CLINICAL RESEARCH STUDY

Bedside Diagnosis of the ‘Red Eye’: A

Systematic Review
Sirisha Narayana, MD,a Steven McGee, MDb
a
Division of Hospital Medicine, Department of Medicine, University of California, San Francisco; and bGeneral Medical Service,
Department of Veterans Affairs Medical Center, University of Washington, Seattle.

ABSTRACT

BACKGROUND: In patients with red eye, traditional teachings suggest that photophobia, visual blurring, and
eye pain indicate serious eye disease; in patients with presumed conjunctivitis, the finding of purulent
drainage traditionally indicates a bacterial cause. The accuracy of these teachings is unknown.
METHODS: A MEDLINE search was performed to retrieve articles published between 1966 and April 2014
relevant to the bedside diagnosis of serious eye disease and bacterial conjunctivitis.
RESULTS: In patients with red eye, the most useful findings indicating serious eye disease are anisocoria
(with the smaller pupil in the red eye and difference between pupil diameters >1 mm; likelihood ratio [LR],
6.5; 95% confidence interval [CI], 2.6-16.3) and photophobia, elicited by direct illumination (LR, 8.3; 95%
CI, 2.7-25.9), indirect illumination (LR, 28.8; 95% CI, 1.8-459), or near synkinesis test (“finger-to-nose
convergence test,” LR, 21.4; 95% CI, 12-38.2). In patients with presumed conjunctivitis, complete redness
of the conjunctival membrane obscuring tarsal vessels (LR, 4.6; 95% CI, 1.2-17.1), observed purulent
discharge (LR, 3.9; 95% CI, 1.7-9.1), and matting of both eyes in the morning (LR, 3.6; 95% CI, 1.9-6.5)
increase the probability of a bacterial cause; failure to observe a red eye at 20 feet (LR, 0.2; 95% CI, 0-0.8)
and absence of morning gluing of either eye (LR, 0.3; 95% CI, 0.1-0.8) decrease the probability of a
bacterial cause.
CONCLUSIONS: Several bedside findings accurately distinguish serious from benign eye disease in patients
with red eye and, in patients with presumed conjunctivitis, distinguish bacterial from viral or allergic
causes.
Published by Elsevier Inc.
The American Journal of Medicine (2015) 128, 1220-1224

KEYWORDS: Diagnosis; Physical examination; Red eye

Evaluation of the “red eye” is a common problem, ac-
counting for up to 1% of primary care office visits1 and
resulting in more than $300 million in annual costs for
treating conjunctivitis alone.2 When evaluating the red eye,
clinicians address 2 distinct issues. First, the clinician must
determine whether the red eye is caused by serious eye
disease (eg, uveitis, keratitis, corneal abrasion, or scleritis),
diagnoses requiring prompt referral to an eye specialist, or a
Funding: None.
Conflict of Interest: SM receives royalties from Elsevier for his text-
book Evidence-based Physical Diagnosis, 3rd Edition.
Authorship: Both authors had access to the data and played a role in
writing this manuscript.
Requests for reprints should be addressed to Steven McGee, MD,
Seattle-Puget Sound VA Health Care System, S-123-GMS, 1660 South
Columbian Way, Seattle, WA 98108.
E-mail address: Steven.McGee@va.gov
more benign disorder of the conjunctiva (eg, conjunctivitis,
episcleritis, or subconjunctival hemorrhage). Second, in
patients with suspected conjunctivitis, clinicians want to
accurately identify those most likely to have a bacterial
cause, because this group is most likely to benefit from
antimicrobial eye drops.
According to traditional teachings, 3 findings indicate
serious eye disorders: significant eye pain, visual blurring,
and photophobia. In patients with suspected conjunctivitis,
classic teachings suggest a bacterial cause is more likely in
patients with disease onset during winter months or if there
is purulent discharge. Nonbacterial conjunctivitis, on the
other hand, is considered more likely if the patient presents
during the summer or there is watery discharge, conjunctival
follicles, or preauricular adenopathy.
The purpose of this review is to identify the accuracy of
these and other traditional bedside findings in distinguishing

