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Eye problems: a step-by-step approach
Most eye textbooks assume you already know ophthalmology. This page doesn't. Follow the same six steps for every eye patient and you will reach a working diagnosis, spot the ones that need an eye doctor today, and write a safe plan for the rest.
Approach👁 VA → 4 questions → outside-in
Pathways🔀 Red eye · visual loss · trauma · lids
Covers📚 30+ eye conditions
0The 60-second stop checks
Before history, before the Snellen chart. Four situations where every minute costs vision.
🧪 Chemical in the eye
Irrigate now, before VA or history. Saline through a giving set, at least 1 litre, 15–30 min, until fornix pH is about 7. Alkali is worse than acid.
Go to chemical injury →🔩 Possible penetrating injury
Hammering metal on metal, grinding, glass, sharp object, odd-shaped pupil. Rigid shield, no pressure on the globe, no drops.
Go to penetrating injury →👁️ Sudden loss of vision
Painless or painful, it is an emergency until proven otherwise. Same-day eye or stroke pathway.
Go to visual loss →🤕 Over 50 with new headache + visual symptoms
Think giant cell arteritis. Jaw claudication, scalp tenderness, PMR symptoms. Steroids today protect the other eye.
Go to GCA →1Visual acuity first: every eye, every time
VA is the vital sign of the eye. An undocumented VA is indefensible, and a drop in VA is the single best clue that something serious is going on.
How to measure
- Snellen chart at 6 m (or 3 m with a mirror chart)
- One eye at a time, cover the other with a palm or occluder
- With their distance glasses on
- Can't see well? Repeat through a pinhole. If it improves, the problem is refractive, not disease
- Painful eye can't open? Instil a drop of local anaesthetic, then test
How to write it
6/12
Top number = distance from chart (m). Bottom = the line they read. Normal is 6/6. Read two letters of the next line? Write 6/12 +2.
If they can't read the top line
Walk closer: top line at 3 m = 3/60. Still no?
- CF – counts fingers at 1 m
- HM – sees hand movements
- PL – perceives light
- NPL – no light perception
Memory hook: "VA before you play." Write VA for both eyes before you touch the eye, put in any drop (except anaesthetic to allow testing) or do anything else. No chart? A near-vision card at 30 cm, or reading phone text, is better than nothing. For people who can't read letters, use a tumbling-E chart.
2The four sorting questions
Four questions put almost every eye patient into the right pathway. Ask them in this order.
PPain?
Real pain or photophobia, not just grittiness or itch
Real pain or photophobia, not just grittiness or itch
VVision down?
Compared with their normal, and not fixed by blinking or pinhole
Compared with their normal, and not fixed by blinking or pinhole
TTrauma?
Blow, chemical, high-speed fragment, UV, contact lens
Blow, chemical, high-speed fragment, UV, contact lens
DDischarge or itch?
Sticky, watery, itchy, both eyes
Sticky, watery, itchy, both eyes
Mnemonic: "PVT Drops". Pain + vision down = danger pathway. Trauma = trauma pathway. Discharge or itch with normal vision and no pain = almost always the safe end (conjunctivitis, blepharitis).
| Answer pattern | Go to | Usual meaning |
|---|---|---|
| Trauma or chemical | 4c Trauma | Depends on mechanism; chemical and high-velocity are emergencies |
| Vision down, eye white, little or no pain | 4b Sudden visual loss | Retina, optic nerve or vascular event |
| Red + painful ± vision down ± photophobia | 4a Red eye (danger) | Keratitis, iritis, acute glaucoma, scleritis |
| Red, gritty/itchy, discharge, vision normal | 4a Red eye (safe) | Conjunctivitis, subconjunctival haemorrhage, episcleritis |
| Lump or swelling of the lid, contact lens issue | 4d Lids & lenses | Stye, chalazion, blepharitis, cellulitis, lens problems |
The rest of the history (quick)
- Which eye, or both? Both eyes usually means conjunctivitis, allergy, arc eye or blepharitis.
