Clinical Evaluation of Red Eyes in Pediatric Patients

Casey Beal, MD; Beverly Giordano, MS, RN, CPNP, PMHS


J Pediatr Health Care. 2016;30(5):506-514. 

In This Article

Eye Injuries

Corneal Abrasion

Definition. A corneal abrasion is an epithelial defect on the surface of the cornea that is most commonly associated with trauma.

History of the Present Illness

  • Acute-onset, severe eye pain associated with blunt trauma or rubbing of the eye

  • Pain worsens with blinking

Physical Examination

  • Diffuse mild conjunctival erythema, tearing

  • Pain improves with instillation of topical ophthalmic proparacaine drops in the clinic; these drops should never be provided to patients because they can lead to corneal melting if used frequently

  • Evert the upper and lower eyelids to evaluate for foreign bodies

Diagnostic Tests

  • Use a Wood's lamp and fluorescein staining of the cornea to diagnose the abrasion and evaluate its extent (Figure 6)

Figure 6.

A corneal abrasion with fluorescein staining under a Wood's lamp.
Photo courtesy of Casey Beal, MD. This figure appears in color online at

Treatment. Treatment entails use of a topical antibiotic drop or ointment four times daily for 3 to 5 days; options include polymyxin B/trimethoprim, ciprofloxacin, moxifloxacin, erythromycin, or bacitracin ophthalmic drops or ointment

  • Follow-up should be scheduled for 48 hours to evaluate for improvement

  • Patching the eye is not recommended

  • Contact lenses should not be worn until the abrasion heals

  • If an underlying infection is associated with the abrasion, the patient should be referred to ophthalmology

Corneal and Conjunctival Foreign Bodies

Definition. Corneal and conjunctival foreign bodies become embedded in the conjunctival or corneal epithelium. Commonly seen foreign bodies include vegetative matter and metal shavings.

History of the Present Illness

  • The inciting event usually can be recounted by the patient

  • The speed and size of the foreign body are crucial for determining the object's potential for damaging the eye; if it was a high-velocity object, such as a piece of metal from a circular saw, it is likely that it is more deeply embedded and therefore more difficult to remove than a low-velocity object, such as vegetative matter or dirt blown up in the wind

Physical Examination

  • The foreign body usually can be seen easily on the surface of the cornea or conjunctiva (Figure 7)

  • Evert the upper and lower eyelids to ensure that no other foreign bodies are present

Figure 7.

A corneal foreign body.
Photo courtesy of Phuchong Choksamai. © This figure appears in color online at


  • If a foreign body is seen, refer the patient to the emergency department or urgently to an ophthalmologist

Subconjunctival Hemorrhage

Definition. A subconjunctival hemorrhage is rupture of a small conjunctival capillary with resultant bleeding into the subconjunctival space. Commonly, eye rubbing, cough, the Valsalva maneuver, or blunt trauma cause subconjunctival hemorrhages. These hemorrhages can be very alarming to patients and their family because of their size, color, and acute onset. However, they do not affect vision and do not cause any significant pain.

History of the Present Illness

  • A sudden onset localized area of subconjunctival blood

  • Specifically inquire about trauma, coughing, or eye rubbing

  • No photophobia, pain, or vision changes are present

Physical Examination

  • A localized area of subconjunctival blood (Figure 8) that does not involve the cornea

Figure 8.

Subconjunctival hemorrhage.
Photo courtesy of Phuchong Choksamai. © This figure appears in color online at


  • No treatment is required, although patients may use artificial tears for any discomfort

  • If a child has recurrent or large subconjunctival hemorrhages, a bleeding disorder (Khaja, Pogrebniak, & Bolling, 2015) or nonaccidental trauma should be suspected


Definition. A hyphema is defined as red blood cells that are present in the anterior chamber of the eye just posterior to the cornea. Most commonly, hyphemas are caused by blunt trauma; however, rarely, a hyphema can present spontaneously without a history of trauma, and this presentation raises concern for leukemia or juvenile xanthogranuloma (Samara et al., 2015).

History of the Present Illness

  • Inquire about a history of trauma and whether the patient has sickle cell disease

  • If the patient has sickle cell disease or trait, the sickling of the red blood cells in the anterior chamber of the eye can clog the drainage system of the eye and cause an acute rise in intraocular pressure, which can precipitate permanent vision loss

Physical Examination

  • Blood, which may be seen in the anterior chamber of the eye overlying the iris, is usually settled inferiorly because of the effect of gravity


  • All patients with hyphemas should be referred urgently to an ophthalmologist for further management and care with steroid and cycloplegic eyedrops. A main concern is the risk for recurrent hemorrhage as the blood clot begins to dissolve. Recurrent hemorrhage is most likely in the first 5 days after the injury, and thus patients should be instructed to avoid any strenuous activity, keep their head elevated, and avoid NSAIDs to reduce this risk.

Ruptured Globe

Definition. A ruptured globe is the result of any breach in the structural integrity of the eye, including corneal or scleral full-thickness lacerations. A ruptured globe is the result of direct trauma to the eye.

History of the Present Illness

  • The speed, size, type, and shape of the projectile determines the extent of the injury

  • Other associated head or facial injuries

Physical Examination

  • If a ruptured globe is suspected based on history, it is important to avoid applying any pressure to the eye during the examination

  • Signs of a ruptured globe include an irregularly shaped pupil, a shallow anterior chamber or exposed iris, or dark choroidal tissue showing through the white sclera

  • Almost always, a significant decrease in visual acuity is found


  • If a ruptured globe is suspected, a Fox shield (i.e., a metal eye shield named for Sidney Fox, MD) should be taped across the eye to protect it without applying any pressure to the eye; a Styrofoam cup also can be used if a Fox shield is not available

  • The patient should be directed to ingest nothing by mouth and should be sent directly to the nearest emergency department for emergent evaluation by an ophthalmologist for surgical repair