What Causes Red Eyes?

Patient Presentation

A 15 year-old female came to clinic with a 2 day history of increased redness in her left eye. The patient states that she has been having bilateral eye redness and discharge for 1 month and was prescribed Patanol® which has helped with some itchiness. For 2 days she has had consistent blurry vision, tearing, photophobia, and mild pain. She also began to have some headache and slight sore throat 1 day ago. She normally wears contact lenses and glasses and has been using the same contact lens cleaner. She denied any trauma. The past medical history showed she is taking cetirizine for seasonal allergic rhinitis. The family history is positive for glaucoma. Previously her eye pressures were normal. The review of systems is negative for fever, rashes, joint pain or swelling, weight changes or other headaches.

The pertinent physical exam revealed normal vital signs including a blood pressure of 90/70. Her visual acuity was grossly normal. Increased clear tearing was noted. Her sclera and palpebral conjunctiva were reddened with increased vasculature particularly around the cornea. There were small bubbles/spots scattered across the cornea with the left side more affected than the right. The retinal examination was grossly normal but suboptimal because of photophobia. No lid or facial skin changes were noted. The diagnosis of probable keratitis was made. The pediatrician contacted the ophthalmologist who wanted to see the patient as soon as possible as keratitis is a potentially vision-threatening condition. Additionally, other problems such as glaucoma could not be excluded. The ophthalmologist’s examination showed visual acuity of 20/30 bilaterally with scattered infiltrates of the cornea L > R, and confirmed epidemic keratoconjunctivitis of viral etiology. Lubricates and oral analgesics were prescribed.

Discussion
Epidemic keratoconjunctivitis is an acute viral disease usually caused by adenovirus types 8, 19, and 37, but also other viruses such as echoviruses. The virus is spread by contaminated secretions directly or indirectly between humans with an incubation period of 4-10 days. It can be transmitted from symptom onset to 12 days later. It is usually associated with decreased visual acuity, watery discharge, pain, photophobia and erythema of the conjunctiva. It can occur unilaterally or bilaterally. Systemic complaints can also occur such as low grade fever, headache, lymphadenopathy and fatigue. Subcorneal infiltrates develop and may persist for up to 2 years and can cause permanent scarring.

Learning Point
Usually the common causes of red eyes can be managed by a primary care physician. If a complete evaluation cannot be done, or if the red eye is thought to be part of a more serious underlying disease process then prompt referral should be made. Additionally, acute iritis, glaucoma, keratitis, scleritis and hyperacute bacterial conjunctivitis should also be referred. Normal acute and chronic conjunctivitis can usually be managed by a primary care physician.

The differential diagnosis for a red eye includes:

  • Anatomic
    • Nasolacrimal duct obstruction
    • Congenital or acquired glaucoma
  • Inflammation
    • Conjunctivitis – allergic, bacterial, viral, possibly fungal
    • Dacrocystitis
    • Iritis
    • Cellulitis – periorbital and orbital
    • Keratitis
  • Trauma
    • Corneal abrasion
    • Dry eye irritation
    • Foreign body – including contact lenses
    • Blunt trauma including rubbing, subconjunctival hemorrhage
    • Penetrating trauma
    • Chemical exposure
  • Systemic illness
    • Ataxia-telangectasia
    • Connective tissue disease
    • DRESS syndrome
    • Herpes simplex
    • Kawasaki disease
    • Leukemia
    • Lyme disease
    • Measles
    • Stevens-Johnson syndrome
    • Varicella

Questions for Further Discussion
1. What is the most common cause of hyperacute bacterial conjunctivitis?
2. What organism has been associated with contact lens solution contamination causing keratitis?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.
To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

Information prescriptions for patients can be found at MedlinePlus for these topics: Eye Diseases and Eye Infections.

Glover G. Infections of the eye. In Pediatrics a Primary Care Approach, Berkowitz CD, edit. W. B Saunders Co. Philadelphia, PA. 1996;200-201.

Schachat AP. The Red Eye. In Principles of Ambulatory Medicine. Williams and Wilkins. 1998;1488-1491.