- Onset: seconds (vascular), hours (glaucoma, infection), days (optic neuritis).
- Flashes, floaters, curtain or shadow? Retinal tear or detachment.
- Contact lenses? Changes everything. A red painful eye in a lens wearer is microbial keratitis until proven otherwise.
- Past eye history: previous iritis, glaucoma, recent eye surgery (endophthalmitis), only one good eye (low threshold to refer).
- Medical: diabetes, hypertension, AF, autoimmune disease (ankylosing spondylitis, IBD), cold sores, shingles.
- Drugs: anticoagulants, steroid drops, anticholinergics (can trigger angle closure).
- Job and driving: welder, grinder, HGV driver.
3Examine outside-in
Work from the front of the face to the back of the eye. Each layer has its own short list of problems.
Face & lids
Swelling, redness, lumps, vesicles in a dermatome, proptosis. Evert the upper lid if there is foreign-body sensation.Conjunctiva
Redness pattern: diffuse (conjunctivitis), a patch (episcleritis), a ring round the cornea (ciliary flush, a danger sign), a flat red blot (haemorrhage).Cornea + fluorescein
Clear or hazy? Stain and look under blue light. Abrasion, ulcer, dendrite, foreign body, Seidel leak. Contact lenses out first.Anterior chamber
Blood level (hyphaema), pus level (hypopyon), shallow chamber (penetration, angle closure).Pupils
Size, shape, light reflex, swinging-light test for a RAPD (optic nerve or big retinal problem). Irregular pupil after trauma = penetration until proven otherwise.Movements & fields
Pain on movement (optic neuritis, orbital cellulitis). Diplopia, restricted upgaze (blow-out). Confrontation fields.Fundus
Red reflex first. Lost reflex = vitreous haemorrhage, dense cataract, big detachment. Then disc and vessels. Leave dilating drops to the eye team.Fluorescein patterns: learn these five pictures
Single geographic patch
Corneal abrasion (fingernail, paper, twig).
Corneal abrasion (fingernail, paper, twig).
Vertical scratch lines ("ice rink")
Foreign body stuck under the upper lid. Evert the lid.
Foreign body stuck under the upper lid. Evert the lid.
Branching tree-like line
Dendritic ulcer: herpes simplex. No steroids, same-day eye referral.
Dendritic ulcer: herpes simplex. No steroids, same-day eye referral.
Many tiny dots, both eyes
Arc eye / UV keratitis, or dry eye.
Arc eye / UV keratitis, or dry eye.
Dye washed away by a stream
Positive Seidel test: aqueous leaking from a full-thickness wound.
Positive Seidel test: aqueous leaking from a full-thickness wound.
White, opaque spot that stains
Corneal ulcer / microbial keratitis, especially in lens wearers.
Corneal ulcer / microbial keratitis, especially in lens wearers.
4aThe red eye
The big question: is this a safe red eye or a sight-threatening red eye? Use the traffic-light table, then open the matching card.
| Feature | Safe red eye (usually) | Sight-threatening red eye |
|---|---|---|
| Pain | Gritty, itchy, mild ache | Deep pain, headache, nausea |
| Vision | Normal, clears with blinking | Reduced and stays reduced |
| Photophobia | No | Yes |
| Redness | Diffuse, or a sectoral patch | Ring around the cornea (ciliary flush) |
| Cornea | Clear | Hazy, white spot, stains with fluorescein |
| Pupil | Normal, reactive | Small and irregular (iritis) or mid-dilated and fixed (glaucoma) |
| Discharge | Sticky or watery | Usually little, or watery with pain |
| Other flags | Both eyes, contacts with cold | Contact lens wearer, recent eye surgery, vesicles on the nose tip, neonate |
Rule: any red eye with reduced VA, abnormal pupil or a corneal problem goes to the eye team. Conjunctivitis never reduces vision once the discharge is blinked away.
