Red Eye
Red Flags — Any one of these requires immediate action before continuing history
| Red flag | Why dangerous | Action |
|---|---|---|
| Severe unilateral pain + halos + vomiting + fixed dilated pupil | Acute Angle Closure Glaucoma (AACG) — IOP can reach 60–80 mmHg; optic nerve damage occurs within hours. Irreversible blindness without emergency treatment. | 999 immediately |
| Chemical splash to eye (especially alkali: bleach, cement, ammonia) | Alkali liquefies proteins and penetrates to anterior chamber within minutes. Permanent corneal scarring and blindness if not irrigated immediately for 15 min minimum. | Irrigate 15 min now + 999 |
| Contact lens wearer + pain + photophobia + reduced VA | Microbial keratitis (Pseudomonas, Acanthamoeba) — can cause corneal perforation within 24 hours without aggressive antibiotic treatment. Same-day ophthalmology essential. | Same-day ophthalmology |
| Hypopyon visible (white fluid layer in anterior chamber) | Endophthalmitis or severe uveitis — ophthalmic emergency. Vision loss can occur within 24–48 hours without intravitreal antibiotics. | Emergency ophthalmology |
| Corneal opacity or white infiltrate visible to naked eye | Bacterial or Acanthamoeba keratitis with established corneal infiltrate. Corneal scarring and perforation risk. Requires intensive topical antibiotics under ophthalmological supervision. | Same-day ophthalmology |
| Post-operative red eye (within 6 weeks of intraocular surgery) | Endophthalmitis — devastating infection of the vitreous cavity. Commonest after cataract surgery. Presents with severe pain, reduced VA, hypopyon. Emergency intravitreal antibiotics needed. | Emergency ophthalmology |
| VA <6/12 in affected eye on Snellen testing | Any unexplained visual loss = urgent referral threshold. Keratitis, uveitis, AACG all reduce VA. Visual loss not explained by simple conjunctivitis must be investigated immediately. | Same-day ophthalmology |
| Penetrating eye injury or trauma | Open globe injury — do NOT apply pressure. Risk of vitreous prolapse, endophthalmitis, permanent blindness. Shield the eye and transfer immediately. | 999 — do not press |
Safeguarding Considerations — Red Eye in Context
🏠 Domestic Violence — Periorbital Injury
- Periorbital bruising, subconjunctival haemorrhage, or blunt ocular trauma with inconsistent or vague mechanism → safeguarding concern
- Use DASH tool: "Does anyone make you feel frightened or unsafe at home?"
- Document injuries photographically if possible. Follow MARAC pathway if DASH ≥14
- Never promise confidentiality before the patient discloses
👴 Non-Accidental Injury in Children
- Bilateral retinal haemorrhages in an infant = non-accidental injury (shaken baby syndrome) until proven otherwise
- Ophthalmoscopy mandatory if NAI suspected — dilated fundoscopy by ophthalmologist
- Any red eye in a child with unexplained bruising or delayed presentation → paediatric safeguarding referral
- Do not discharge the child without a safeguarding plan if NAI suspected
👴 Self-Harm — Chemical or Foreign Body
- Chemical injury to the eye can be a form of self-harm, particularly in patients with known mental illness or in crisis
- Screen sensitively: mental health history, current stressors, PHQ-2
- If self-harm suspected: refer to psychiatry / crisis team after ophthalmological treatment
- Do not discharge without a safety plan and documented risk assessment
💊 Occupational Exposure & Work Safety
- Chemical eye injury in the workplace may indicate inadequate PPE provision — this is a Health and Safety (RIDDOR) reportable incident
- Advise patient of their employer’s duty to provide appropriate eye protection
- Fit note may be required if reduced VA impairs ability to work safely
- For healthcare workers with viral conjunctivitis: exclude from direct patient contact until discharge has resolved
- Not asking about VA early in the history — VA is the single most important discriminator
- Missing the contact lens detail — the key risk factor for keratitis
- Not asking about photophobia — distinguishes conjunctivitis from keratitis / uveitis
- Asking about information already in the stem (e.g. “do you wear contact lenses?”)
