A 29-year-old man wakes with both eyes dramatically blood-red — it happened overnight. The eyes are watery and gritty with swollen, exquisitely tender glands in front of both ears. His vision is normal and there is no injury. He returned from travelling two days ago. He is alarmed by his reflection.
Examination Findings
Both eyes show dramatic diffuse subconjunctival haemorrhages with an underlying follicular conjunctivitis and watery discharge. The preauricular lymph nodes are markedly enlarged and tender — a distinguishing feature. Vision is 6/6 in each eye, pressures are normal, and the corneas are clear. There is mild eyelid swelling. He is otherwise well with no neurological symptoms.
Investigations
The diagnosis is clinical — the explosive overnight onset of haemorrhagic conjunctivitis with tender preauricular adenopathy is characteristic of enterovirus 70 or coxsackievirus A24. No swab is needed in the classic sporadic picture. Vision and pressures are documented to exclude the alarming mimics. Neurological symptoms are asked about because enterovirus 70 has a rare association with a polio-like motor weakness, though this is uncommon.
Questions to Think About
- What features distinguish this from adenoviral conjunctivitis?
- Why is the management mostly about hygiene rather than drops?
- What rare systemic association should be asked about?
Diagnosis
Sporadic acute haemorrhagic conjunctivitis (enteroviral).
Reasoning
Reasoning: Explosive overnight bilateral haemorrhagic conjunctivitis with markedly tender preauricular nodes is acute haemorrhagic conjunctivitis — enterovirus 70 or coxsackievirus A24 — rather than adenovirus, which evolves more gradually and bleeds less dramatically. The normal vision and pressures exclude the dangerous mimics, and the appearance, though frightening, reflects subconjunctival bleeding over a viral conjunctivitis, not intraocular damage. Diagnosis: sporadic acute haemorrhagic conjunctivitis. Management: typical management is supportive care with lubricants and cold compresses, explicit reassurance that vision is not threatened, and rigorous infection-control counselling — this is among the most contagious eye conditions, and the household and workplace need protection more than the patient needs drops. He returns only if vision changes, pain escalates or neurological symptoms develop.
Differential Diagnosis
- Adenoviral conjunctivitis — ruled out: the dramatic overnight subconjunctival haemorrhages and exquisitely tender preauricular nodes favour enterovirus/coxsackie.
- Bacterial conjunctivitis — ruled out: watery, not purulent, discharge; explosive onset.
- Traumatic subconjunctival haemorrhage — ruled out: no trauma; bilateral with follicular reaction and nodes.
- Acute angle closure — ruled out: no pain, normal pressures, no halos from pressure.
Management
Typical management is supportive: cold compresses, lubricants and reassurance — antibiotics and steroids have no role in the uncomplicated case. The patient is counselled that the blood-red appearance resolves over one to two weeks without affecting vision. Infection control is the main prescription: meticulous hand hygiene, no eye-touching, separate towels and pillowcases, and staying home from work while acutely red and weeping. He is told to return if vision blurs, pain worsens, or neurological symptoms appear.
Key Learning Points
- Acute haemorrhagic conjunctivitis is the most dramatic conjunctivitis: blood-red eyes within hours, caused by enterovirus 70 or coxsackievirus A24.
- Exquisitely tender preauricular nodes help distinguish it from adenoviral disease.
- Despite the alarming appearance, the course is self-limiting over one to two weeks with vision spared.
- It is explosively contagious — the public-health message matters more than any prescription.
Red Flags
- Reduced vision or severe pain — not typical; reconsider the diagnosis urgently.
- Neurological symptoms (limb weakness) — rare enterovirus 70 association; urgent medical review.
- Pus replacing the watery discharge — possible bacterial superinfection.
Educational content only — not medical advice. Clinical decisions must be made by a qualified professional for the individual patient.
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