Safe end: manage in clinic
Infective conjunctivitis Manage
Clues
- Red, gritty, often both eyes (second eye follows)
- Bacterial: sticky yellow discharge, lids stuck in the morning
- Viral: watery, recent cold, tender node in front of the ear
- Vision normal
Confirm
- VA normal, pupils normal, cornea clear
- No ciliary flush, no photophobia
- You cannot reliably tell viral from bacterial; it rarely matters
Plan
- Most settle in 1–2 weeks without treatment
- Clean lids with cooled boiled water
- No towel sharing; hand hygiene
- Antibiotic only if severe or not settling: chloramphenicol 0.5% drops or 1% ointment (check BNF)
- Stop contact lenses until settled
Refer same day if
- Baby under 28 days (ophthalmia neonatorum)
- Reduced VA, photophobia, corneal staining
- Contact lens wearer with pain
- Copious purulent discharge (gonococcal)
Allergic conjunctivitis Manage
Clues
- Itch is the key word
- Both eyes, watery, puffy lids
- Hay fever season, pets, new cosmetics
Confirm
- Normal VA and cornea
- Swollen, jelly-like conjunctiva (chemosis) in acute cases
Plan
- Avoid the trigger, cold compresses
- Topical antihistamine or mast-cell stabiliser drops (e.g. sodium cromoglicate), oral antihistamine
- No steroid drops from urgent care
Safety-net
- Return if pain, light sensitivity or blurred vision develop
Subconjunctival haemorrhage Manage
Clues
- Bright red flat patch, sharp edges, painless
- Noticed in the mirror or by someone else
- After coughing, straining, sneezing, or nothing at all
Confirm
- Normal VA, pupils, cornea
- Check BP; INR if on warfarin
- After trauma: can you see the back edge of the blood? If not, think orbital fracture
Plan
- Reassure: clears in about 2 weeks, may go yellow first
- Lubricants if mildly irritable
Refer if
- Trauma with reduced VA, no posterior limit, or high-velocity mechanism
- Recurrent: look for bleeding disorder or raised BP
Episcleritis Manage
Clues
- A wedge or patch of redness on one side of the eye
- Mild ache or discomfort, not severe pain
- Young adult, sometimes recurrent
Confirm
- VA, pupils, cornea, anterior chamber all normal
- Vessels move when you push the conjunctiva with a cotton bud
- Tender to touch only a little
Plan
- Usually settles in 1–3 weeks
- Cold compresses, lubricants
- Oral NSAID if uncomfortable (check contraindications)
- GP review if not resolving
Not episcleritis if
- Severe boring pain that wakes them at night, very tender globe, bluish-purple redness: scleritis
Danger end: same-day or emergency eye referral
Acute angle-closure glaucoma Emergency
Clues
- Older, long-sighted (thick glasses that magnify), often female, often Asian heritage
- Severe eye pain + headache + nausea and vomiting (can look like a migraine or a "surgical abdomen")
- Haloes round lights, blurred vision
- Often starts in the evening or in dim light, or after anticholinergic drugs
Confirm
- VA reduced
- Hazy, steamy cornea
- Pupil mid-dilated, oval, fixed
- Eye feels rock hard through the closed lid compared with the other side
- Measure pressure if you have a tonometer (often 40–70 mmHg)
Plan
- Phone the on-call eye team now
- Lie flat on their back
- IV/IM analgesia and antiemetic
- Pressure-lowering drugs while awaiting review, per eye team/local protocol: acetazolamide 500 mg and pilocarpine drops (2% light iris, 4% dark iris)
Pitfall
- Vomiting + headache in an older person sent for a CT head while the eye goes blind. Always look at the eye.