- Not eliciting all three ICE components
999 / Same-Day Emergency Ophthalmology
Act within minutes- Acute Angle Closure Glaucoma: severe pain + halos + vomiting + fixed dilated pupilIOP 60–80 mmHg → irreversible optic nerve damage within hours → 999 immediately; pilocarpine 2% if available, IV acetazolamide at hospital
- Chemical splash (especially alkali)Irrigate copiously with normal saline or water for 15 min minimum without delay; then 999 or blue-light transfer to ophthalmology / A&E
- Penetrating eye injury / open globeDo NOT press or pad the eye — risk of vitreous prolapse; shield only; 999; nil by mouth in case of surgery
- Hypopyon (white level in anterior chamber visible)Endophthalmitis / severe uveitis → intravitreal antibiotics without delay → emergency ophthalmology
- Post-operative red eye within 6 weeks of intraocular surgeryEndophthalmitis → same-day emergency ophthalmology; intravitreal vancomycin + ceftazidime
Same-Day Ophthalmology Referral
Within 24 hours- Contact lens wearer + pain + photophobia + reduced VAMicrobial keratitis → same-day ophthalmology; stop contact lenses immediately; no antibiotic drops until corneal scrapes taken
- Anterior uveitis / iritis: circumcorneal flush, photophobia, irregular pupilSame-day ophthalmology; topical cyclopentolate + steroids under specialist guidance only
- Corneal opacity or white infiltrate visible to naked eyeCorneal ulcer / keratitis with infiltrate → same-day ophthalmology; corneal scrapes before initiating antibiotics
- VA <6/12 in affected eye not explained by refractive errorUrgent ophthalmology referral — any unexplained visual loss requires slit-lamp assessment
- Herpes simplex keratitis (dendritic ulcer on fluorescein)Aciclovir 3% ointment 5× daily; urgent ophthalmology; NEVER topical steroids alone
Primary Care Management
GP / pharmacist- Bacterial conjunctivitis (mucopurulent discharge, VA normal, no pain, no photophobia)Chloramphenicol 0.5% drops QDS (or fusidic acid 1% gel BD); self-limiting in 7–14 days; hygiene measures; review if no improvement at 1 week
- Viral conjunctivitis (watery discharge, recent URTI, bilateral, follicles)Self-limiting; cool compresses; hand hygiene; no antibiotics unless secondary infection; 2–3 weeks resolution; healthcare workers: exclude from work while symptomatic
- Allergic conjunctivitis (itch, bilateral, seasonal, atopy, VA normal)Olopatadine 0.1% BD or sodium cromoglicate 2% QDS; oral antihistamine if rhinitis; allergen avoidance; cool compresses
- Dry eye syndrome (bilateral, gritty, worse evening, screen use, VA normal)Hypromellose 0.3% QDS; 20-20-20 rule; optician review; preservative-free drops if frequent use
- Subconjunctival haemorrhage (painless, unilateral, sharp red patch, VA normal)Reassure: fully resolves in 2–3 weeks; no treatment; check BP; check INR if anticoagulated
- Blepharitis (lid margin inflammation, flaky debris, both eyes, chronic)Lid hygiene (warm compress + cotton bud cleaning) twice daily; long-term management; fusidic acid if infected; doxycycline if rosacea-associated
- Prescribing chloramphenicol drops to a CL wearer with pain + reduced VA without ophthalmology referral
- Not advising cessation of contact lens wear immediately
- Prescribing topical steroids for an undifferentiated red eye in primary care
- Discharging without safety-netting the signs of worsening / AACG
- Instilling drops before testing VA — drops alter the examination
- Not examining both eyes (bilaterality is a key diagnostic sign)
- Skipping pupillary reactions when AACG or uveitis is possible
- Not testing VA before instilling any treatment drops
- Taking corneal scrapes in primary care — this is an ophthalmological procedure
- Starting antibiotics in a CL wearer before ophthalmology review (masks organism on scrapes)
"The redness and pain in your eye, combined with the slightly blurry vision, is concerning me because you wear contact lenses. There’s a specific type of infection called keratitis — that’s an infection of the clear surface at the front of your eye, the cornea. Contact lenses, especially when worn overnight, create the perfect conditions for this type of infection. I can’t fully assess this without the specialist equipment they have at the eye hospital, so I’m going to refer you to be seen there today. I know that sounds worrying — most people who are seen promptly do very well — but it is important we don’t delay. Please stop wearing your contact lenses right now and don’t put them back in until the specialist says it’s safe."
"I thought it was just conjunctivitis — can’t I just have some antibiotic drops?"
"It might well turn out to be something mild — but the combination of the blurriness and the pain, especially given you wear contact lenses, means I can’t be sure without a specialist look. The problem with just giving drops without knowing what’s happening at the surface of your eye is that we could make things worse if it turns out to be a particular type of infection. I’d rather be cautious today and know you’re safe."