Viney KA, Kehoe PJ, Doyle B, Sheppeard V, Roberts-Witteveen AR, Semirli H, McPhie KA, Dwyer DE, McAnulty JM. An outbreak of epidemic keratoconjunctivitis in a regional ophthalmology clinic in New South Wales. Epidemiol Infect. 2008 Sep;136(9):1197-206.

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Interpersonal and Communication Skills
    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

  • Systems Based Practice
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • What Causes Peeling Fingers and Toes?

    Patient Presentation
    A 5-year-old male was seen in clinic for his health supervision visit. His mother had no concerns but mentioned that his fingers and toes seemed to peel quite a bit. She stated that this was a chronic problem where he seemed to have thicker skin that would peel. There was no erythema, pruritis or pain. It did not affect his nails or hair and he had not had any localized infections because of the peeling. She said that it was not a real problem but more of an annoyance. The family history and review of systems were non-contributory, and he had no problems with his teeth.

    The pertinent physical exam showed a healthy male with normal vital signs and growth parameters in the 75-90%. HEENT showed normal teeth with the secondary left front incisor growing in. He had a normal scalp hair pattern, and had appropriate body hair. His nails were not affected. He had mildly thickened skin on the pads of his fingers and especially of his toes. The ball and heel of the feet were also affected. There was no obvious erythema but there were several uneven areas at the affected edges where tissue divots could be seen. The rest of his examination was normal. The diagnosis of palmar and planter hyperkeratosis was made. As he has no other physical or historical elements that would be consistent with a syndrome, this was thought to be an isolated problem. The physician recommended 10% salicylic acid/emollient preparation to help with the exfoliation. The mother stated that her mother was a licensed cosmetologist and had been using a plant-derived exfoliative agent occasionally which had helped. The mother agreed to try the salicylic acid along with manicure/pedicure care.

    Discussion
    Palmar and plantar hyperkeratosis is localized or diffuse thickening of the palmar and solar stratum corneum. It can occur in isolation or as part of a generalized disorder such as Sjögren-Larsson syndrome, Conradi’s syndrome, psoriasis, and hypohidrotic ectodermal dysplasia. Treatment includes agents to increase exfoliation such as lactic acid, salicylic acid or urea and soaking and mechanical exfoliation with a pumice stone or scalpel. These are used so tissue build up is decreased. Emollients need to be applied to help prevent fissuring from mechanical stress. Other possible treatments include topical psoralens with ultraviolet A light, topical retinoids or corticosteroids.

    Learning Point
    The differential diagnosis of desquamating digits includes:

    • Localized or semi-localized desquamation
      • Burns
      • Congenital ectodermal defects
      • Keratosis pilaris
      • Lichen planus
      • Lichen spinulosis
      • Palmar and plantar hyperkeratosis
      • Psoriasis
    • Generalized desquamation
      • Atopic dermatitis
      • Ichthyosis
      • Hypothyroidism
      • Lupus
      • Pityriasis rosea or alba
    • Infectious
      • Human papilloma virus
      • Kawasaki disease
      • Leprosy
      • Measles
      • Scabies
      • Staphylococcus
      • Streptococcus
      • Syphilis
      • Trichophytosis
      • Tuberculosis
    • Medication – anticonvulsants, griseofulvin, isoniazid, nitrofurantoin, penicillin, phenothiazines, salicylates, streptomycin, sulphonamides, chemotherapeutic agents
    • Environmental agents – arsenic, mercury, chemical dermatitis
    • Idiopathic
    • Malignancy
    • Malnutrition

    Questions for Further Discussion
    1. List common ichyoses.
    2. List common congenital ectodermal defects.

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for this topic: Skin Conditions

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    Illingworth RS. Common Symptoms of Disease in Children. Blackwell Scientific Publications: Oxford. 1988:357.

    Hurwitz S. Clinical Pediatric Dermatology. 2nd Edit. W.B., Saunders Company. 1993;177.

    Patel S, Zirwas M. English III, JC. Acquired palmoplantar Keratoderma. Am J. Clin Dermatol. 2007;8(1):1-11.

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Interpersonal and Communication Skills
    17. A therapeutic and ethically sound relationship with patients is created and sustained.

  • Systems Based Practice
    23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • How Can I Test for Nickel?

