Eye pain and red eye — Medicine Library

Summary

Eye pain and redness are symptoms that often manifest together, but not always. They present a diagnostic challenge due to the wide range of possible causes requiring quick risk stratification and appropriate action. Causes are generally diagnosed clinically and include traumatic injury, inflammatory and/or infectious conditions, and other (e.g., neurological) conditions. Vision-threatening causes must be urgently ruled out. Assessment begins with a focused history, including both ophthalmologic and relevant nonophthalmologic symptoms, medical history (e.g., contact lens use, autoimmune conditions), and past surgeries. A focused ophthalmologic examination is then performed, which includes many aspects of the comprehensive eye examination (e.g., visual acuity, examination of the extraocular muscles, and slit-lamp examination). The diagnosis is narrowed based on clinical findings, and condition-specific diagnostics and treatment are initiated. Vision-threatening causes of eye pain require urgent ophthalmology consultation, while most non-vision-threatening causes may be followed up with outpatient ophthalmology.

Etiology

Etiologies of eye pain (with or without redness) can be categorized by immediate threats to vision and underlying mechanism.

Vision-threatening causes [1]

Traumatic

Vision-threatening traumatic injuries are frequently associated with eye redness.

Open globe injury
Corneal foreign body
Blunt trauma
Orbital fracture
Ocular burns
Retrobulbar hematoma
Corneal laceration

Inflammatory and/or infectious

Inflammatory and/or infectious vision-threatening causes of eye pain generally manifest with a red eye.

Keratitis
- Bacterial keratitis
- Viral keratitis
- Fungal keratitis
- Acanthamoeba keratitis
Scleritis
Anterior uveitis
Corneal ulcer
Orbital cellulitis
Herpes zoster ophthalmicus
Endophthalmitis

Other

Red
eye
- Acute angle-closure glaucoma
- Orbital compartment syndrome
- Stevens-Johnson syndrome or toxic epidermal necrolysis
Non-red
eye
- Optic neuritis
- Giant cell arteritis
- Cavernous sinus thrombosis

Non-vision-threatening causes [1]

Traumatic

Red
eye
- Hyphema
- Corneal abrasion
- Corneal erosion
Non-red
eye
- Eyelid laceration
- Lacrimal duct laceration

Inflammatory and/or infectious

Red
eye
- Photokeratitis
- Keratoconjunctivitis
- Inflamed pinguecula
Non-red
eye
- Preseptal cellulitis
- Dacryocystitis
- Dacryoadenitis
- Hordeolum

Conjunctivitis, blepharitis, episcleritis, and allergic contact dermatitis are typically painless but can manifest with discomfort if inflammation is severe.

Other

Red eye: Keratoconjunctivitis sicca (dry eye disease)
Non-red
eye
- Orbital tumor
- Intracranial tumor

Cluster headaches and certain types of migraines can manifest with pain localized to the eye (see “Mimics”).

Initial management

Approach

Perform a focused clinical evaluation to narrow the diagnosis and localize the lesion (see “Clinical evaluation”).
Begin critical interventions immediately as indicated, e.g.:
- Acute management of traumatic eye injuries (including open globe injuries)
- Treatment of acute angle-closure glaucoma
- Lateral canthotomy and cantholysis in orbital compartment syndrome
- Immediate large-volume irrigation of ocular chemical burns
- Corneal foreign body removal
Consult ophthalmology urgently for vision-threatening causes of eye pain or red flags for painful red eye.
Administer analgesia as indicated, e.g., analgesia for corneal pain
Obtain additional diagnostics as indicated and initiate condition-specific treatment.

Red flags for painful red eye [3]

Moderate to severe eye pain
Visual impairment
Red flags for serious eye injury (e.g., ocular chemical burn, penetrating eye injury)
Opacification or visible defect of the cornea
Irregular pupil
Impaired pupillary reflex
Ciliary flush

Clinical evaluation

Focused history [1][2]

Ophthalmologic

Symptom onset
Character of pain (e.g., burning, dull, sharp, foreign body sensation)
Presence or absence of eye redness
Visual disturbances
- Changes in visual acuity or vision loss
- Visual field defects
- Diplopia
- Changes in color vision
Photophobia
Discharge or crusting
Eyelid swelling
Mechanism of injury, if applicable
Recent ocular surgery
New ocular medications
Contact lens hygiene
- Wear schedule (e.g., sleeping in contact lenses, overnight wear)
- Factors increasing contamination risk
  - Wearing lenses past the expiration date
  - Rinsing lenses in tap water and/or improper storage
  - Swimming or hot tub use while wearing lenses