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Narayana and McGee Diagnosis of the Red Eye 1221

serious from benign eye disease and, in patients with pre- disorders (herpes simplex infection, corneal abrasion, and
sumed conjunctivitis, distinguishing bacterial causes from miscellaneous causes of keratitis).
viral or allergic causes. Two findings—anisocoria and the presence of pain during
maneuvers causing pupillary constriction—accurately indi-
cated serious disease. All 3 methods of inducing pupillary
MATERIALS AND METHODS constriction were accurate: direct light reaction (“direct
We searched PubMed to identify
photophobia,” LR, 8.3; 95% confi-
all English-language studies that
dence interval [CI], 2.7-25.9)
evaluated the diagnostic accuracy CLINICAL SIGNIFICANCE (Table 2), consensual light reaction
of the patient interview and phys-
ical examination in adult patients

In patients with red eye, the findings of (“indirect photophobia,” LR, 28.8;
anisocoria or painful pupillary constric- 95% CI, 1.8-459), and near
presenting with a red eye. The
synkinesis pupillary constriction
specific search strategy is shown in tion indicate serious eye disease.
(“finger-to-nose convergence test,”
Appendix E1, (available online).
Although the findings of eye pain and LR, 21.4; 95% CI, 12-38.2). The
We included all studies
visual blurring have unknown diagnostic absence of pain during pupillary
meeting the following 3 criteria:
accuracy, either finding should prompt constriction decreased the
(1) The study enrolled either
referral to a specialist. probability of serious disease,
consecutive unselected adults with
especially the negative finger-to-
red eye, all of whom eventually
Bacterial conjunctivitis is more likely nose convergence test (LR, 0.3,
underwent the diagnostic standard than viral or allergic conjunctivitis if 95% CI, 0.1-0.6) and negative direct
of slit-lamp examination to there is bilateral matting of the eyes, photophobia test (LR, 0.4; 95% CI,
distinguish serious disease (uve- conjunctival redness obscuring tarsal 0.3-0.5). Anisocoria, defined as the
itis, keratitis, corneal abrasion, or
vessels, or purulent drainage. smaller pupil in the affected red eye
scleritis) from benign disorders
and a difference greater than 1 mm,
(conjunctivitis, episcleritis, or
increased the probability of
subconjunctival hemorrhage) or consecutive adults with red
serious disease (LR, 6.5; 95% CI, 2.6-16.3). No studies
eye and presumed conjunctivitis, all of whom underwent were identified investigating the accuracy of abnormal vi-
bacterial culture of their conjunctival secretions. Bacterial
sual acuity or eye pain in patients with the red eye.
conjunctivitis was defined as recovery of a known pathogen
from conjunctival secretions (ie, Streptococcus pneumonia,
Haemophilus influenzae, Moraxella catarrhalis, or Staphy- Distinguishing Bacterial from Nonbacterial
lococcus aureus); (2) the clinical findings were defined (Viral, Allergic) Conjunctivitis
clearly; and (3) the study presented sufficient information to
Three studies enrolling 281 consecutive patients with pre-
create 2  2 tables and calculate sensitivity, specificity, and
sumed conjunctivitis were included in our review.9-11 All
likelihood ratios (LRs). Studies enrolling children (age <18 patients underwent bacterial cultures, and 45% had positive
years) and studies of patients with suspected trachoma were
bacterial cultures. Most studies excluded patients with pre-
excluded.
vious trauma, eye surgery, chemical injury, visual blurring,
Both authors independently read all the articles related to
contact lenses, conspicuous uveitis (ie, perilimbal ciliary
either of the 2 study questions and extracted data to calculate
flush), or obvious deep orbital pathology.
sensitivity, specificity, and positive and negative LRs using
In these studies, the findings increasing the probability of
standard definitions. Any differences were settled by dis-
positive bacterial culture the most were complete redness of
cussion. If any cell in the 2  2 table contained the value of
the conjunctiva obscuring tarsal vessels (LR, 4.6; 95% CI,
0, 0.5 was added to all cells before calculating LRs or 1.2-17.1) (Table 3), observed purulent discharge (LR, 3.9;
pooled estimates. Pooled estimates were calculated using the
95% CI, 1.7-9.1), matting of both eyes in the morning
DerSimonian and Laird random-effects model.3 Specific
(LR, 3.6; 95% CI, 1.9-6.5), and onset during winter or
definitions of selected findings are shown in Table 1.
spring (vs summer; LR, 1.9; 95% CI, 1.1-3.2). Findings
increasing the probability of a nonbacterial cause include
RESULTS absence of a red eye when observed at 20 feet (LR, 0.2;
95% CI, 0-0.8), absence of morning gluing of either eye
Distinguishing Serious From Benign Eye (LR, 0.3; 95% CI, 0.1-0.8), and presentation during
Disease summer (vs winter or spring, LR, 0.4; 95% CI, 0.1-0.9).
Five studies enrolling 957 consecutive patients were Of note, the patient’s report of “purulent drainage” was
included in this review. Four studies recruited patients with unhelpful diagnostically (LR, 0.8; 95% CI, 0.3-2.1), in
red eye,4-7 and 1 study enrolled patients with “miscellaneous contrast to its value when discovered during examination.
eye complaints.”8 All patients underwent slit-lamp bio- Different qualities of eye discomfort—burning or
microscopy: Serious disease was found in 4% to 59% itching—were unhelpful diagnostically. The findings
(mean, 27%), mostly anterior uveitis (iritis) and corneal of preauricular adenopathy, conjunctival follicles, and