Acute anterior uveitis (iritis) Same day
Clues
- Young to middle-aged, one eye
- Aching pain, photophobia, blurred vision, watering
- Previous episodes; back pain (ankylosing spondylitis), IBD, psoriasis, sarcoid
Confirm
- Ciliary flush around the cornea
- Small or irregular pupil
- Light into the good eye hurts the bad eye
- Slit lamp: cells in the anterior chamber, sometimes a hypopyon
Plan
- Same-day eye clinic: they start steroid and dilating drops
- Oral analgesia, sunglasses meanwhile
- Do not start steroid drops yourself
Remember
- Recurrent iritis + back pain = ask about inflammatory back pain and refer to rheumatology via GP
Microbial keratitis / corneal ulcer (incl. contact lens) Same day
Clues
- Contact lens wearer, especially sleeping in lenses or swimming in them
- Painful red eye, photophobia, watering, blurred vision
- Acanthamoeba: pain out of proportion to signs, tap water or swimming exposure
Confirm
- White or grey spot on the cornea that stains with fluorescein
- Hypopyon suggests bacterial infection
Plan
- Same-day eye casualty: they scrape and culture before intensive drops
- Lenses out; bring the lenses and case with the patient
- Chloramphenicol does not cover Pseudomonas well, so do not "trial" it and send home
Never
- Steroid drops: can melt the cornea
Herpes simplex keratitis Same day
Clues
- Red, watery, light-sensitive eye, one side
- History of cold sores or previous episodes
Confirm
- Fluorescein shows a branching dendrite
- Reduced corneal sensation compared with the other side
Plan
- Same-day eye referral; they start topical antivirals
- Oral analgesia
Never
- Steroid drops: turn a dendrite into a large ulcer
Herpes zoster ophthalmicus (shingles near the eye) Treat + same-day eye if eye signs
Clues
- Burning or tingling forehead, then a vesicular rash in the V1 dermatome, one side, stops at the midline
- Older or immunosuppressed
Confirm
- Hutchinson's sign: vesicles on the tip or side of the nose raise the chance of eye involvement
- Check VA, redness, fluorescein, pupil
Plan
- Oral antiviral, ideally within 72 h of rash onset (e.g. aciclovir 800 mg five times daily for 7 days; check BNF and renal function)
- Analgesia
- Red eye, reduced VA or staining cornea = same-day eye referral
- No eye signs: safety-net to return if the eye becomes red or painful
Remember
- Immunosuppressed or very unwell: discuss with medics
Scleritis Same day
Clues
- Severe, boring pain that wakes them at night and spreads to the face
- Rheumatoid arthritis, vasculitis
Confirm
- Deep, dusky or bluish-red colour
- Very tender globe
- Vessels don't move with a cotton bud
Plan
- Same-day eye referral
- Analgesia meanwhile
Key difference
- Episcleritis: irritating. Scleritis: agony.
Preseptal vs orbital cellulitis Preseptal: treat Orbital: emergency
Clues
- Red, swollen, tender lids
- Recent sinusitis, insect bite, stye, scratch
- Children are more prone
Orbital if any of
- Proptosis
- Painful or restricted eye movements, double vision
- Reduced VA or colour vision, RAPD
- Fever and systemically unwell
Plan
- Preseptal (lids only, eye itself normal): oral antibiotics per local guideline (often co-amoxiclav), review in 24–48 h. Low threshold to involve paediatrics in children
- Orbital: sepsis screen, IV antibiotics, CT orbits and sinuses, urgent eye and ENT
Why it matters
- Orbital cellulitis can cause blindness, cavernous sinus thrombosis and meningitis
4bSudden loss of vision
Sort by two questions: did it come back? and does it hurt? Then the fundus usually tells you which one.
Transient, now back to normal
Amaurosis fugax (TIA of the eye). In over-50s, always think GCA too.
Persistent + painless
Retinal artery or vein occlusion, vitreous haemorrhage, retinal detachment, ischaemic optic neuropathy (GCA).