Nonophthalmologic

Fever
Headache
Concurrent neurological symptoms
Jaw claudication
Skin lesions (e.g., periorbital erythema, vesicular rash)
History of:
- Systemic diseases (e.g., multiple sclerosis, Sjogren syndrome)
- Immunocompromise
- Allergies

Focused physical examination [1][2]

Diagnosis

Most conditions causing eye pain and redness are diagnosed clinically; laboratory testing and imaging are indicated in select cases.

Laboratory testing [1]

Diagnostics for giant cell arteritis: e.g., ESR, CRP
Urgent diagnostics for trauma patients
Additional diagnostics as requested by ophthalmology

Imaging [1][2]

CT head and/or
orbits
- Penetrating trauma and/or foreign body
- Orbital cellulitis (for confirmation and/or to assess for complications such as abscess)
MRI
- Suspected neurological cause: e.g., optic neuritis, intracranial tumor
- Contraindicated if a metallic foreign body is suspected
Ocular POCUS
- May be useful for assessing suspected penetrating eye injury or intraocular foreign body
- Contraindicated if open globe injury is suspected

Common vision-threatening causes

Common vision-threatening causes of eye pain [1]
	Characteristic clinical features	Diagnostic findings	Management
Traumatic eye injuries [4][5][6]	Vary by type of trauma Periocular ecchymosis Ocular motility dysfunction Vision changes Abnormal pupil See “Clinical features of traumatic eye injuries” for details.	Clinical diagnosis CT: fractures, foreign bodies, intraocular injury Ultrasound: lens dislocation, foreign bodies, retrobulbar hemorrhage	See “Approach to traumatic eye injuries.”
Orbital compartment syndrome [7][8]	Proptosis Periorbital swelling Firm globe resistant to digital retropulsion Ophthalmoplegia and/or diplopia	Clinical diagnosis Relative afferent pupillary defect (RAPD) Tonometry: elevated intraocular pressure (IOP) Fundoscopy: papilledema, venous congestion, retinal artery pulsation	Lateral canthotomy and cantholysis See “Treatment” in “Orbital compartment syndrome.”
Orbital cellulitis [9][10]	Pain, swelling, and/or erythema Systemic signs of infection (e.g., fever, malaise) Red flags for orbital cellulitis	Clinical diagnosis CT orbits and sinuses with contrast may show an orbital abscess or foreign bodies.	IV antibiotics and/or antifungals See “Management” in “Orbital cellulitis.”
Endophthalmitis [11][12]	Acute vision loss Conjunctival hyperemia and chemosis	Clinical diagnosis RAPD Fundoscopy: reduced or absent red reflex Slit-lamp examination: hazy cornea or aqueous chamber; hypopyon	Intravitreal and IV antibiotics and/or antifungals See “Treatment” in “Endophthalmitis.”
Acute angle-closure glaucoma [13][14]	Sudden onset Unilateral firm, red eye; ciliary flush Midsized, unresponsive pupil Halos around light sources Decreased visual acuity; loss of peripheral vision Nausea and vomiting	Clinical diagnosis Tonometry: elevated IOP (> 21 mm Hg) Slit-lamp examination: shallow anterior chamber, hazy cornea	Urgent reduction of IOP See “Acute management checklist for acute angle-closure glaucoma.”
Optic neuritis [15][16]	Reduced visual acuity Subacute vision loss Visual field defects, dyschromatopsia Retrobulbar pain that worsens with eye movement	Clinical diagnosis RAPD MRI head and orbits: optic nerve enhancement	Neurology consultation High-dose glucocorticoid therapy See “Treatment” in “Optic neuritis.”
Cranial giant cell arteritis (GCA) [17][18]	Headache typically over the temples Tender temporal artery Jaw claudication Vision loss: scotoma, amaurosis fugax Diplopia Constitutional symptoms (e.g., fever, weight loss)	ESR ≥ 50 mm/hour CRP ≥ 10 mg/L Thrombocytosis Duplex ultrasound: vessel wall thickening, stenosis, or occlusion; noncompressible artery	High-dose glucocorticoid therapy Rheumatology consultation See “Treatment of GCA.”
Herpes zoster ophthalmicus [19]	Painful erythematous vesicular rash in the ophthalmic nerve dermatome Fever, headache, fatigue Conjunctival injection, chemosis, photophobia Impaired vision Hutchinson sign of the nose	Clinical diagnosis Slit-lamp examination with fluorescein staining: punctate or pseudodendritic corneal lesions	Antiviral therapy for herpes zoster See “Treatment” in “Herpes zoster ophthalmicus.”
Bacterial keratitis [20]	Red eye, photophobia, blurry vision Foreign body sensation Purulent discharge History of contact lens use	Clinical diagnosis Slit-lamp examination: hypopyon Fluorescein staining: round corneal ulcer or infiltrate	Topical broad-spectrum antibiotics See “Treatment” in “Bacterial keratitis.”
Herpes simplex keratitis [21]	Typically unilateral Red eye, photophobia, blurry vision Foreign body sensation Corneal hypesthesia	Clinical diagnosis Fluorescein staining: superficial dendritic ulcers	Topical or oral antivirals See “Treatment” in “Herpes simplex keratitis.”
Corneal ulcer [22]	Often a complication of keratitis Foreign body sensation Epiphora, conjunctival injection Blurry and/or decreased vision	Clinical diagnosis Slit-lamp examination: corneal epithelial defect, stromal edema, cells and flare	Treatment of underlying cause (e.g., topical antibiotics or antivirals) See “Management” in “Corneal ulcer.”
Corneal foreign body [23]	Sudden onset of symptoms, often after a triggering event Epiphora, photophobia, foreign body sensation Blurred vision Difficulty keeping eye open	Slit-lamp examination and/or eversion of the upper eyelid: visible foreign body, rust rings, corneal defect Positive Seidel test indicates open globe injury. CT or ultrasound orbit: foreign body	Corneal foreign body removal Tetanus prophylaxis and antibiotics as indicated See “Management” in “Corneal foreign body.”
Anterior uveitis [24][25]	Dull periocular pain Red eye, photophobia, blurry vision Epiphora Ciliary injection	Clinical diagnosis Slit-lamp examination: cells and flare, hypopyon	Supportive care (e.g., topical corticosteroids or cycloplegics) Treatment of underlying cause See “Management” in “Uveitis.”

