18, 2008 Stephen Allen Christensen

Viral conjunctivitis is a benign cause of red eyes that is caused by the same viruses that cause colds. It must be distinguished from other causes of red eyes.

It happens all the time: A child gets sent home from school with “pinkeye,” even though nearly every other student in the class is coughing, sneezing, sniffing, and blowing.

In the majority of children with red eyes, the culprit is adenovirus, the same microorganism that causes colds. It’s just that most people (teachers included) tend to panic when they encounter a youngster with an eye that out-glows Rudolph’s nose.

Since teachers are charged with guarding the health of their pupils (and since they’ve all heard how contagious pinkeye can be), they unnecessarily send the kid with the inflamed orbit home.

It is possible, however, that even at the height of the cold and flu season a red eye can signal something more ominous than a viral infection. A few simple questions and a brief examination can differentiate those eyes with minor problems from those that need further evaluation.

Causes of Red Eyes in Children

Red eyes are caused either by dilation of the vessels in the usually transparent conjunctiva (the clear covering over the white of the eye) or by sub-conjunctival hemorrhage. The former (conjunctivitis) is characterized by a network of blood vessels tracking over the eye’s surface, while the latter looks like a spot of blood painted on the eye.

Viral conjunctivitis: Symptoms (watering, crusting, irritation, redness) develop gradually over 24-36 hours and may last up to four weeks. May be accompanied by cold symptoms (low fever, runny nose, cough, etc.). The lymph nodes in front of the ears are often swollen.
Allergic conjunctivitis: Similar in appearance to viral conjunctivitis, but itching may be a major complaint. Secretions tend to be stringy. Small, fluid-filled “blebs” may appear on the conjunctiva. There may be a history of contact with allergens.
Bacterial conjunctivitis: Symptoms begin suddenly; discharge is thick and purulent. Redness may be striking.
Foreign body or corneal abrasion: Symptoms begin suddenly; there may be a history of trauma or high-risk activity (e.g., playing outside in blowing sand). Sensation of foreign body may or may not be present. Light sensitivity is common.
Trauma: A direct blow to the eye may not reveal any obvious injury, but bleeding or inflammation within the orbit may lead to conjunctivitis.
Hordeolum (stye): The eye may be inflamed due to an infected gland on the eyelid.
Tumors behind the eye are rare causes of a red eye in children. Closed-angle glaucoma, uveitis, corneal ulcers, and scleritis are all potential causes of red eyes in adults, but they are not frequently seen in children.

Questions to Ask a Child with a Red Eye

Does it hurt to look into a bright light?
Are there halos or rainbows around lights?
Is there a deep ache inside your eye?
Has there been an injury to your eye (finger poke, direct blow, etc.)?
Can you still see as well as you did before?

Things to Look for in a Red Eye

What does the discharge look like (see above)?
Are the eyelids red and puffy?
Are the pupils both round; are they equal in size and (more importantly) do they both respond well when a light is shined in the eyes?
Is the child extremely sensitive to light?
Does the affected eye seem to protrude more than the normal one?
Are there any obvious foreign bodies, lacerations, or bleeding?

Viral conjunctivitis is self-limited and usually responds to gentle cleaning with warm water. Any suspicion of a more serious process should prompt a visit to a health care professional.

(Sources: Merck Manual, 18th Edition 2006 pg 877; Vafidis G. When is red eye not just conjunctivitis? Practitioner July 2002;246:469-81)

The copyright of the article Not Every Red Eye is Pinkeye in General Medicine is owned by Stephen Allen Christensen. Permission to republish Not Every Red Eye is Pinkeye in print or online must be granted by the author in writing.

Conjunctivitis