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1222 The American Journal of Medicine, Vol 128, No 11, November 2015

Table 1 Definitions of Findings

Finding Definition
Pupil constriction tests
Direct photophobia Pain in the affected eye when illuminated with a penlight
Indirect (consensual) photophobia Pain in the affected eye when the contralateral eye is illuminated with a penlight
Finger-to-nose convergence test Pain in the affected eye as the patient focuses on his or her outstretched finger and slowly
moves the finger toward his or her nose
Conjunctival appearance
Tarsal vessels Conjunctival blood vessels that are visible on everted upper or lower eyelids
Papillae (papillary conjunctivitis) Contiguous tiny red vascular bumps replacing the normally smooth conjunctival surface,
giving the conjunctiva a velvety or cobblestone appearance. Traditionally, this is found
in bacterial or allergic conjunctivitis.
Follicles (follicular conjunctivitis) Discrete 1- to 2-mm diameter white avascular bumps on the normally smooth conjunctival
surface. Traditionally, this suggests viral or chlamydial conjunctivitis.
Preauricular adenopathy Palpable superficial nodes located anterior to the tragus of the ear. Traditionally, this
suggests viral or chlamydial conjunctivitis.
Diagnostic score for bacterial conjunctivitis
(Rietveld)10
2 glued eyes in the morning þ5 points
1 glued eye in the morning þ2 points
Itching 1 points
History of conjunctivitis 2 points

conjunctival papillae also were diagnostically inaccurate
(although the point estimate of papillary conjunctivitis, LR
of 4.4, almost reached statistical significance).
The Rietveld scoring scheme is accurate: A score of þ4
or more increases probability of bacterial conjunctivitis (LR,
6.6; 95% CI, 3-14.6), whereas a score of 0 or less decreases
probability (LR, 0.4; 95% CI, 0.2-0.8).
DISCUSSION
Most ophthalmologic diagnosis depends on empiric obser-
vation by specialists using slit-lamp biomicroscopy. How-
ever, our results demonstrate that some clinical variables
easily observed by primary providers without a slit lamp
also accurately diagnose serious eye disease and bacterial
conjunctivitis.
Simple observation of the pupil and the patient’s
response to pupillary constriction provide important clues
suggesting serious eye disease. Inflammation of the iris and
spasm of the ciliary body are likely responsible for the
miosis and painful pupillary constriction characteristic of
iritis; the cause of relative miosis in corneal disorders is
unclear. Although our results confirm the value of relative
miosis, relative mydriasis (ie, anisocoria with the red eye
having a larger pupil) is not a benign finding but may
indicate acute angle-closure glaucoma, another diagnosis
requiring prompt referral to a specialist (the studies in this
review included only 1 patient with this diagnosis). Of note,
the absence of photophobia or anisocoria does not exclude
the possibility of serious disease: Our results show that 23%
to 56% of patients with serious pathology lack photophobia,
and 81% lack anisocoria.
In contrast to the proven value of photophobia, we found
no studies evaluating the other 2 traditional signs of serious
eye pathology (abnormal visual acuity and eye pain). These
signs are likely insensitive, however; in other studies of
patients with proven uveitis, for example, 53% had a visual
acuity of 20/60 or better.12 Obviously, any patient with red
eye and abnormal visual acuity or significant pain must be
referred promptly to a specialist.
In patients with conjunctivitis, the findings of bilateral
matted eyes, redness obscuring tarsal vessels, and purulent

Table 2 Diagnosing Serious Eye Disease in Patients with Red Eye

Finding No. of Patients Sensitivity (%) Specificity (%) Positive LR (95% CI) Negative LR (95% CI)
4,5,7
Direct photophobia 214 54-77 80-98 8.3 (2.7-25.9) 0.4 (0.3-0.5)
Indirect photophobia4 78 44 98 28.8 (1.8-459) 0.6 (0.4-0.7)
Finger-to-nose convergence test8 426 74 97 21.4 (12-38.2) 0.3 (0.1-0.6)
Anisocoria, red eye with smaller 317 19 97 6.5 (2.6-16.3) 0.8 (0.8-0.9)
pupil (difference >1 mm)6
Findings in boldface indicate the point estimate is statistically significant, that is, CI excludes the value of 1.0.
CI ¼ confidence interval; LR ¼ likelihood ratio.

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Narayana and McGee Diagnosis of the Red Eye 1223

Table 3 Diagnosing Bacterial Infection in Patients with Presumed Conjunctivitis

Positive Negative
Finding No. of Patients Sensitivity (%) Specificity (%) LR (95% CI) LR (95% CI)
Risk factors
Winter/spring vs summer9 45 78 59 1.9 (1.1-3.2) 0.4 (0.1-0.9)
History of conjunctivitis10 177 9 79 0.4 (0.2-1) 1.2 (1-1.3)
Female sex10 177 63 43 1.1 (0.9-1.4) 0.9 (0.6-1.3)
Symptoms
Itching9,10 222 33-58 37-70 0.9 (0.7-1.2) 1 (0.8-1.4)
Burning sensation9,10 222 11-65 43-74 0.9 (0.4-2) 1 (0.7-1.5)
Discharge9
Watery 45 39 70 1.3 (0.6-3) 0.9 (0.6-1.4)
Purulent 45 28 67 0.8 (0.3-2.1) 1.1 (0.7-1.6)
Glued eyes, in the morning10
0 177 9 73 0.3 (0.1-0.8) .
1 53 . 0.9 (0.6-1.1) .
2 39 89 3.6 (1.9-6.5) .
Signs
Redness of conjunctiva
Peripheral only10 177 28 58 0.7 (0.4-1.1) 1.2 (1-1.5)
Red eye observed at 20 ft11 59 94 36 1.5 (1.1-1.9) 0.2 (0-0.8)
Redness completely obscures 59 33 93 4.6 (1.2-17.1) 0.7 (0.5-1)
tarsal vessels11
Discharge9,11 104
None 12-28 41-56 0.4 (0.2-0.8) .
Watery 6-12 . 0.4 (0.2-1.2) .
Mucous 6-44 . 1.8 (0.9-3.8) .
Purulent 32-50 85-94 3.9 (1.7-9.1) .
Follicular conjunctivitis9 45 50 48 1.0 (0.5-1.7) 1.0 (0.6-1.9)
Papillary conjunctivitis9 45 24 95 4.4 (0.8-25.5) 0.8 (0.6-1.1)
Preauricular adenopathy9,11 104 6-16 70-88 0.6 (0.1-4) 1.1 (0.8-1.6)
Combined findings
Rietveld score10 177
þ4 or more 39 94 6.6 (3-14.6) .
þ1 to þ3 46 . 0.8 (0.6-1.1) .
3 to 0 16 62 0.4 (0.2-0.8) .
Findings in boldface indicate the point estimate is statistically significant, that is, CI excludes the value of 1.0.
CI ¼ confidence interval; LR ¼ likelihood ratio.