Orbital cellulitis Fungal endophthalmitis Acute angle-closure glaucoma Papillitis in optic neuritis Giant cell arteritis Herpes zoster keratitis Herpes zoster ophthalmicus Hutchinson sign of the nose Infective keratitis Herpes simplex keratitis Corneal ulcer Corneal foreign body Corneal rust ring Anterior uveitis

**Acute angle-closure glaucoma**
Photograph of the eyes of an adult woman with an intraocular pressure of 42 mm Hg in the right eye
The left eye appears normal. Mixed injection is seen in the right eye and the right pupil is mid-dilated and nonreactive to light.
This is the typical appearance of acute, markedly elevated intraocular pressure, often due to acute angle-closure glaucoma.

Source: “Acute angle closure glaucoma” by James Heilman, MD, Wikimedia Commons, licensed under CC BY-SA 3.0.

**Angle-closure glaucoma**
Slit-lamp photograph of anterior eye segment
Prominent blood vessels are visible on the sclera and conjunctiva (mixed injection). The pupil is medium wide and its shape is slightly irregular. Iris details appear blurred due to corneal endothelial decompensation, leading to corneal edema.

Source: “Acute Angle Closure-glaucoma” by Jonathan Trobe, Wikimedia Commons, licensed under CC BY 3.0.

**Papillitis in optic neuritis**
Fundus photography of the left eye of a patient with acute vision loss and painful eye movements
Discrete optic disc edema is visible: Discrete blurring of the nasal superior, superior, and temporal superior disc margin can be seen (green overlay). Otherwise, the fundus is normal.

This finding, in addition to the patient's symptoms, suggests papillitis in optic neuritis.
M: macula; circle: optic disc

Source: © IMPP

**Giant cell arteritis**
The superficial temporal artery is prominent, which is suggestive of giant cell arteritis.

Source: © IMPP

**Herpes zoster ophthalmicus**
Three erythematous, maculopapular lesions with crusting can be seen on the left side of the face, at the hairline and supraorbitally. Left periorbital swelling and erythema are also visible.
The distribution and appearance of these lesions suggest herpes zoster ophthalmicus affecting the ophthalmic division of the trigeminal nerve.

