Inflammation can affect any layer of the eye. The key nursing skill is to separate benign, self-limited "red eye" (most conjunctivitis, blepharitis) from sight-threatening red eye (keratitis, anterior uveitis, acute angle-closure glaucoma, orbital infection). Pain, reduced vision, and light sensitivity are the warning trio.
| Disorder | Structure | Main causes | Hallmark |
|---|
| Conjunctivitis | Conjunctiva | Viruses (adenovirus most common), bacteria, allergy, chlamydia, gonorrhea | Redness, discharge, gritty feeling; vision normal |
| Keratitis | Cornea | Bacteria (Pseudomonas in contact lens wearers), herpes simplex virus (HSV), fungi, Acanthamoeba | Marked pain, photophobia, blurred vision, corneal opacity or ulcer |
| Anterior uveitis (iritis) | Iris and ciliary body | Autoimmune (HLA-B27 conditions), infection, trauma, idiopathic | Deep aching pain, photophobia, small (constricted) pupil, ciliary flush |
| Blepharitis | Eyelid margins | Staphylococcal colonization, meibomian gland dysfunction, seborrhea | Crusting, itching, burning; chronic and relapsing |
| Hordeolum / chalazion | Eyelid glands | Acute bacterial infection (hordeolum); blocked gland (chalazion) | Painful red lump (hordeolum); painless firm nodule (chalazion) |
Conjunctivitis types
| Type | Discharge | Other features | Contagious? |
|---|
| Viral | Watery | Often starts in one eye then spreads, preauricular lymph node, recent cold | Highly contagious (up to about 2 weeks) |
| Bacterial | Purulent or mucopurulent, lids stuck together in the morning | Usually no itching | Contagious |
| Allergic | Watery or stringy mucus | Itching is the key symptom, both eyes, history of allergy | No |
| Hyperacute (gonococcal) | Copious pus, rapid onset | Chemosis, lid swelling, can perforate the cornea within days | Yes; eye emergency |
Acute hemorrhagic conjunctivitis is an epidemic viral form caused mainly by enterovirus 70 and coxsackievirus A24; it causes sudden redness with subconjunctival hemorrhage and spreads rapidly in crowded settings.
Keratitis mechanism. Loss of the corneal epithelium lets organisms invade the stroma. The cornea is avascular and densely innervated, so infection is very painful and can progress to ulceration, scarring, and perforation. HSV keratitis produces a classic dendritic (branching) ulcer seen with fluorescein stain; it tends to recur.
Uveitis mechanism. Inflammatory cells and protein leak into the anterior chamber ("cells and flare" on slit lamp). The inflamed iris can stick to the lens (posterior synechiae), which may block aqueous flow and raise intraocular pressure (IOP). Spasm of the ciliary muscle causes the deep ache.