"Am I going to lose my sight?"
"I completely understand why that’s your first thought — the eye is precious and of course you’re worried. The good news is that most cases of contact lens keratitis, when they’re picked up early and treated promptly, do resolve well. By coming in today and acting quickly, you’re doing exactly the right thing. The specialist today will be able to tell you much more once they’ve examined your eye properly."
Bacterial Conjunctivitis
Mucopurulent discharge · lid crusting in morning · VA 6/6 · no photophobia · self-limiting 7–14 days
Viral Conjunctivitis
Watery discharge · recent URTI · follicles on everted lid · preauricular node · bilateral spread · no antibiotics
Allergic Conjunctivitis
Bilateral itch · seasonal · atopy · pale boggy conjunctiva · VA 6/6 · antihistamine drops
Subconjunctival Haemorrhage
Painless · unilateral · sharp red sector · alarming but benign · VA 6/6 · resolves 2–3 weeks
Dry Eye Syndrome
Bilateral gritty · worse evening · screen use · VA 6/6 · artificial tears
Blepharitis
Lid margin inflammation · flaky debris · chronic · lid hygiene · rosacea-associated
Anterior Uveitis / Iritis
Circumcorneal flush · photophobia · irregular pupil · deep pain · reduced VA · HLA-B27 / IBD association
Keratitis (CL-associated)
Pain + photophobia + reduced VA + CL history · white infiltrate · same-day ophthalmology · corneal scrapes
HSV Keratitis
Dendritic ulcer on fluorescein · previous cold sores · reduced VA · aciclovir 3% ointment + urgent ophth
Scleritis
Severe deep boring pain · tender to touch · scleral nodule · associated RA / Wegener’s · urgent ophthalmology
Acute Angle Closure Glaucoma
Severe pain · halos · vomiting · fixed dilated pupil · hard globe · IOP >50 → 999
Endophthalmitis
Severe pain · hypopyon · reduced VA · post-op or post-injection → intravitreal antibiotics within hours
Chemical Injury
Alkali splash → irrigate 15 min immediately → 999 · do not delay for any reason
Orbital Cellulitis
Proptosis · restricted eye movement · fever · periorbital oedema → CT orbit + IV antibiotics → 999
- Diagnosing “conjunctivitis” without considering keratitis in a CL wearer with pain and reduced VA
- Not addressing the blindness concern explicitly
- Providing a diagnosis without inviting questions or chunk-and-check
- Prescribing topical steroids for suspected HSV or undifferentiated keratitis
- Starting antibiotic drops in a CL wearer before ophthalmology scrapes
- Not advising cessation of CL wear as part of the referral safety advice
Validate — name the expectation
Most patients with a red eye expect antibiotic drops as a matter of course. This expectation is so embedded it is rarely even verbalised — which is why you must name it before the plan.
"You’ve probably come in expecting antibiotic eye drops, which I completely understand — most people do with a red eye."Explain — share your clinical reasoning
Explain why antibiotics are or are not the right answer in this specific case. Patients respond to the reasoning, not the refusal.
"In your case, because of the blurriness and your contact lenses, I actually need the specialists to look at your eye first — starting drops now could make it harder for them to identify what’s causing this."Negotiate — offer something today
Even if antibiotic drops are not appropriate, there is always something you can offer: a clear plan, a referral, advice on hygiene and comfort measures.
"What I can do today is get you seen at the eye clinic this afternoon. I’ll also give you some advice on what you can do in the meantime to keep comfortable."Contact lenses create a hypoxic microenvironment, reduce corneal epithelial integrity, and act as a vector for bacterial adherence (Pseudomonas has high affinity for CL material). Overnight wear further reduces oxygen delivery to an already compromised cornea.
Stop lenses today. Discard current lenses and case. Do not resume wearing until ophthalmology explicitly clears you. Switch to daily disposables after recovery. Never sleep in lenses. Never rinse case with tap water (Acanthamoeba risk).
Adenoviral conjunctivitis is highly contagious (fomite transmission on shared towels, pillow cases, hands). Can survive on surfaces for up to 49 days. Secondary spread to household contacts and through healthcare settings is common.
Dedicated personal towel. Do not share eye makeup. Avoid rubbing the eye. Healthcare workers and nursery staff must be excluded from work while symptomatic with viral conjunctivitis.
