• Hordeolum and chalazion
• Dacryocystitis
• Blepharitis
• Phthiriasis (louse)
• Frontal sinus infection or other sinusitis
• Orbital cellulitis
• Periorbital cellulitis
• Dental abscess
• Contact dermatitis
• Seborrhea

• Frequent eye rubbing
• Blunt trauma

• Neuroblastoma
• Leukemia
• Neurofibroma

• Cavernous sinus thrombosis
• Prolonged crying

• Conjunctivitis

• Blunt trauma or laceration

• Orbital tumors (e.g., retinoblastoma)

• Atropine
• Scopolamine
• Smog
• Makeup
• Smoke
• Chemical
• Contact lenses

• Allergic conjunctivitis
• Keratoconjunctivitis sicca and other dry eye disorders
• Nasal inflammation
• Sjögren syndrome and other collagen vascular diseases
• Kawasaki syndrome
• Stevens-Johnson syndrome
• Inflammatory bowel disease
• Juvenile rheumatoid arthritis

• Subconjunctival hemorrhage (secondary to severe cough, bacteremia, blood dyscrasia, or vomiting)

• Keratitis
• Syphilis

• Contact lenses
• Corneal ulcer
• Corneal abrasion
• Chemical irritant

• Iridocyclitis
• Reiter syndrome

• Hyphema

Determine which ocular structure(s) is/are affected. This is critical in reaching an accurate diagnosis given that the differential diagnosis is determined by the site involved.

Phase 1: Determine the acuity and severity of the disease process. For example, cellulitis requires emergency treatment, while most other disorders in the differential diagnosis do not.

Phase 2: Assess whether or not referral is necessary for optimal outcome of non-emergent situations. For example, prolonged symptoms in a contact lens wearer should be referred to an ophthalmologist.

Phase 3: Good follow-up is necessary for all but the most minor eye diseases to ensure that optimal function is maintained.

Question: Age at onset of illness?
Significance: Ocular inflammation in the first 24 hours of life is most likely the result of chemical irritation. Silver nitrate is the most frequent cause of neonatal chemical conjunctivitis, although other antibiotics used for prophylaxis can also cause conjunctivitis. Inflammation occurring between 2 and 6 days of life is likely due to gonococcal (GC) disease. Between 1 to 3 weeks of age, ocular inflammation usually represents chlamydial conjunctivitis. Older children with conjunctivitis usually have allergic or infectious disease.

Question: History of trauma?
Significance: Patients presenting with a red eye and a history of trauma need to be evaluated for a corneal abrasion.

Question: History of systemic symptoms, including fever or ill appearance?
Significance: Suggests orbital or periorbital cellulitis.

Question: Decrease in the patient’s vision?
Significance: Herpes keratitis, orbital cellulitis, scars on the cornea from abrasions or foreign body may affect visual acuity.

Question: Does the patient wear contact lenses?
Significance: Protozoan infections (specifically acanthamoeba), virulent gram-negative infections, and unusual fungal infections are seen almost exclusively in people who wear contact lens.

Question: Is pruritus a prominent symptom?
Significance: May represent allergic conjunctivitis.

Finding: Edema of the eyelids and conjunctivae (chemosis), local pain, and a copious purulent discharge
Significance: GC conjunctivitis. Swelling and discharge can be so extensive that the orbit may be difficult to view.

Finding: Clusters of vesicles on the face, eyelids, and mucous membranes
Significance: Suggests conjunctivitis due to herpes simplex virus.

Finding: Tearing, purulent discharge, conjunctival hyperemia, and foreign body sensation
Significance: These findings may be seen with bacterial conjunctivitis. The eyelids are often crusted and closed on arising in the morning.

Finding: Subconjunctival hemorrhage
Significance: Haemophilus influenzae and Streptococcus pneumoniae conjunctival infections are often associated with this finding.

Finding: Serous or lightly purulent discharge, profuse tearing
Significance: These findings suggest viral conjunctivitis (non-herpetic).

Finding: Significant erythema and swelling of the lids; diffuse conjunctival hyperemia, rhinitis, and other allergic symptoms may also be present.
Significance: Suggests allergic conjunctivitis.

Finding: A lesion draining on the inside of the eyelid (the conjunctival side)
Significance: This is suggestive of an infected chalazion.

Finding: Diffuse injection of the conjunctiva, watery discharge, pain, decreased visual acuity
Significance: Suggests corneal abrasion. All patients suspected of having a corneal abrasion should have a flourescein examination of the eye.

Finding: Decreased range of motion, of ocular muscles, proptosis, visual changes, or papil-ledema in association with a tender, erythematous or violaceous eyelid.
Significance: Orbital cellulitis carries a greater risk for damage to the visual axis than periorbital cellulitis. Fever is common.

• Bacterial culture, including chocolate agar or Thayer-Martin plates, and Gram stain of the purulent material should be obtained. In up to 95% of cases of GC conjunctivitis, gram-negative intracellular diplococci will be identified by Gram stain.
• Chlamydia culture and rapid assay: should be obtained on conjunctival scrapings (not purulent material).
• Conjunctival scrapings for herpes should be obtained if herpes conjunctivitis is part of the differential diagnosis. Culture recovery of the herpes virus is successful in only 70% of patients with herpetic conjunctivitis.