This image is an adaptation. Source of original image: Wikimedia Commons. Original title: “Herpes Zoster im Augenbereich”. Created by: StromBer. Licensed under Public Domain. Modifications to original image: Added censor bar.

**Hutchinson sign of the nose**
Photograph showing reactivation of Herpes zoster infection
On the left side of the face, multiple partially confluent vesicles are visible on the tip and side of the nose (Hutchinson sign) and on the upper lip and cheek.
A positive Hutchinson sign of the nose indicates herpes zoster involvement of the nasociliary nerve (a branch of the ophthalmic division of the trigeminal nerve) and is associated with herpes zoster ophthalmicus.

Source: “Figure 2, in: Hutchinson’s Sign” by Lau L, Mirzakhani H, Governatori N, JETem, licensed under CC BY 4.0.

**Herpes zoster keratitis**
Slit-lamp photography, blue-light filter with fluorescein staining of a left eye
Superficial patchy erosions, marked by the fluorescein staining, are visible in a geographic pattern on the surface of the cornea (examples indicated by red overlay).
In combination with the cutaneous red lesions in the supraorbital region, the findings are typical for keratitis caused by herpes zoster ophthalmicus.

Source: “HerpesZosterOpth” by James Heilman, MD, Wikimedia Commons, licensed under CC BY-SA 4.0. The supplementary image with overlays of relevant areas was adapted from the image mentioned above and licensed under CC BY-SA 4.0.

**Infective keratitis**
Prominent blood vessels are visible on the sclera and conjunctiva (mixed injection; examples indicated by arrowheads). A dense corneal infiltration (white opacification; green overlay) is visible at the center of the cornea. The peripheral cornea shows slight opacification indicating corneal decompensation (blurred details of the iris). An accumulation of white-yellow exudate (hypopyon; blue overlay) consisting of inflammatory cells and/or bacteria/fungi within the anterior chamber can be seen completely covering the inferior aspect of the iris.
These findings are consistent with infective keratitis, associated here with contact lens use.

Source: © IMPP

**Herpes simplex keratitis**
Slit-lamp photography of the cornea (fluorescein stain)
Dendritic lesions (red overlay) are visible on the cornea.
This finding is characteristic of herpes simplex keratitis.

Source: © IMPP

**Corneal ulcer**
Slit-lamp photography of the right eye of a patient with a history of contact lens overuse
Paracentral clouding (yellow overlay) is visible on the cornea, suggesting corneal infiltration. There is also a hypopyon (blue overlay) at the base of the anterior chamber, and marked mixed injection (a combination of ciliary and conjunctival injection) is visible.
These findings are typical of a corneal ulcer, which can be caused by contact lens overuse.

© Massachusetts Medical Society. All rights reserved. AMBOSS SE, exclusive licensee.

**Corneal foreign body**
Right eye
A small brown foreign body (arrowhead) and a slight rust ring can be seen on the temporal corneal margin. Significant conjunctival injections are also visible.

Source: “Foreign body in eye” by E van Herk, Wikimedia Commons, licensed under CC BY-SA 3.0. The supplementary image with overlays of relevant areas was adapted from the image mentioned above and licensed under CC BY-SA 3.0.

**Corneal rust ring**
Slit-lamp photography of the right eye (fluorescein stain) of an individual with tearing and redness after working with a grinding wheel
The paracentral cornea shows a brown rust ring (green overlay). The small brownish flecks are iris nevi (example indicated by arrowhead).
Rust rings develop from metallic foreign bodies of the cornea that are not removed promptly.

Source: "51434_001.JPG", Mayo Clinic Jacksonville, Florida, Retina Gallery licensed under Public Domain

**Anterior uveitis**
Photograph of the right eye
The bulbar conjunctiva and limbus are hyperemic as a result of mixed conjunctival and ciliary injection. There is posterior synechia (adhesion between the iris and the lens), in this case affecting 360° of the pupil.
These features are characteristic of anterior uveitis.

Source: "Anterior Uveitis Vemurafenib - Zelboraf", S. M. Cohen, Retina Gallery licensed under Public Domain

Common non-vision-threatening causes

Common non-vision-threatening causes of eye pain [1]
	Characteristic clinical features	Diagnostic findings	Management
Corneal abrasion [23]	Foreign body sensation Epiphora, photophobia Conjunctival injection Blurred vision	Clinical diagnosis Slit-lamp examination with fluorescein stain: pattern of abrasive injury consistent with underlying mechanism Pain resolves with local anesthetic	Removal of corneal foreign body Topical antibiotics as indicated See “Management” in “Corneal abrasion.”
Preseptal cellulitis [26][27]	Eyelid and periorbital swelling and erythema No red flags for orbital cellulitis	Clinical diagnosis CT orbits and sinuses with contrast: soft tissue thickening anterior to the orbital septum	Empiric antibiotics See “Treatment” in “Preseptal cellulitis.”
Dacryoadenitis and dacryocystitis	Localized erythema and tenderness over lower eyelid Possibly, purulent discharge	Clinical diagnosis CT head and orbits to rule out orbital cellulitis and periorbital cellulitis	Treatment of underlying cause (e.g., antibiotics) See “Dacryoadenitis” and “Dacryocystitis.”
Blepharitis [28]	Recurring redness, swelling, and/or scaling of the eyelid margins Itchiness Foreign body sensation	Clinical diagnosis	Supportive (e.g., warm compresses, eyelid cleansing) See “Management” in “Blepharitis.”
Hordeolum	Erythematous pustule on the eyelid Eyelid edema	Clinical diagnosis	Supportive (e.g., warm compresses and massage) See “Management” in “Hordeolum.”
Keratoconjunctivitis sicca [29]	Dry eye Burning or itching sensation Blurred vision Conjunctival injection	Clinical diagnosis Slit-lamp examination Punctate epithelial erosions Epithelial filaments on the corneal surface	Supportive therapy for conjunctivitis Treatment of underlying cause See “Treatment of keratoconjunctivitis sicca.”
Conjunctivitis [30][31]	Conjunctival injection Chemosis Burning, itching, foreign body sensation Discharge	Clinical diagnosis	Supportive therapy for conjunctivitis Cause-specific treatment (e.g., pharmacological treatment for allergic conjunctivitis) See “Treatment of conjunctivitis.”

Corneal abrasion highlighted by fluorescein staining Corneal abrasion due to foreign body under the upper eyelid Preseptal cellulitis Acute dacryoadenitis Dacryocystitis Blepharitis External hordeolum Conjunctivitis

**Preseptal cellulitis**
The left eyelid appears swollen and erythematous.
These clinical features are suggestive of preseptal cellulitis, an inflammation of tissue anterior to the orbital septum.

Source: “Preseptal Cellulitis” by Tripp, flickr, licensed under CC BY 2.0.

**Acute dacryoadenitis**
Swelling and hyperemia of the left lateral upper eyelid can be seen, resulting in the characteristic S-shaped ptosis (green line).
This is the typical appearance of acute dacryoadenitis.

Source: © IMPP

**Dacryocystitis**
Right eye of a 54-year-old male patient
A solid and immobile mass can be seen in the right fossa lacrimalis. There is no discharge of pus or other secretions.
These findings are typical of dacryocystitis, which can result from chronic inflammation of the lacrimal sac and/or chronic stenosis of the tear duct.

Source: “Figure 1, in: Clinical, Radiological, Microbiological, and Histopathological Aspects of Acquired Dacryocystoceles” by Selam Yekta Sendul, Sonmez Cinar, Halil Hüseyin Çağatay, Mehmet Demir, Burcu Dirim, Dilek Guven, Hindawi, licensed under CC BY 3.0.

**Blepharitis**
Slit-lamp photography
There is crusting at the base of the eyelashes and the lid margin appears injected.
This is the typical appearance of blepharitis.

Source: “Anterior Blepharitis” by Imrankabirhossain, Wikimedia Commons, licensed under CC BY-SA 4.0.

**External hordeolum**
Right eye (temporal view)
There is erythema and swelling of the upper eyelid. A yellow pus point is visible at the lid margin near the base of the eyelash follicle.
This is the typical appearance of an external hordeolum.

Source: "File:Stye02.jpg", Jacek Halicki, Wikimedia Commons licensed under Public Domain

**Conjunctivitis**
Left eye
Significant conjunctival injection is visible. There is increased tearing visible in the inferior fornix.
These findings are typical for conjunctivitis. The absence of purulent secretion suggests a viral infection, although conjunctival injection can also be caused by various other conditions.

Source: “Conjunctivitis” by Raimundo Pastor, Wikimedia Commons, licensed under CC BY 4.0.

Acute management checklist

Perform a focused clinical evaluation, including:
- Eye examination
- Slit-lamp examination
Narrow the diagnosis based on the suspected location of the lesion and characteristic clinical features.
Begin critical interventions immediately as indicated, e.g.:
- Management of traumatic eye injuries
- Treatment of acute angle-closure glaucoma
- Lateral canthotomy and cantholysis in orbital compartment syndrome
- Immediate large-volume irrigation of ocular chemical burns
- Corneal foreign body removal
Consult ophthalmology urgently for the following:
- Red flags for painful red eye
- Vision-threatening causes of eye pain
Obtain additional diagnostics as indicated and initiate condition-specific treatment.

Mimics

Headache and facial pain

Trigeminal neuralgia (involving V1 of trigeminal nerve)
Cluster headache
Migraine
Tension headache
Frontal or ethmoid sinusitis
Postherpetic neuralgia
Referred pain from:
- Otitis media
- TMJ dysfunction
- Dental infection
- Nasal masses

Painless causes of red eye [30]

The following conditions are typically painless but can cause eye discomfort when severe.

Viral conjunctivitis
Bacterial conjunctivitis
Allergic conjunctivitis
Conjunctivitis due to irritants (e.g., contact lenses, chlorinated water, dust)
Drug-induced conjunctival hyperemia (e.g., cannabis, prostaglandin analogs) [32]
Blepharitis
Subconjunctival hemorrhage
Episcleritis
Conjunctival melanoma
Irritation of pinguecula or pterygium

Painless causes of red eye are typically non-vision-threatening.

Viral conjunctivitis Bacterial conjunctivitis Allergic conjunctivitis Conjunctival melanoma Blepharitis Subconjunctival hemorrhage Episcleritis

Painless eyelid or orbital swelling

Chalazion
Angioedema
Lymphedema
Graves ophthalmopathy
Allergic contact dermatitis

Chalazion Hereditary angioedema Graves' ophthalmopathy

Painless visual disturbances

Sudden
- Monocular
  - Central retinal artery occlusion
  - Central retinal vein occlusion
  - Retinal detachment
  - Vitreous hemorrhage
  - Nonarteritic anterior ischemic optic neuropathy
  - Macular hole
  - Retinal migraine aura
  - Scotoma
- Binocular
  - Occipital stroke (cortical blindness)
  - Posterior reversible encephalopathy syndrome
  - Toxic or metabolic causes (e.g., methanol poisoning)
Gradual
- Cataracts
- Open-angle glaucoma
- Age-related macular degeneration
- Diabetic retinopathy
- Refractive errors (e.g., myopia, hyperopia, astigmatism)
- Retinitis pigmentosa
- Hereditary optic neuropathies (e.g., Leber hereditary optic neuropathy)
- Fuchs endothelial corneal dystrophy

Sudden painless visual loss (especially monocular) is a medical emergency that requires urgent evaluation and in many cases ophthalmology consultation.

Functional vision disorders can manifest suddenly or gradually with monocular or binocular symptoms.

Acute central retinal artery occlusion Central retinal vein occlusion Rhegmatogenous retinal detachment Vitreous hemorrhage Papilledema in non-arteritic anterior ischemic optic neuropathy (NAION) Macular hole Cataract Exudative age-related macular degeneration Proliferative diabetic retinopathy Retinitis pigmentosa

**Types of ocular hyperemia (red eye)**
Three main patterns of ocular hyperemia help to identify the underlying cause.
– Conjunctival hyperemia: diffuse redness of the eye that is most marked in the periphery (i.e., near the conjunctival fornices), can reach far anteriorly, but spares the circumlimbal region. It is caused by dilation of the conjunctival vessels, which can be moved over the sclera with the conjunctiva. This pattern is typically seen in conjunctivitis.
– Ciliary flush: focal ocular redness in the circumlimbal region (i.e., a perilimbal halo). It is caused by dilation of the deep vessels, which cannot be moved over the sclera with the conjunctiva. This pattern is typically seen in anterior uveitis, keratitis, and acute angle-closure glaucoma, and it is sometimes more easily detected without the slit-lamp as a diffuse blue-red coloration of the circumlimbal region.
– Mixed: a combination of peripheral and perilimbal hyperemia. This pattern is frequently seen in various conditions.

