Red eyes

One of the most common phone queries we receive from patients is in regard to red eyes.  Unfortunately, the phrase ‘red eyes’ covers a wide range of problems, so our phone triage personnel will typically ask several questions to elicit a more precise description of the problem.  The three most common problems are (a) generalized redness and irritation throughout the entire surface of the eye, (b) a chronic redness and irritation called episcleritis that often starts on the outside of the eyes away from the tear ducts, and (c) a brighter but more localized redness consistent with a subconjunctival hemorrhage.

Generalized redness with or without irritation
Red eyes have a variety of causes, including smoke, smog, fatigue, reading, close work, allergies, dry eyes and systemic diseases.  Many of these causes are short-term and easily remedied, but patients often ask whether they can purchase eye drops to alleviate the irritation, dryness, redness or excessive tearing.  There are two types of eye drops that patients can buy without a prescription that are commonly used for red eyes: decongestants and lubricants.

Primarily due to effective marketing campaigns, decongestants are more widely recognized and include Visine, Murine and Clear Eyes.  Decongestant drops work by constricting the tiny blood vessels in the conjunctiva, the clear covering over the white portion of your eye.  The decongestants provide temporary comfort and cosmetic relief by ‘getting the red out,’ but the drops do not address the underlying symptoms of the redness.  In some instances, the redness may become even more pronounced once the effects of the drops have dissipated.

The most common lubricants, also referred to as ‘artificial tears,’ are Tears Plus, Refresh, Hypotears, Tears Naturale and TheraTears.  Lubricant drops and ointments are used to improve the eye’s tear film balance and keep the eye moist.  Ointments provide more effective lubrication but also distort vision for a longer period than drops.  With lubricant applied every few hours, symptoms may resolve within two days but could require ongoing treatment for severe conditions.  Most brands have a ‘preservative-free’ product that reduces allergic reactions, but patients are mixed about which brand is most effective.

Some patients may experience red eyes several times each year, and their condition may be more pronounced than the normal redness and irritation.  If red eyes return rather routinely, it may be a sign that the patient has episcleritis.

Episcleritis is an inflammation of the outermost layer of the sclera; the sclera is the white part of the eye.  When episcleritis is active, all or part of the sclera becomes pink or light red and your eye may feel dry, gritty and irritated.  Episcleritis often starts on the outside of the eyes, away from tear ducts on the interior of the eye, since this portion of the eye may receive fewer lubricating tears.

Episcleritis is a chronic condition that comes and goes, although the frequency and duration of the condition varies widely among patients.  There are weak causal links to what may trigger the condition out of dormancy, including allergies, heavy computer use, viruses and rheumotologic conditions such as lupus and arthritis, but the origin of the condition is generally unknown.

Because we don’t have a cure for episcleritis, we focus our treatment on alleviating its symptoms.  Frequent use of artificial tears is advised for moderate episcleritis, while topical steroids may be used during severe episodes.  Since episcleritis is a self-limited condition that is not sight-threatening, some patients simply endure the occasional episodes without treatment.  There appear to be no long-term effects of episcleritis, although severe cases of episcleritis may be a contra-indication for LASIK or PRK since those surgeries can exacerbate the condition.

Subconjunctival hemorrhages
The conjunctiva is a thin, clear membrane that covers the white of the eye (sclera).  The conjunctiva protects and lubricates the eye.  Although the conjunctiva is transparent, it contains thousands of microscopic blood vessels.  When one of these blood vessels breaks, it can bleed, creating what we call a subconjunctival hemorrhage.

Subconjunctival hemorrhages usually appear as a small, deep red spot on the sclera.  They usually remain small, localized and defined, although they sometimes cover the entire white of the eye.  Subconjunctival hemorrhages usually have no symptoms and may cause only a mild, scratchy sensation in the affected eye.

The most common cause of a subconjunctival hemorrhage is rubbing of the eyes.  Other causes include trauma, sneezing, heavy lifting, coughing and straining.  It is rare for this condition to be associated with high blood pressure, bleeding conditions or any serious medical conditions.

Though subconjunctival hemorrhages can cause alarm and look very serious, they are not normally associated with any diseases that cause vision loss.  These hemorrhages usually resolve in 2 to 3 weeks without any treatment.  If you experience vision loss at the same time as a subconjunctival hemorrhage, you have more than just a broken blood vessel.  If you have vision loss or if you have blood within the iris (the colored center of the eye surrounding the pupil), you should seek care from an eye doctor immediately.

The animation below provides an introduction to subconjunctival hemorrhages.

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