discharge all increase the probability of a bacterial cause. Study Limitations

These findings likely represent a more severe inflammatory
response, which produces prominent vasodilation of
conjunctival vessels and neutrophilic exudate. Other studies
using Giemsa staining of conjunctival secretions have
demonstrated a correlation between neutrophilic predomi-
nance and bacterial cause.9 The accuracy of the Rietveld
score combines the value of eye matting from inflammatory
infiltrate with the absence of symptoms characteristic of
allergic causes (itching and prior conjunctivitis). Although
our study failed to prove the accuracy of conjunctival fol-
licles or papillae as individual findings, another study of 700
patients with red eye showed that the combination of folli-
cles, preauricular lymph nodes, and scant water discharge
predicted a viral cause, whereas the combination of muco-
purulent discharge without follicles or adenopathy corre-
lated with positive bacterial cultures.13
Limitations of our review include the small size and number
of studies forming the basis of our conclusions. Also, in the
pupillary constriction studies, it is possible that there was
lack of blinding between “test” and “diagnosis,” because the
person performing the penlight test was likely also
the clinician later performing slit-lamp biomicroscopy.
Finally, it is possible that our second research question—
distinguishing bacterial from nonbacterial conjunctivitis—is
unimportant because most bacterial conjunctivitis sponta-
neously resolves without complications within 7 days even
without antibiotics.14 Nonetheless, we believe this distinc-
tion is important, because antimicrobial treatment of bacte-
rial conjunctivitis shortens duration of symptoms by 0.5 to
1.5 days on average, and the number-needed-to-treat with
antibiotics to get 1 extra patient into remission in the first 2
to 5 days is only 6.14

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1224 The American Journal of Medicine, Vol 128, No 11, November 2015
CONCLUSIONS
In patients with the red eye, simple examination of the pu-
pils and response to pupillary constriction accurately iden-
tify patients who require immediate referral to an
ophthalmologist. All patients with visual blurring and sig-
nificant eye pain also require immediate referral, although
these findings have not been evaluated systematically. In
patients with conjunctivitis, a bacterial cause is more likely
if there is bilateral matting of the eyes, conjunctival redness
obscuring tarsal vessels, and purulent drainage. These pa-
tients are most likely to benefit from topical antimicrobials.
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APPENDIX
Supplementary material accompanying this article can be
found in the online version at http://dx.doi.org/10.1016/j.
amjmed.2015.06.026.
Narayana and McGee Diagnosis of the Red Eye 1224.e1

APPENDIX E1
With the use of MEDLINE (January 1966 to April 2014),
both authors performed the following search strategy,
limited to English-language publications and human sub-
jects, to retrieve all relevant publications on the diagnostic
value of the patient interview and physical examination in
diagnosing serious eye disease and bacterial conjunctivitis
in patients with red eye. The Medical Subject Heading term
eye disease/diagnosis was combined with the Medical
Subject Heading terms eye pain, photophobia, visual acuity,
anisocoria, sensitivity/specificity, and physical examination;
and text words penlight and red eye. The search tool “all
related articles” and the bibliographies of selected articles
were consulted to obtain further citations. The titles of
10,000 articles were reviewed, 76 articles were retrieved and
read, and 8 studies met our inclusion criteria and included in
our review.

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