© AMBOSS

**Viral conjunctivitis**
Left eye
The conjunctival blood vessels are dilated (injection). There is no purulent discharge.
This finding is consistent with viral conjunctivitis.

Source: “An eye infected with viral conjunctivitis” by Joyhill09, Wikimedia Commons, licensed under CC BY-SA 3.0.

**Bacterial conjunctivitis**
Left eye
There is massive conjunctival injection (hyperemia) and purulent discharge, especially visible in the medial corner of the eye and the margin of the lower lid.
This is the characteristic appearance of bacterial conjunctivitis.

Source: “Swollen eye with conjunctivitis” by Tanalai, Wikimedia Commons, licensed under CC BY 3.0.

**Allergic conjunctivitis**
Right eye of an older adult
Conjunctival injection, massive chemosis, and tearing are visible. The eyelids appear edematous.
This is the classical appearance of allergic conjunctivitis.

Source: “Allergic conjunctivitis” by James Heilman, MD, Wikimedia Commons, licensed under CC BY-SA 4.0.

**Subconjunctival hemorrhage**
Slit-lamp photography of the left eye
The temporal conjunctiva shows a subconjunctival hemorrhage.

Source: © IMPP

**Episcleritis**
Left eye
The temporal episclera shows vascular injection and a nodule shaped swelling.
This is the typical appearance of a nodular episcleritis.

Source: “Episcleritis.jpg” by Imrankabirhossain, Wikimedia commons, licensed under CC BY 4.0.

**Conjunctival melanoma**
Slit-lamp photography of the left eye
The temporal conjunctiva shows a darkly pigmented and irregurlarly demarcated lesion. Prominent afferent blood vessels and infiltrative growth in the cornea are further signs for a malignancy process.

Source: © IMPP

**Chalazion**
Left eye with ectropionized lower eyelid
A localized, nodular swelling is visible on the medial portion of the ectropionized lower eyelid. Both bulbar and tarsal conjunctiva are hyperemic.
This is the typical appearance of a chalazion.

Source: “Hordoleum” by Michal Klajban, Wikimedia Commons, licensed under CC BY-SA 3.0.

**Hereditary angioedema**
Facial edema, primarily affecting the eyelids, is visible on the patient's face.

Source: © IMPP

**Graves' ophthalmopathy**
The left eye shows retraction of the upper eye lid, resulting in the visibility of the superior sclera (Dalrymple sign). The globe protrudes from the orbital cavity (exophthalmos). Conjunctival injection is evident and there is swelling of the eyelids. Comparison of light reflexes in the corneas shows the light reflex at the inferior margin of the pupil in the right eye and in the middle of the pupil in the left eye. The patient is trying to look upwards but the elevation of the left eye is impaired. Furthermore, reduced elevation of the left eye (ocular misalignment) becomes apparent as the patient tries to look upward, resulting in binocular diplopia, a further classic symptom of Graves ophthalmopathy.

Source: © IMPP

**Acute central retinal artery occlusion**
Fundus photography of a right eye
Narrow retinal arteries with box-carring of the retinal vessels (black dashed outline) and a pale retina indicating nerve fiber layer edema are visible. The fovea centralis appears red (cherry-red spot; purple overlay) due to the transparency of this part of the retina lacking nerve fibres, causing the well-vascularized choroid to shine through. Additionally, at the temporal superior arcade an embolus is present (arrow-head).
This is the classical finding of acute central retinal artery occlusion.
Purple circle: Optic disc

Source: © IMPP

**Central retinal vein occlusion**
Fundus photography of a right eye
Multiple punctual hemorrhages in every quadrant of the retina and flame-shaped hemorrhages in the peripapillary and perivascular region are present (examples marked by blue overlay), as are markedly dilated tortuous veins (example framed by white lines) and mild disk edema (blurry margin of the disc marked by dashed blue line, sharply demarcated margin marked by blue line).
This is the classic appearance of central retinal vein occlusion.
M: Macula

Source: “Figure 1, in: Intravitreal Bevacizumab in the treatment of neovascular glaucoma secondary to central retinal vein occlusion: a case report” by Tarek Alasil, Michael E Rauser, Cases Journal, licensed under CC BY 2.0. The supplementary image with overlays of relevant areas was adapted from the image mentioned above (© AMBOSS).