    Patient Presentation
    A 14-year-old female came to clinic with a rash on her earlobes intermittently for several days. She had purchased a new pair of pierced earrings and the rash appeared approximately 1 day after wearing them. She removed the earrings and the rash went away, but recurred when she wore them again. With further questioning she reported that she also got rashes on her abdomen after wearing a pair of jean shorts. The intermittent rash with the jeans and jewelry was mildly pruritic/painful. She had no difficulties breathing or eating. The past medical history was positive for keratosis pilaris and seasonal allergic rhinitis that were easily controlled with emollients and oral antihistamines. The family history was positive for seasonal allergic rhinitis and “some skin problems” in maternal aunts and cousins. The review of systems was negative.

    The pertinent physical exam showed a healthy female with normal growth parameters and vital signs. Bilateral earlobes showed generalized erythema of the lobe that extended to approximately 0.5 cm of the surrounding skin of the head in a semi-circular pattern. There was some mild swelling. There was no extension upwards into the helical area or into the external auditory canal. She had shoddy anterior cervical nodes. Her lateral upper arms and thighs had some mild non-erythematous papular lesions that were scattered. Her lung examination was normal. The rest of her examination was normal. The diagnosis of allergic contact dermatitis probably due to nickel was made, along with keratosis pilaris. The patient was advised to stop wearing the offending jewelry and to take antihistamines to help with the pruritis and irritation. She was also given information to purchase a nickel test kit to be able to test various items in her current wardrobe and home, and to test items before purchase in the future.

    Discussion
    Allergic contact dermatitis (ACD) is often under-recognized but a frequent problem. Atopic dermatitis and irritant skin reactions are often difficult to distinguish from ACD. There are about 100 common sensitizers that cause ACD including nickel and poison ivy. Most are small molecules that can easily penetrate the skin and cause a delayed T-cell hypersensitivity reaction (Type IV). ACD reactions usually are linear or geometric lesions that are well demarcated and persistent.

    Nickel is found in many household and wardrobe items including dental braces, jewelry, clothing fasteners such as clasps, snaps, buckles and zippers, coins, and tools (including cellphones, eating utensils, etc.). Most people require prolonged and intimate contact with items before having ACD; general contact such as handling coins or tools usually does not cause problems for most people. Nickel ACD usually results from contact with jewelry (including eyeglasses) or clothing fasteners, but an Id reaction with pruritic papules on the trunk or upper extremities can also be seen.

    Learning Point
    Nickel test kits are commercially available at many pharmacies usually for < $20. A drop of 1% dimethylglyoxime-ammonia is added to a cotton tip applicator and the applicator is rubbed against the metal. If the cotton swab turns pink the metal contains nickel in a concentration of at least 1:10,000.

    Practical tips for avoiding nickel including testing but also includes barriers such as layers of clothing between the item and skin, using a coating (Nickel Guard® or electroplating of jewelry), putting plastic on handles/tools and using gloves. Decreasing contact by only wearing an item when necessary, or changing the backing of earring to stainless steel, titanium or plastic may also help. Keeping the skin in good condition to decrease concomitant atopic dermatitis can also decrease the penetration of the nickel into the skin.

    Questions for Further Discussion
    1. Describe the natural history of poison ivy allergic contact dermatitis?
    2. What is the role of steroid treatment for allergic contact dermatitis?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Allergy and Rashes.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    Hanks JW and Venters WJ. Nickel Allergy From a Bed-Wetting Alarm Confused With Herpes Genitalis and Child Abuse. Pediatrics. Vol. 90 No. 3 September 1992, pp. 458-460.

    Militello G, Jacob SE, Crawford GH. Allergic contact dermatitis in children. Curr Opin Pediatr. 2006 Aug;18(4):385-90.

    Nickel Institute. Nickel Allergic Contact Dermatitis. Available from the Internet at http://www.nickelinstitute.org/index.cfm/ci_id/99.htm (rev. 2007, cited 10/22/09).

    Noble J, Ahing SI, Karaiskos NE, Wiltshire WA. Nickel allergy and orthodontics, a review and report of two cases. Br Dent J. 2008 Mar 22;204(6):297-300.

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.

  • Systems Based Practice
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital