Eye complaints are extremely common in both outpatient and emergency settings. They range from minor irritation to sight-threatening emergencies like globe rupture, acute glaucoma, orbital cellulitis, or retinal detachment.
This guide is based on the detailed clinical chart you provided, covering traumatic vs. atraumatic causes, history clues, workup, treatment, and critical red flags.
Introduction: Why Eye Complaints Matter
The eye is a delicate organ. Many conditions can lead to permanent vision loss within minutes to hours.
Therefore, clinicians must quickly determine:
- Is this painful or painless?
- Is there vision loss?
- Was there trauma or chemical exposure?
- Are there signs of infection or inflammation?
- Does the patient require emergency ophthalmology consultation?
The chart divides eye complaints into:
- Traumatic (physical or chemical injury)
- Atraumatic (infections, inflammations, vascular disorders, glaucoma)
This structure is ideal for clinical learning.
Red Flags in Eye Complaints
These symptoms indicate possible sight-threatening disease:
Red Flags
- Painful vision loss
- Sudden vision change
- Photophobia
- Trauma or chemical exposure
- Contact lens use + pain/redness
- Proptosis
- Irregular pupil / fixed pupil
- Eye movement pain (EOM pain)
- Severe headache
- Fever / systemic symptoms
- APD (Afferent Pupillary Defect)
Any red flag → Urgent ophthalmology referral.
Traumatic Eye Complaints
Based on the chart’s upper section.
1. Blowout Fracture
Clues:
- Trauma
- Diplopia
- Restricted eye movement
- Enophthalmos
Treatment:
→ Ophthalmology/ENT consult
2. Chemical Conjunctivitis (Emergency)
Clues:
- Chemical exposure (alkali worse than acid)
- Severe pain, redness
Treatment:
- Immediate copious irrigation
- Antibiotic drops
- Ophthalmology consultation
3. Corneal Abrasion
Clues:
- FB sensation
- Fluorescein uptake
Treatment:
- Remove FB if present
- Antibiotic ointment
4. Eyelid Laceration
Clues:
Involvement of tarsus or canthusTreatment:
→ Ophthalmology repair (due to cosmetic & functional significance)
5. Globe Rupture (Vision-Threatening)
Clues:
- Irregular pupil
- Positive Seidel sign
- Trauma
Treatment:
- Protective shield
- Ophthalmology emergency
6. Retrobulbar Hematoma
Clues:
- Proptosis
- APD
- Limited EOM
- ↑ IOP
Treatment:
- Lateral canthotomy/cantholysis
- Emergent ophthalmology care
7. Subconjunctival Hemorrhage
Clues:
- Bright red patch of blood
- Painless
Treatment:
- Reassurance
- Avoid NSAIDs/ASA
Atraumatic Eye Complaints
The chart divides these into three categories:
- External eye
- Internal eye
- Extraocular conditions
A. External Eye Conditions
1. Conjunctivitis
Clues:
- Redness
- Discharge (purulent in bacteria)
Workup: Clinical
Treatment:
- Antibiotic drops (fluoroquinolones if contact lens user)
2. Corneal Ulcer
Clues:
- Red eye
- FB sensation
- Fluorescein staining
Treatment:
- Antibiotic ointment/drops
- No contact lenses
3. Episcleritis
Clues:
- Red eye
- No vision loss
- Blanches with phenylephrine
Treatment:
- NSAIDs
- Self-limited
4. Herpes Zoster Ophthalmicus
Clues:
- V1 dermatome rash
- Painful eye
- Hutchinson sign
- Dendritic lesions
Treatment:
- Systemic + topical antivirals
5. Keratitis
Clues:
- Painful, red eye
- Photophobia
- Punctate lesions
- Often related to welding/UV
Treatment:
- Topical cycloplegic
6. Scleritis
Clues:
- Severe pain
- Systemic autoimmune disorders
- Does not blanch with phenylephrine
Treatment:
- NSAIDs or topical steroid
7. Anterior Uveitis
Clues:
- Painful red eye
- Photophobia
- Limbic flush
Treatment:
- Topical steroid + cycloplegic
- Ophthalmology follow-up
B. Internal Eye Conditions