Persistent + painful
Optic neuritis (pain on moving the eye), acute angle closure, keratitis, uveitis, GCA (headache).
| Diagnosis | Story | Key sign | Fundus |
|---|---|---|---|
| Central retinal artery occlusion | Sudden, painless, profound loss. Vascular risk factors, AF | RAPD, VA often CF or worse | Pale retina, cherry-red spot |
| Central retinal vein occlusion | Painless blur, often on waking. Hypertension, diabetes, glaucoma | Variable VA, may have RAPD | "Stormy sunset": haemorrhages everywhere, swollen veins |
| Vitreous haemorrhage | Diabetic, or sudden shower of floaters | Reduced or absent red reflex | Can't see the retina |
| Retinal detachment | Flashes, floaters, then a curtain or shadow. Short-sighted, post-cataract, trauma | Field defect | Grey, billowing retina (often hard to see without dilation) |
| GCA (arteritic AION) | Over 50, headache, jaw claudication, scalp tenderness | RAPD, tender temporal artery | Pale, swollen disc |
| Optic neuritis | Young woman, vision worse over days, pain on eye movement | RAPD, red looks washed out | Often normal disc |
Memory hook: artery = pale retina (no blood in), vein = bloody retina (blood can't get out).
Amaurosis fugax TIA pathway
Clues
- A curtain coming down over one eye for seconds to minutes, then full recovery
- Vascular risk factors, carotid disease, AF
Check
- Pulse (AF), BP, carotid bruit, glucose, ECG
- Over 50: ask GCA questions and check CRP/ESR
Plan
- Treat as a TIA: aspirin 300 mg unless contraindicated and specialist TIA assessment within 24 h (NICE NG128)
- If GCA is likely, treat as GCA instead
Safety-net
- No driving until seen by the TIA service
- 999 for any further weakness, speech or vision loss
Central retinal artery occlusion Emergency
Clues
- Sudden, painless, profound loss of vision in one eye
- Previous amaurosis fugax
Confirm
- RAPD; pale retina with cherry-red spot
- Pulse for AF, carotid bruit, BP, glucose
- Over 50: CRP/ESR to exclude GCA
Plan
- It is a stroke of the eye. Phone the on-call eye team immediately and follow your local pathway; many units route this through the stroke team
- Aspirin as per stroke/eye team advice
- Older bedside remedies (globe massage, acetazolamide) lack good evidence; do them only if the eye team asks
Don't miss
- GCA as the cause: the other eye is at risk within days
Central retinal vein occlusion Urgent eye referral
Clues
- Painless blurring, older patient
- Hypertension, diabetes, glaucoma, high lipids, polycythaemia
Confirm
- "Stormy sunset" fundus: flame haemorrhages, engorged veins, swollen disc
Plan
- Urgent eye referral as per local pathway
- BP, glucose, FBC, lipids, ESR; GP to manage risk factors
Why refer
- Treatable complications (macular oedema, new vessels, glaucoma)
Retinal detachment / tear and vitreous haemorrhage Same day
Clues
- New flashes and a shower of floaters
- A shadow or curtain spreading across the vision
- Short-sighted, previous cataract surgery, trauma, diabetes
Confirm
- VA, confrontation fields (field defect), red reflex
- A normal undilated fundoscopy does not exclude a tear or detachment
Plan
- Field loss or reduced VA: same-day eye referral
- New flashes/floaters with normal vision and fields: urgent eye assessment for a dilated exam (local pathway, usually within 24 h)
- Vitreous haemorrhage: same-day referral; sit up to let blood settle
Safety-net
- Return immediately if a curtain or shadow appears or vision worsens
Giant cell arteritis Steroids today
Clues
- Over 50, new headache (often temporal)
- Jaw claudication (pain on chewing), scalp tenderness when brushing hair
- Shoulder/hip girdle stiffness (PMR), weight loss, fatigue
- Transient or permanent visual loss, double vision
Confirm
- Tender, thickened or pulseless temporal artery
- RAPD, pale swollen disc if the eye is involved
- CRP, ESR, FBC (platelets often high), taken before steroids but never delay steroids for the result
Plan
- Start prednisolone the same day: 40–60 mg if no visual symptoms; 60 mg if visual symptoms, and same-day eye referral (specialists may give IV methylprednisolone) (BSR 2020)
- Refer via your local fast-track GCA pathway (rheumatology ± ophthalmology)
- Gastric protection; bone protection per specialist
Why
- Untreated, the other eye can go blind within days
Optic neuritis Urgent same/next day
Clues
- Young adult, more often female
- Vision worsens over hours to days
- Pain on moving the eye
- Previous neurological symptoms (numbness, weakness)
Confirm
- Reduced VA, RAPD
- Red desaturation: a red object looks faded in the affected eye
- Disc often normal (inflammation behind the eye)
Plan
- Urgent eye/neuro-ophthalmology referral per local pathway
- Most recover; some go on to develop MS, so specialist follow-up matters
Atypical = more urgent
- No pain, both eyes, very severe loss, older age, no recovery: think other causes
4cEye trauma
Mechanism decides the pathway. Ask exactly what happened.