Subjective
- Redness, discharge, itching, foreign-body or gritty sensation
- Pain — mild irritation in conjunctivitis; moderate to severe in keratitis and uveitis
- Photophobia and blurred vision — red flags for corneal or intraocular disease
- Contact lens use, recent eye trauma, sick contacts, sexual history (for gonococcal or chlamydial infection), autoimmune history (ankylosing spondylitis, inflammatory bowel disease, sarcoidosis)
Objective
- Visual acuity in each eye (the "vital sign" of the eye) — always check first
- Pattern of redness: diffuse conjunctival injection (conjunctivitis) vs. ciliary flush (red ring around the cornea, suggesting keratitis or uveitis)
- Discharge character
- Pupil size and reaction: small, sluggish pupil in anterior uveitis; mid-dilated fixed pupil suggests acute angle-closure glaucoma
- Corneal clarity: white infiltrate, haze, or hypopyon (layer of pus in the anterior chamber)
- Vesicles on the forehead or tip of the nose (Hutchinson sign) suggest herpes zoster ophthalmicus with likely eye involvement
| Test | Purpose |
|---|
| Visual acuity (Snellen chart) | Baseline and trend; decrease suggests corneal or intraocular disease |
| Fluorescein staining with cobalt-blue light | Shows epithelial defects; dendritic pattern in HSV keratitis |
| Slit-lamp examination | Cells and flare in uveitis; corneal infiltrates; anterior chamber depth |
| Tonometry (IOP) | Uveitis may raise or lower IOP; long-term steroid use can raise it |
| Corneal scraping for culture | Before starting intensive antibiotics for suspected bacterial, fungal, or Acanthamoeba keratitis |
| Conjunctival culture / NAAT | Hyperacute, neonatal, or suspected chlamydial or gonococcal conjunctivitis |
| Workup for systemic disease | Recurrent or bilateral uveitis (HLA-B27, syphilis serology, chest imaging for sarcoidosis or tuberculosis) |
Conjunctivitis
- Viral: supportive — cool compresses, artificial tears; antibiotics do not help
- Bacterial: topical antibiotic drops or ointment (e.g., erythromycin ointment, polymyxin B–trimethoprim, fluoroquinolone drops); often self-limited
- Allergic: avoid allergens, cold compresses, topical antihistamine/mast-cell stabilizer drops (e.g., olopatadine, ketotifen)
- Gonococcal: systemic ceftriaxone plus eye irrigation; treat for chlamydia as well; same-day eye referral
- Chlamydial: systemic azithromycin or doxycycline; treat sexual partners
Keratitis
- Bacterial: intensive topical antibiotics (often every hour at first, including overnight), sometimes fortified drops
- HSV: topical antiviral (ganciclovir gel, trifluridine) or oral acyclovir/valacyclovir. Topical corticosteroids are contraindicated in active epithelial HSV keratitis — they can worsen the ulcer
- Fungal and Acanthamoeba: specialist agents; prolonged therapy
- Severe or perforated ulcers: tissue adhesive, corneal transplant
Anterior uveitis
- Topical corticosteroid (e.g., prednisolone acetate) to suppress inflammation
- Cycloplegic-mydriatic drops (cyclopentolate, atropine) to relieve ciliary spasm pain and prevent posterior synechiae
- Treat the underlying cause; systemic immunosuppression for chronic or recurrent disease
Blepharitis: warm compresses and daily lid hygiene; topical antibiotic ointment for flares; chronic control rather than cure.
Drug safety
| Drug class | Key safety points |
|---|
| Topical corticosteroids | Raise IOP (steroid-induced glaucoma) and cause cataract with long use; worsen HSV and fungal infection; taper — do not stop abruptly; check IOP regularly |
| Cycloplegics (atropine, cyclopentolate) | Blurred near vision, photophobia (wear sunglasses); systemic anticholinergic effects (tachycardia, flushing, confusion, especially in children and older adults); can trigger angle closure in narrow angles |
| Topical fluoroquinolones / aminoglycosides | Local irritation; aminoglycosides can cause corneal toxicity with prolonged use; check allergies |
| Oral acyclovir / valacyclovir | Dose-adjust for kidney function; maintain hydration |
| Ceftriaxone | Check beta-lactam allergy |
| Doxycycline / azithromycin | Doxycycline: avoid in pregnancy (use azithromycin), photosensitivity, take upright with a full glass of water; azithromycin: GI upset, QT prolongation |
| Trifluridine drops | Corneal epithelial toxicity with use beyond about 21 days; stinging |
Listed in priority order.
