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Red Eye & Eye Emergencies

Vision + pain + halos = ophthalmology tonight.

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Your objective: explain the approach, recognize important warning signs, then test your recall.

Abbreviations explained
ACS
Acute coronary syndrome
OMI
Occlusion myocardial infarction
ECG
Electrocardiogram
PE
Pulmonary embolism
POCUS
Point-of-care ultrasound
QTc
QT interval corrected for heart rate
LBBB
Left bundle branch block
RBBB
Right bundle branch block
hs-cTn
High-sensitivity cardiac troponin
CTA
Computed tomography angiography
ICU
Intensive care unit
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The jobVision + pain + halos = ophthalmology tonight.

  1. Chemical burn: irrigate until pH 7.0–7.4, then examine.
  2. Visual acuity in every other red eye.
  3. Pain, halos, or a white spot (especially contact-lens wearers) is ophthalmology tonight.
  4. CRAO is a stroke equivalent — call both pathways.

Red eyes are mostly benign (conjunctivitis), but the vision- or globe-threatening causes — chemical burn, angle-closure glaucoma, keratitis, orbital cellulitis, sudden vision loss — are time-critical.

A chemical burn is the one true treat-before-you-assess emergency.

Chemical burn (alkali worse than acid) Critical

Key: Immediate copious saline irrigation until conjunctival pH is 7.0–7.4 (often 30+ min / litres). Check pH after, then assess. Do not wait for a full exam.

Acute angle-closure glaucoma Critical

Key: Painful red eye, halos, mid-dilated fixed pupil, cloudy cornea, vision loss — lower IOP + ophthalmology NOW.

Infectious keratitis (bacterial / herpetic) Critical

Key: Contact lens + pain + white corneal infiltrate = ulcer; never patch, never start topical steroids, urgent ophthalmology.

Orbital cellulitis Critical

Key: Proptosis, painful eye movement, fever — CT orbits + IV antibiotics (preseptal is milder).

Endophthalmitis Critical

Key: Post-surgery/injection severe pain with hypopyon — emergency intraocular therapy.

Central retinal artery occlusion Critical

Key: Sudden painless profound monocular vision loss; pale retina, cherry-red spot. Treat as a stroke equivalent (AHA) — emergency ophthalmology + stroke pathway. IV tPA evidence is mixed; do not delay the call.

Retinal detachment Emergent

Key: Curtain over vision, shower of floaters — urgent ophthalmology (hours, not days, if macula is threatened).

Conjunctivitis / subconjunctival hemorrhage Common

Key: Benign when acuity, pupils, and cornea are normal.

Tick what your patient has — the banner updates as you go.

Contact lenses (ulcer risk), trauma, ocular surgery/injections, chemical exposure

Pain

deep vs superficial; photophobia; discharge character

Vision change

blurring, curtain, floaters, halos around lights

Systemic disease

autoimmune (scleritis/uveitis), recent shingles

Visual acuity in EVERY red eye — with pinhole and correction (except irrigate first in chemical burns)

Pupils

swinging-flashlight for afferent defect

Fluorescein staining (ulcer, dendrite), chamber depth, cells/flare, hypopyon

Everted lids for foreign body (after anesthetic); red reflex

Proptosis, painful eye movements, periorbital edema

Bedside

  • Acuity, fluorescein staining; tonometry when glaucoma is suspected
  • Chemical splash: irrigate first, then measure pH until 7.0–7.4

Labs

  • As indicated: CBC/inflammatory markers for orbital cellulitis; ophthalmology-led corneal scraping

Imaging

  • CT orbits for cellulitis, intraocular foreign body, or fracture
  • None needed for simple conjunctivitis; stroke-protocol imaging for CRAO
Medication safety reminder

Use this as a first-pass prompt; verify all medications, doses, concentrations, contraindications, weight, pregnancy status, and local protocols before administration.

Check indication, allergy, route, renal/hepatic risk, interactions, monitoring, and local formulary.

Discharge

  • Uncomplicated conjunctivitis or subconjunctival hemorrhage with normal acuity, pupils, and cornea — hygiene advice and follow-up.

Urgent ophthalmology (same day)

  • Keratitis, uveitis, retinal-detachment symptoms, hyphema, preseptal cellulitis.

Emergency ophthalmology / admission / stroke pathway

  • Chemical burn (after irrigation), angle-closure glaucoma, endophthalmitis, orbital cellulitis, CRAO.

Use objective reassessment and the local pathway.

Before the next decision · reassess and hand over

Use these learning prompts with the presentation’s pathway. They are not discharge criteria.

  1. Reassess: compare symptoms, observations and examination with the initial assessment and response to treatment.
  2. Warning signs for Red Eye & Eye Emergencies:
    • Any loss of visual acuity
    • Moderate-severe pain, photophobia, or halos
    • Contact-lens wearer with pain or a white spot
    • Proptosis, limited/painful movement, fever
    • Abnormal pupil or afferent pupillary defect
    • Chemical splash — irrigate immediately, no exceptions
    • Hypopyon or corneal infiltrate
  3. Reconsider: check unresolved findings and alternative explanations, including the pitfalls below.
  4. Escalate: communicate deterioration, uncertainty or needs beyond the current setting.
  5. Plan the transition: identify outstanding results, responsibility for follow-up, patient understanding and specific return advice.
Review this presentation’s disposition pathway →Practice a handover →

Clinical Pearls

  • Visual acuity in every red eye — after you finish irrigating a chemical burn.
  • Irrigate alkali/acid until conjunctival pH is 7.0–7.4, then examine.
  • Contact lens + pain + a white spot is a corneal ulcer until fluorescein proves otherwise.
  • CRAO is a stroke equivalent — call ophthalmology and the stroke pathway together.

Pitfalls

  • Never patch or give steroids over a possibly herpetic or ulcerated cornea.
  • Chemical burns: delayed irrigation means permanent damage — triage straight to eye-wash and keep going until pH normalizes.
  • Contact lens + red eye + pain = ulcer until fluorescein proves otherwise.
  • Skipping visual acuity is the universal red-eye pitfall.
  • Periorbital swelling + fever: test eye movement and proptosis to separate preseptal from orbital.
  • CRAO is a stroke until the workup says otherwise — look for GCA in patients ≥50 y with preceding headache/jaw claudication.
PRACTICE REFRESHER

Rapid recall

Test your first action and the dangerous diagnoses before revealing the answer.

01 · First move

Before you scroll, what needs to happen first?

02 · Immediate threats

Name at least two diagnoses that cannot wait.

PRIVATE TO THIS DEVICE

Your learning note

Capture a weak point, a teaching pearl, or a question to take to your next shift.

Review schedule starts when marked reviewed
HeadacheDiplopiaSore Throat & Neck

Foundational references below. No separate topic-specific guideline check is recorded here.

  • Rosen’s Emergency Medicine, 10th ed. (2023) — ocular emergencies
  • AAO Preferred Practice Patterns (bacterial keratitis, primary angle closure, CRAO)
  • AHA: CRAO as a stroke equivalent; Tintinalli’s 9th ed. — eye emergencies
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