1. CRAO – Central Retinal Artery Occlusion
Clues:
- Sudden painless vision loss
- APD
- “Cherry-red spot”
Workup: ESR/CRP, cardiac evaluation
Treatment:
- Ocular massage
- Lower IOP
- Stroke evaluation
2. CRVO – Central Retinal Vein Occlusion
Clues:
- Painless vision loss
- “Blood and thunder” retina
Treatment:
- Manage HTN, diabetes
- Ophthalmology care
3. Endophthalmitis (Emergency)
Clues:
- Severe pain
- Vision loss
- Hypopyon
- ↑ IOP
Treatment:
- Intravitreal antibiotics
4. Glaucoma (Acute Angle-Closure) – Emergency
Clues:
- Painful vision loss
- Halos
- Vomiting
- Mid-dilated fixed pupil
- ↑ IOP
Treatment:
- Topical + systemic IOP-lowering meds
- Ophthalmology consultation
5. Hyphema
Clues:
- Trauma
- Blood in anterior chamber
Treatment:
- Elevate head
- Avoid NSAIDs
- Sedation if needed
6. Retinal Detachment
Clues:
- Flashes
- Floaters
- Curtain-like vision loss
Workup: Ocular ultrasound
Treatment: Ophthalmology intervention
C. Extraocular Conditions
1. Hordeolum (Stye)
Clues:
- Painful, erythematous eyelid lump
Treatment:
- Warm compress
- Antibiotic ointment
2. Optic Neuritis
Clues:
- Pain with eye movement
- APD
- Decreased color vision
Workup: MRI
Treatment:
- Steroids
- Neurology consult
3. Orbital Cellulitis
Clues:
- Fever
- Pain with EOM
- Proptosis
Workup: CT face
Treatment:
- IV antibiotics
- Hospital admission
4. Preseptal Cellulitis
Clues:
- Eyelid erythema
- No pain with EOM
- No proptosis
Treatment:
- Oral antibiotics
- Warm compresses
Pain vs. Redness vs. Vision Loss: A Simple Clinical Algorithm
PAINFUL RED EYE
Think:
- Keratitis
- Scleritis
- Anterior uveitis
- Acute glaucoma
- Herpes zoster
- Corneal ulcer
PAINLESS VISION LOSS
Think:
- CRAO
- CRVO
- Retinal detachment
- Vitreous hemorrhage
PAIN + PROPTOSIS
Think:
- Orbital cellulitis
- Retrobulbar hematoma
RED EYE + NORMAL VISION
Think:
- Conjunctivitis
- Episcleritis
- Hordeolum
Examination Checklist (From Documentation Section)
Always assess:
History
- Fever
- Neuro symptoms
- Systemic illness
- Vision changes
- Trauma/chemical exposure
- Contact lenses
Skin
- Vesicles (zoster)
- Rash
- Erythema
- Lacerations
Eye Exam
- Pupils and APD
- EOM
- Visual acuity
- Fluorescein staining
- Fundoscopy
- Slit lamp
- IOP (if suspected glaucoma or hyphema)
Treatment Principles
1. Protect vision first
Painful vision loss = emergency.
2. Avoid steroids unless the diagnosis is clear
Steroids can worsen infections (especially viral/fungal).
3. Contact lens users need special attention
High risk for Pseudomonas corneal ulcers.
4. Chemical injuries need immediate irrigation
Do not delay.
5. NSAIDs/ASA avoided in hyphema
Risk of rebleeding.
How to Prioritize Eye Emergencies
Immediate Ophthalmology Consultation
- Globe rupture
- Retrobulbar hematoma
- Corneal ulcer
- Acute glaucoma
- Endophthalmitis
- Retinal detachment
- CRAO/CRVO
- Orbital cellulitis
Urgent (24–48 hours)
- Anterior uveitis
- Keratitis
- Scleritis
Routine / Outpatient
- Conjunctivitis
- Hordeolum
- Episcleritis
FAQs About Eye Complaints
1. What is the most dangerous eye emergency?
Globe rupture and retrobulbar hematoma—both can rapidly cause permanent blindness.
2. Do all red eyes need antibiotics?
No. Many causes are inflammatory, not infectious.
3. How do I distinguish episcleritis from scleritis?
Episcleritis blanches with phenylephrine; scleritis does not.
4. When is vision loss painless?
In CRAO, CRVO, retinal detachment, and vitreous hemorrhage.
5. Should steroids be used for red eyes?
Only with a confirmed diagnosis (e.g., uveitis). Never empirically.
6. What symptoms require CT imaging?
Proptosis, pain with EOM, suspected cellulitis, or trauma.