- Identify sight-threatening disease early
- Check visual acuity before any treatment (except chemical injury, which is irrigated first)
- Escalate urgently for pain, photophobia, reduced vision, corneal opacity, hypopyon, copious pus, or a contact lens wearer with a painful red eye
- Infection control
- Hand hygiene before and after touching the eyes or giving drops — the most important measure to stop spread
- Use separate drop bottles for each client and for each eye if only one is infected; do not let the tip touch the eye
- Clean discharge from the inner to outer canthus with a separate swab for each eye
- Disinfect shared equipment (tonometer tips, slit lamp)
- Protect the cornea and prevent perforation
- Keratitis: give antibiotic drops exactly on schedule, including at night
- Teach the client not to rub or press on the eye
- Do not patch an eye with suspected bacterial keratitis or in a contact lens wearer — patching creates a warm, dark environment for Pseudomonas
- Comfort
- Dim lights and sunglasses for photophobia
- Cool compresses for viral or allergic conjunctivitis; warm compresses for blepharitis and hordeolum
- Analgesics as ordered; cycloplegics relieve uveitis pain
- Medication administration
- Wait at least 5 minutes between different eye drops; give drops before ointment
- Apply gentle pressure to the inner canthus (nasolacrimal occlusion) for about 2–3 minutes after drops to reduce systemic absorption, especially with atropine
- Safety — blurred vision from ointment or cycloplegics increases fall risk; orient to surroundings
- Eye drop technique: wash hands, tilt head back, pull down the lower lid to form a pocket, instill into the pocket (not onto the cornea), close the eye gently (do not squeeze or blink hard), press the inner corner, wash hands again
- Viral conjunctivitis spreads easily: do not share towels, pillows, or makeup; avoid touching eyes; stay away from work, school, or swimming pools while the eye is red and discharging, per local policy
- Stop wearing contact lenses during any eye infection; discard lenses and cases used during the infection; never sleep in or swim with lenses; never rinse lenses with tap water
- Complete the full course of antibiotic drops even if the eye looks better
- Blepharitis is chronic: continue daily warm compresses and lid cleaning even after symptoms settle; stopping early leads to relapse
- Do not squeeze a hordeolum or chalazion
- Steroid drops: use only as prescribed, keep follow-up appointments for pressure checks, and never use leftover steroid drops for a new red eye
- Report worsening pain, vision loss, or light sensitivity at once
| Complication | What to watch for |
|---|
| Corneal ulcer / perforation | Increasing pain, white spot on cornea, sudden gush of fluid, flat anterior chamber |
| Corneal scarring | Permanent blurred vision; may need transplant |
| Endophthalmitis | Severe pain, marked vision loss, hypopyon |
| Secondary glaucoma | From synechiae or steroid use — rising IOP, halos, headache |
| Cataract | Gradual blurring after long-term steroid use |
| Gonococcal corneal perforation | Rapid purulent discharge with lid swelling |
| Orbital cellulitis | Fever, painful or limited eye movement, proptosis — emergency |
- Hand hygiene before and after eye drops is the core teaching for infectious conjunctivitis
- Viral = watery, highly contagious; bacterial = purulent; allergic = itching
- Acute hemorrhagic conjunctivitis: enterovirus 70 / coxsackievirus A24, subconjunctival hemorrhage
- Keratitis priority: pain control and prevention of corneal perforation
- HSV keratitis = dendritic ulcer on fluorescein; no topical steroids in active epithelial disease
- Anterior uveitis triad: pain, photophobia, reduced vision; pupil is constricted; slit lamp shows cells and flare
- Uveitis treatment: steroid drops + cycloplegic/mydriatic to relieve spasm and prevent synechiae
- Long-term steroid drops → glaucoma and cataract; monitor IOP
- Never patch an eye with suspected bacterial keratitis or in a contact lens wearer
- Blepharitis is chronic — continue lid hygiene after symptoms improve
- Wait 5 minutes between drops; press the inner canthus afterward
Country Notes
United States
- Contact lens–related keratitis is a leading preventable cause; public health messaging stresses no sleeping, showering, or swimming in lenses.
- Neonatal ocular prophylaxis with erythromycin ointment is standard to prevent gonococcal ophthalmia neonatorum (required by law in many states; USPSTF grade A).
Philippines
- Conjunctivitis is widely called "sore eyes," and outbreaks are common during the hot and rainy seasons; school and workplace clustering is typical.
- Clients may self-treat with over-the-counter drops, some containing steroids — ask specifically about drops bought without a prescription.