Vasoconstriction reduces hyperaemia and reduces mast cell degranulation in allergic conjunctivitis. Reduces lid oedema and provides symptomatic relief in viral conjunctivitis. Lubrication helps remove discharge in bacterial conjunctivitis.
Use a clean, cool, damp flannel held gently over closed eyelids for 10 minutes, 4 times a day. For allergic: refrigerated artificial tears applied QDS also reduce itch. Do not use hot compresses unless blepharitis (opposite effect in conjunctivitis).
Eye rubbing in allergic conjunctivitis causes mechanical mast cell degranulation, amplifying the allergic response. In keratoconus or post-LASIK corneas, rubbing causes progressive corneal ectasia. In keratitis, rubbing spreads the organism and worsens epithelial damage.
Teach patient to use cool compress instead of rubbing. Antihistamine drops reduce itch (trigger for rubbing). In children: consider nighttime cotton mittens. Alert any allergy patient about keratoconus risk from chronic rubbing.
Blepharitis is caused by Staphylococcal colonisation of the lid margin and meibomian gland dysfunction. Warm compresses liquefy the inspissated meibomian secretions. Lid scrubs remove the colonising organisms and keratin debris.
Warm compress (warm flannel) over closed eyelids for 2 minutes. Then gently scrub the lid margin with cotton bud dipped in diluted baby shampoo (1:10 in boiled cooled water) or proprietary lid wipes (Blephasol). Twice daily long-term.
Prolonged screen use reduces blink rate from ~15/min to ~5/min, reducing tear film replenishment. This causes aqueous tear deficiency and evaporative dry eye, both of which cause red, gritty, uncomfortable eyes that mimic conjunctivitis.
20-20-20 rule: every 20 minutes, look at something 20 feet away for 20 seconds. Position screen below eye level (reduces palpebral fissure width = less evaporation). Use preservative-free artificial tears QDS if symptoms frequent.
- First-line: Chloramphenicol 0.5% drops — QDS for 5–7 days; or 1% ointment at night
- Alternative: Fusidic acid 1% gel BD (better tolerance; used especially in pregnancy)
- Self-limiting in 7–14 days — antibiotics shorten course by 1–2 days only (NNT high)
- Do NOT prescribe for viral or allergic conjunctivitis — antibiotic stewardship
- Olopatadine 0.1% drops — BD; dual action: antihistamine + mast cell stabiliser; faster onset
- Sodium cromoglicate 2% drops — QDS; mast cell stabiliser; takes 2–4 weeks for full effect; better for long-term prevention
- Add oral antihistamine (cetirizine or loratadine) if rhinitis coexists
- Avoid allergen; cool compresses; no rubbing; refrigerate drops for extra relief
- Topical steroids (dexamethasone, prednisolone) in primary care — risk of: steroid glaucoma, herpes simplex dendritic ulcer expansion, fungal keratitis, cataract. Never prescribe for undifferentiated red eye.
- Combined antibiotic + steroid drops (e.g. Maxitrol) — equally dangerous without a confirmed bacterial + inflammatory diagnosis
- Oral steroids for ocular disease — only under specialist guidance
- Aciclovir 3% ophthalmic ointment — 5 times daily for 7–10 days (licensed indication); within 48h window
- Urgent ophthalmology referral required alongside — slit-lamp confirmation of dendritic pattern
- After 2+ episodes: prophylactic oral aciclovir 400mg BD may be considered (ophthalmology decision)
- NEVER add topical steroids without concurrent antiviral and ophthalmology cover
- Hypromellose 0.3% (HPMC) — artificial tear; QDS or more frequently; suitable for frequent use
- Preservative-free formulations preferred if using >4 times/day (e.g. Minims or unit-dose preservative-free)
- Carbomer 0.2% gel (Viscotears) — longer-lasting; useful at night
- For blepharitis + dry eye: lid hygiene + lubricant; consider omega-3 supplements (modest evidence)
Select confirmed diagnosis — drug card highlighted below ↓
"These drops will help clear up the infection. Put one drop in your lower eyelid four times a day for 5 to 7 days, wash your hands before and after, and don’t share them with anyone. Your eye should start to improve within 2–3 days — if it doesn’t, come back."
SCA: Warn about viral conjunctivitis resistance — antibiotics are not needed and will not help if the cause is viral. If prescribing, explain the rationale. Healthcare workers with bacterial conjunctivitis must still follow exclusion guidance.