🧪 Chemical
Irrigate first, think later.🔩 High-velocity
Hammer, chisel, grinder: assume an intraocular FB.👊 Blunt
Fist, ball, elbow: globe, orbit, retina.✋ Superficial
Fingernail, grit, UV: abrasions and FBs.Chemical injury Emergency: irrigate now
Do immediately
- Local anaesthetic drop, then irrigate with saline through a giving set: at least 1 litre, 15–30 min
- Hold lids open, ask them to look in every direction
- Evert the upper lid and sweep the fornices with a moist cotton bud for particles (lime, cement)
Then check
- Wait 5–10 min, test pH in the fornix: aim for about 7 (6.5–7.6)
- Not there? Keep irrigating and re-test
- Now do VA, fluorescein, look for a white ischaemic limbus or hazy cornea
Refer
- Alkali (cement, oven cleaner, drain cleaner, bleach) or acid with any corneal haze, limbal whitening or reduced VA: emergency eye referral after irrigation
- Identify the substance; check TOXBASE
Mild, settled injury
- Normal VA, minimal staining, normal pH: lubricants ± chloramphenicol ointment, review next day
Penetrating injury / intraocular foreign body Emergency
Clues
- Hammering metal on metal, grinding, chiselling, explosion, broken glass
- Often surprisingly little pain
- Ordinary glasses without side shields don't protect
Look for
- Pear- or teardrop-shaped pupil pointing to the wound
- Shallow anterior chamber, hyphaema, positive Seidel
- Entry wound on the lid, cornea or sclera (check under the lids gently)
Plan
- Rigid shield, never a pad; no pressure on the globe
- No drops or ointment; do not remove embedded objects
- Nil by mouth, analgesia, antiemetic (vomiting raises eye pressure)
- Tetanus status; IV antibiotics per local policy
- Imaging: X-ray or CT orbits (no MRI if metal is possible)
- Emergency eye referral, even if other injuries need attention too
Pitfall
- "Something flew into my eye at work" with a tiny corneal mark: X-ray before you discharge
Blunt trauma: hyphaema, blow-out fracture, retrobulbar haematoma Assess carefully
Check in this order
- VA
- Proptosis + tight lids + reduced VA + RAPD = retrobulbar haematoma
- Pupils, eye movements (restricted upgaze, diplopia)
- Numb cheek/upper lip (infra-orbital nerve) and sunken eye = blow-out fracture
- Blood level in the anterior chamber = hyphaema
- Fluorescein for abrasion; fundus for retinal damage
Retrobulbar haematoma
- Orbital compartment syndrome: vision can go within 90 minutes or so
- Emergency lateral canthotomy and cantholysis by ophthalmology or a trained ED doctor
- Call senior help immediately
Hyphaema
- Same-day eye referral
- Sit up at 45°, rest, analgesia
- Avoid NSAIDs and aspirin
Blow-out fracture
- CT orbits if suspected; maxillofacial follow-up
- No nose blowing (orbital emphysema)
- Antibiotics per local policy
- Eye referral if diplopia, reduced VA or globe injury
Corneal abrasion Manage
Clues
- Fingernail, baby's hand, paper, twig, make-up brush
- Pain, watering, light sensitivity, can't open the eye
Confirm
- LA drop, then VA
- Fluorescein: a single bright-green patch
- Evert the upper lid to exclude a hidden FB
- Exclude penetration (pupil shape, Seidel)
Plan
- Chloramphenicol 1% ointment for large or contaminated abrasions (check BNF for dosing and duration)
- Oral analgesia; cyclopentolate 1% for significant pain from ciliary spasm
- No eye pad
- Contact lens wearer: no lens wear and a Gram-negative-active antibiotic; discuss with eye team