• Culture is necessary only if an unusual or serious pathogen is suspected (e.g., in contact lens wearers). Generally, conjunctivitis in the older child is treated without performing diagnostic tests.

• Cultures in cases of dacryocysitis, although not routinely indicated, are recommended if the infection does not respond to topical antibiotics.

• Blood culture: should be obtained because an organism may be isolated when there is associated bacteremia.
• Cultures of the purulent discharge: may also aid in identifying the offending organism.

• Computed tomography: should be employed whenever orbital cellulitis is considered; is essential when neoplasm is suspected.

• Corneal abrasion: if the pain persists for more than 24 hours after the initial.
• GC conjunctivitis: an extremely invasive disease warranting early ophthalmologic input.
• Herpetic conjunctivitis
• Varicella conjunctivitis: the association with corneal destruction and loss of vision makes early referral necessary.
• Foreign body: refer if embedded, or if not easily removed in the office setting.
• Dacryocystitis: if prolonged, or resulting in inflammation/infection (cellulitis) of skin.
• Orbital cellulitis: All cases should be referred.
• Corneal abrasion: lack of improvement in pain over a 24-hour period should result in prompt referral.
• Contact lens wearers: because of the unusual organisms and increased risk for significant morbidity, all patients who wear contact lenses and present with conjunctivitis should be referred to an ophthalmologist within 12 to 24 hours.

• Neonatal conjunctivitis: While the classic presentation of these infections differ, treatment should be broad until culture, immunologic studies, or clinical presentation have definitively ruled out conditions associated with poor outcomes. This includes frequent (every 1 to 2 hours) irrigation of the eye in GC conjunctivitis, and intravenous antibiotics.
• Herpes conjunctivitis. Treatment should begin immediately and consists of lubrication, patching, and treatment with acyclovir.
• Foreign body: Inability to remove an ocular foreign body should prompt immediate referral to an ophthalmologist. In addition, any open globe injury requires immediate ophthalmologic attention. The eye should be patched using an eye shield WITHOUT pressure.
• Periorbital and orbital cellulitis: Prompt initiation of therapy is important in these two serious diseases. Orbital cellulitis requires hospitalization and intravenous antibiotics. Early periorbital cellulitis can be managed on an outpatient basis if the child is not toxic-appearing and if close (at least daily) follow-up is arranged. Intramuscular ceftriaxone is appropriate for outpatient management. Surgical drainage may be required in cases of orbital cellulitis.
• Presence of a hyphema warrants immediate ophthalmology input.

• Important note: Serious harm can result if steroids are inadvertently prescribed for a patient with herpetic conjunctivitis.
• Bacterial and viral conjunctivitis. Non-herpetic viral conjunctivitis is treated in the same fashion as bacterial conjunctivitis. Treatment involves instillation of antibiotic drops and periodic removal of eye discharge with warm, wet washcloths. Improvement usually occurs within 3–4 days. In the event of treatment failure, a second antibiotic should be chosen, with a significantly different spectrum from the first antibiotic prescribed. Treatment should begin in a timely fashion, but is not urgent or emergent.
• Corneal abrasion: Foreign bodies should be removed by irrigation with sterile saline. All patients suspected of having a corneal abrasion should have a flourescein examination of the eye. When a slit lamp is not available, this is best done with a Wood’s lamp. The flourescein will flouresce over any abraded area. After careful evaluation, a sterile, light pressure-dressing should be placed over the eye for approximately 24 hours. Many also recommend topical antibiotic drops. The eye should be examined daily until fully healed. Topical anesthetics should never be given to a patient for repeated home instillation after corneal injury as it delays healing, masks further damage, and can lead to permanent corneal scarring.

Q: When will congenital dacryostenosis, and the resultant dacryocystitis resolve?
A: Dacryostenosis usually will spontaneously resolve by 1 year of age. If it has not, referral to an ophthalmologist for probing is recommended.

Q: How do I treat lice in the eye lashes (phthiriasis)? Aren’t the pediculocides unsafe in the eyes?
A: Lindane, permethrin and other pediculocides should not be used in or near the eyes. To safely kill lice in eye lashes, coat the lashes heavily with petroleum jelly for a 12-hour (or overnight) period.

Q: Do I need to treat or worry about tiny eyelid lacerations?
A: Before choosing a treatment of cleansing and observation only, make sure the laceration does not cross or affect the tear duct which will need to be surgically repaired.

Q: Some children seem to get styes (hordeola) very frequently. What can I do to help?
A: Reduce the bacterial growth in the area by washing the eyelashes daily with baby shampoo.

Bertolini J, Pelucio M. The red eye. Emerg Med Clin North Am 1995;13(3):561–579.

Gigliotti F. Acute conjunctivitis. Pediatr Rev 1995;16(6):203–208.

King RA. Common ocular signs and symptoms in childhood. Pediatr Clin North Am 1993;40:753–766.