**Rhegmatogenous retinal detachment**
Fundus photography of the eye
The detached part of the retina is visible as a yellow-gray, bullous elevation (blue overlay) in the upper part of the image. The detachment is due to a retinal tear (dashed outline).

Source: © IMPP

**Vitreous hemorrhage**
Fundus photography of the left eye
Fundus details appear blurred. Dark red flowing patches of blood (green overlay) are visible at the temporal edge and in the central fundus, completely covering the aspect of the retina.
This is the typical appearance of a vitreous hemorrhage.
White circle: optic disc

Image source of original image: retinagallery.com. Original title: “Diabetic Vitreous Hemorrhage Left Eye”. Created by: Dr. Steve Cohen.

**Papilledema in non-arteritic anterior ischemic optic neuropathy (NAION)**
Fundus photography of a right eye
The optic disc (dashed circle) shows blurred margins and radial bleedings (arrowheads). The retinal veins are dilated and tortuous (examples indicated by white lines). In addition, the macula (M) shows pigment alterations (blue overlay).
This is the typical appearance of papilledema, in this case caused by NAION. Papilledema can also be caused by arteritic anterior ischemic optic neuropathy (AAION), inflammatory processes, or elevated intracranial pressure.
Hatched overlay: artifacts

Image source of original image: Retina Gallery. Original title: “Acute Non-arteritic Anterior Ischemic Optic Neuropathy Right Eye”. Created by: Dr. Steve Cohen.

**Macular hole**
Fundus photography of the left eye
A round defect is visible in the macula (blue overlay).
This is the typical appearance of a macular hole.
Circle: optic disc

Source: “Figure 1 B, in: Wider Retinal Artery Trajectories in Eyes with Macular Hole Than in Fellow Eyes of Patients with Unilateral Idiopathic Macular Hole” by Yoshihara N, Sakamoto T, Yamashita T, Yamashita T, Yamakiri K, Sonoda S, et al., PLoS ONE, licensed under CC BY 4.0. Modifications: image has been cropped and a letter was removed. The supplementary image with overlays of relevant areas was adapted from the image mentioned above (© AMBOSS).

**Cataract**
Slit-lamp photograph of a left eye
The pupil is dilated. The lens (solid green overlay) appears cloudy and yellow.
This is the typical appearance of cataracts.
Dashed lines: optical path from the slit-lamp to the eye
Hatched green overlay: optical cross-section of the cornea, produced by the light of the slit-lamp

Source: © IMPP

**Exudative age-related macular degeneration**
Fundus photography of the left eye
Subretinal and intraretinal hemorrhage (blue overlay) is visible in the region between the optic disc (blue circle) and macula (the macula is not visible, its approximate position is marked with an “M”). The light-yellow spots in the region of the macula indicate exudates and drusen (hatched overlay).
Subretinal and intraretinal hemorrhages can result from pathological neovascularization of the choroid (CNV). The presence of CNV is required for the diagnosis of exudative/wet/neovascular macular degeneration.

Source: © IMPP

**Proliferative diabetic retinopathy**
Fundus photography of a right eye
Neovascularization (example indicated by arrowhead) is evident at the temporal superior arcade as tortuous vessels originate from the normal retinal vasculature. Microaneurysms and retinal hemorrhages appear as small red dots and larger red blotches (examples indicated by blue overlay). Hard exudates appear as yellow lesions (examples indicated by green overlay). The retinal veins show periodic dilatations (venous beading; example indicated by yellow overlay).
The diagnosis of proliferative disease requires the presence of neovascularization.

Source: © IMPP

**Retinitis pigmentosa**
Fundus photography of a left eye
The retina shows pigmentary deposits (blue overlay) resembling bone spicules in the mid periphery of the fundus along with retinal atrophy (yellow overlay), enhancing the visibility of the choroid vessels (examples indicated by arrowheads). The macula (M) shows a circular depigmentation (green overlay). The retinal blood vessels are attenuated.
This is the typical fundoscopic appearance of retinitis pigmentosa.
Circle: optic disc

Source: “Figure 1. in: Retinitis pigmentosa” by Christian Hamel, Orphanet Journal of Rare Diseases, licensed under CC BY-SA 2.0. The supplementary image with overlays of relevant areas was adapted from the image mentioned above and licensed under CC BY-SA 2.0.

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