Safety-net
- Should be much better in 24–48 h
- Return if worse, vision drops, or a white spot appears
- No driving until vision is back to normal (and after dilating drops)
Corneal, conjunctival and sub-tarsal foreign body Manage
Clues
- Grit blown in by wind, metal while grinding
- Scratchy feeling, worse on blinking (sub-tarsal)
Find it
- Lower fornix: pull the lower lid down
- Upper lid: evert over a cotton bud while they look down
- Vertical scratch lines on fluorescein = sub-tarsal FB
Remove it
- LA drop, then a moist cotton bud (roll over it)
- Embedded corneal FB: needle at the slit lamp only if trained, approaching from the side with the head firmly supported
- Afterwards: chloramphenicol ointment, analgesia
Refer if
- Rust ring left, central or deep FB, failed removal
- High-velocity mechanism (X-ray first)
- Not better in 24–48 h
Arc eye / snow blindness (UV keratitis) Manage
Clues
- Welding without a mask, sunbed, skiing or climbing without goggles
- Both eyes painful, watering, can't open them, starting 6–12 hours later (often wakes them at night)
Confirm
- LA drop gives dramatic relief, allowing examination
- Fluorescein: many tiny punctate dots, both eyes
Plan
- Oral analgesia
- Lubricating or antibiotic ointment
- Cyclopentolate 1% if very sore
- Usually resolves within 24–48 h
Safety-net
- No driving until recovered
- Return if not better in 48 h
- Proper eye protection next time
Eyelid laceration and superglue Often refer
Lid laceration
- Always examine the globe underneath: a lid wound can hide a penetrating injury
Refer (eye/oculoplastics) if
- Involves the lid margin
- Near the inner corner (tear duct)
- Fat visible (deep, through the septum)
- Any globe injury
Superglued lids
- Warm water soaks; lids usually separate on their own within a few days
- Don't force them apart or cut lashes close to the eye
Refer if
- FB sensation once open (glue lump causing abrasion)
- Can't examine the eye and symptoms persist
4dLids, lumps and lenses
Common, usually benign, and very satisfying to manage well.
| Problem | Looks like | Plan | Guideline |
|---|---|---|---|
| Stye (external hordeolum) | Painful red pustule at the lash line | Warm compresses several times a day; usually drains on its own. Antibiotics only if spreading cellulitis | CoO · leaflet |
| Chalazion | Painless firm lump within the lid, away from the margin | Warm compresses and lid massage; many settle over weeks. Refer if persistent, affecting vision, or atypical (recurrent in same place: exclude cancer) | CoO · NHS Scot |
| Blepharitis | Crusty, red lid margins, gritty, both eyes, chronic | Daily lid hygiene (warm compress + clean margins). It's long-term control, not a cure. Check the cornea is clear | CoO · leaflet |
| Dacryocystitis | Red, tender swelling at the inner corner below the eye, sticky eye | Oral antibiotics per local guideline (often co-amoxiclav); refer if spreading, unwell, or recurrent | CoO |
| Stuck or lost contact lens | Lens can't be found or removed | Saline, look in both fornices and evert the upper lid; soft lens: pinch out | — |
| Painful red eye in a lens wearer | Any pain, photophobia, white spot | Lenses out; same-day eye casualty (see keratitis) | CoO |
5Build the plan and choose the disposition
Three boxes. Every eye patient leaves in one of them.