"These drops prevent the allergic reaction rather than just treating it. They do take a couple of weeks to build up to full effect, so it’s important to use them regularly even when your symptoms are mild. Take your lenses out before using them."
SCA: The delayed onset is a key counselling point — patients who stop because they don’t feel immediate relief will not benefit. This scores counselling and adherence marks.
"These drops work in two ways — they block the allergic reaction and prevent it from starting. Take your contact lenses out first, put one drop in each eye morning and evening, and wait 15 minutes before putting your lenses back in. Keeping them in the fridge can help with the itching."
SCA: Distinguishing cromoglicate (preventive, delayed onset) from olopatadine (faster acting, dual mechanism) demonstrates clinical depth and scores prescribing knowledge marks.
"This ointment treats the virus causing the problem on the surface of your eye. You need to apply it 5 times a day — I know that’s quite frequent. It will blur your vision for a few minutes after each application, which is normal. Keep going for the full course even if your eye feels better."
SCA: The “never topical steroids without antivirals in HSV” rule is a high-yield safety knowledge point. If asked about steroids, the answer is unambiguous: not in primary care, not without ophthalmology, never without antiviral cover in HSV.
"These are artificial tear drops — they top up your natural tears and relieve the dryness and grittiness. There’s no limit on how often you can use them. Try the 20-20-20 rule for screen work: every 20 minutes, look 20 feet away for 20 seconds — that helps your eyes rest and blink more."
SCA: Linking dry eye to the patient’s screen use and explaining the mechanism (reduced blink rate) demonstrates clinical depth. Recommending preservative-free drops if using frequently shows prescribing safety awareness.
"This antibiotic gel treats the bacterial infection in your eye. It’s only twice a day, which is easier to remember. Apply it to your lower eyelid morning and evening, wash your hands before and after, and finish the whole course."
SCA: Being able to offer fusidic acid as an alternative to chloramphenicol (and knowing when to prefer it, e.g. pregnancy, children, BD for adherence) demonstrates prescribing knowledge depth and scores Tasks domain marks.
Work & Occupation
Viral conjunctivitis is highly contagious via fomite transmission. Healthcare workers, nursery teachers, and food handlers must be excluded from direct patient, child or food contact until discharge has fully resolved.
For office / screen workers: reduced VA + photophobia impairs computer work. Phased return or temporary adjustments may be needed. Occupational health referral if significant impact on function.
"Does your work involve contact with patients or children? While you have this, I’d advise you not to go in — I can give you a sick note for today."Driving & DVLA
VA <6/12 in the better eye — cannot legally drive a Group 1 vehicle in the UK. If the unaffected eye meets the standard, short-term driving may continue but advise caution with depth perception from monocular effects.
For commercial vehicle drivers (HGV, LGV): stricter VA requirements. Any significant or prolonged visual impairment may require DVLA notification if bilateral or persistent.
"If your vision feels blurry, please don’t drive today — it’s not safe and could be an offence if your vision doesn’t meet the driving standard."Contact Lens Identity & Loss
For many young people, contact lens use is integral to daily life and identity (sport, appearance, social confidence, freedom from glasses). Being told to stop wearing lenses — potentially long-term — can provoke genuine anxiety and distress.
Acknowledge this explicitly. Reassure that most people can resume lenses safely after full recovery. Recommend daily disposables and a better wearing schedule. Optometrist review on discharge.
"I know stopping your lenses is a big deal — it affects so much of your daily life. The goal is to get your eye right so you can wear them again safely in the future."Spread to Family Members
Viral conjunctivitis is highly contagious. Partners, children and household members are at risk. Patients who do not receive clear prevention advice frequently cause secondary cases within the family within 48 hours.
Advise: separate towels, pillow cases, washcloths. No sharing eye makeup. Avoid touching the eye then touching surfaces. The adenovirus can survive on surfaces for weeks.
"To protect your family, please use a dedicated towel just for your face and don’t share anything that touches your eyes. Wash your hands very carefully whenever you touch your eye."Cosmesis & Appearance
A severely red or bloodshot eye — especially a subconjunctival haemorrhage — can be cosmetically alarming and cause significant social anxiety, embarrassment and concern. Patients may present primarily because of how the eye looks rather than any symptom.
Subconjunctival haemorrhage: explicitly reassure it is benign and will fully resolve. Bacterial conjunctivitis: reassure that discharge resolves within days on treatment.