Phone the eye team now
- Chemical injury (after irrigation)
- Penetrating injury / IOFB
- Retrobulbar haematoma
- Acute angle closure
- Retinal artery occlusion
- GCA with visual symptoms
- Orbital cellulitis
Same-day / urgent eye clinic
- Keratitis, corneal ulcer, contact-lens red eye
- HSV dendrite, HZO with eye signs
- Iritis, scleritis
- Hyphaema
- Retinal detachment, vitreous haemorrhage
- Optic neuritis, retinal vein occlusion
- Rust ring, deep or central FB
Treat and discharge
- Conjunctivitis (infective, allergic)
- Subconjunctival haemorrhage
- Episcleritis
- Simple corneal abrasion
- Removed superficial FB
- Arc eye
- Stye, chalazion, blepharitis, preseptal cellulitis (adult, well)
The urgent care "never" list
Never send a patient home with local anaesthetic drops (they mask injury and stop healing)
Never start steroid eye drops in urgent care
Never pad an eye with a possible penetrating injury
Never skip or forget to document VA
Never discharge a high-velocity FB injury without imaging
Never use fluorescein with soft contact lenses in (permanent staining)
Discharge advice checklist
- Driving: not until vision has returned to normal, after dilating drops have worn off, and never wearing an eye patch. Patients must meet the DVLA visual standards.
- Contact lenses: out until fully settled and symptom-free.
- How to use ointment: pull the lower lid down, apply into the pocket, close the eye for a minute or two.
- Return if: vision worsens, pain increases, light sensitivity, a white spot on the eye, or not improving in 24–48 h.
QRPatient leaflets — scan & go
Official NHS pages. Tap “Show to patient” to make the code full screen.
Practise it on Need for Bleep
The single-condition pages have the decision pathway, model note, prescriptions with BNF links and leaflets.
Red eye & conjunctivitisConjunctivitis is a diagnosis of exclusion — check acuity and pain first.Practice pathway · prescriptions · QR leafletsCorneal abrasion & eye foreign bodyFluorescein, evert the lid — and never miss the penetrating injury.Practice pathway · prescriptions · QR leafletsShinglesWho gets aciclovir, and the shingles you must send to eyes.Practice pathway · prescriptions · QR leafletsSinusitisViral until day 10 — and don’t miss the orbit.Practice pathway · prescriptions · QR leafletsHeadacheScreen SNOOP, then treat tension and migraine well — and avoid opioids.Practice pathway · prescriptions · QR leaflets
6Document it
A model note for revision practice. Copy, then adapt to the case.
Eye problem — clinic note
PC: [R/L/both] eye – [redness / pain / reduced vision / injury] for [duration]
HPC: Onset [sudden/gradual]. Pain [Y/N], photophobia [Y/N], discharge [type],
itch [Y/N]. Flashes/floaters/curtain [Y/N]. Trauma: [mechanism, high-velocity Y/N,
chemical Y/N]. Contact lenses [Y/N]. Previous eye problems/surgery [ ].
PMH [ ] DH [ ] (anticoagulant Y/N) Allergies [ ] Job/driver [ ]
O/E:
VA (Snellen, own glasses/pinhole): R 6/__ L 6/__
Lids/face: [ ]
Conjunctiva: [diffuse / sectoral / ciliary flush / haemorrhage]
Cornea + fluorescein: [clear / abrasion size & site / dendrite / FB / ulcer]
Lids everted: [no FB]
Anterior chamber: [clear / hyphaema / hypopyon]
Pupils: [equal, reactive, no RAPD]
Eye movements: [full, no diplopia, painless]
Fundus/red reflex: [ ]
Impression: [diagnosis]
Red flags excluded: [reduced VA, RAPD, penetration, chemical, contact lens keratitis]
Plan:
- [treatment, dose, duration]
- Advice: no driving until vision normal; contact lenses out; ointment technique
- Safety-net: return if worse vision, increasing pain, photophobia, not better 24–48 h
- [Referred to on-call ophthalmology – name/time/plan agreed]
Revision use only. This page is for learning and exam preparation, not for live patient care. Always follow your local trust pathways, the BNF for prescribing, and senior or ophthalmology advice. Guidelines linked above were checked October 2026; some NHS Scotland pages are flagged by their authors as due for update.