"I understand it looks quite alarming — people tend to stare! But I can reassure you it’s completely harmless and will clear up on its own over about 2 to 3 weeks."Fear of Blindness
Eye symptoms — even mild ones — generate disproportionate fear of blindness. This is rational (the eye is precious and irreplaceable) but often goes unvoiced. Patients with keratitis or uveitis may be terrified but not say so.
Name the fear directly. Provide proportionate reassurance that includes the caveat: the key is acting promptly. Late presentation carries more risk than early presentation.
"I can see this is very worrying — and it’s completely understandable to be scared about your eyesight. The most important thing is that you’ve come in today. Most people who act quickly do very well."48 hours — Treatment response check (bacterial conjunctivitis)
Phone or F2F: is the discharge reducing? VA still 6/6? Any new photophobia or pain (would suggest keratitis / uveitis developing)? If no improvement in 48h or worsening: immediate ophthalmology referral.
1 week — Review if not resolved (all conjunctivitis)
Bacterial conjunctivitis should resolve within 7–14 days. Viral takes up to 3 weeks. If not resolving by 1 week: review diagnosis; consider chronic aetiology (blepharitis, dry eye, chlamydial, trachoma). Re-examine, check VA, evert lids.
Ophthalmology follow-up — as directed by specialist
For keratitis: daily review initially (to check corneal healing); then weekly. For uveitis: follow-up within ophthalmology for slit-lamp IOP monitoring and steroid tapering. GP’s role: manage systemic comorbidities, medication monitoring.
Optometrist review — 4–6 weeks post-resolution (CL wearers)
Contact lens wearers should not resume lenses until ophthalmology-cleared and seen by optometrist. Review lens type (switch to daily disposables), wearing schedule (reduce to max 12h/day), lens care regimen, and corneal topography if keratitis caused significant scarring.
Systemic follow-up — for uveitis with HLA-B27 associations
Refer to rheumatology if HLA-B27 positive (screen for AS, Reiter’s). Refer to gastroenterology if IBD symptoms. Annual ophthalmology review for patients with recurrent uveitis on systemic immunosuppression (methotrexate, azathioprine — LFT/FBC monitoring).
Memory rule — VISION monitoring framework
V — Visual acuity: document at each visit; target return to baseline
I — Infection response: is the discharge reducing? Is the cornea clearing on fluorescein?
S — Systemic disease: is uveitis linked to AS, IBD, Reiter’s? HLA-B27 result?
I — IOP (intraocular pressure): target <21 mmHg; recheck if on topical steroids (risk of steroid glaucoma)
O — Ophthalmology review: is follow-up secured? Date confirmed?
N — Non-pharmacological: CL cessation maintained? Lid hygiene? Fomite precautions in place?
⚠ Three scenario-specific safety-netting phrases
Why safety-netting matters beyond the consultation
- Prescribing topical steroids for undifferentiated red eye — unacceptable in primary care
- Starting antibiotic drops in a CL wearer with pain before ophthalmology scrapes
- Not advising contact lens cessation — critical patient safety intervention
- AACG symptoms not covered in safety-netting (halos + severe pain + vomiting)
- Not acknowledging the blindness concern — must be named and addressed
- No explicit follow-up timeframe offered
- VA tested before any drops instilled
- Red flags elicited and acted upon appropriately
- Correct triage: CL wearer + pain + reduced VA = same-day ophthalmology
- Contact lens cessation explicitly advised
- Safety-netting: AACG symptoms + keratitis worsening named specifically
- Blindness concern named and directly addressed
- ICE explored and referenced in the management plan
- CL cessation impact acknowledged empathetically
- Antibiotic expectation addressed without dismissing
- Plain English throughout; shared decision making
- Closing question asked: “Is there anything else?”
Who you are
Aisha, 28. Graphic designer working full-time from home. Wears monthly contact lenses for 5 years. Active social life; wears lenses 14–16 hours/day and admits to sleeping in them “occasionally” when she falls asleep on the sofa.
Hidden agenda
Terrified of going blind — her grandmother lost vision in one eye from glaucoma. She has been researching symptoms online and is scared it might be “something serious in my eye”. Will only disclose this fear if the GP asks directly about concerns.
Symptoms if asked directly
- Right eye: moderately painful (5/10), worse when blinking and in bright light
- Vision: slightly blurry right eye, clear left eye (she can tell the difference)
- Discharge: slight watery/mucopurulent (if pressed: “a bit sticky in the morning”)
- No halos, no vomiting, no nausea with the pain (AACG screen negative)
- No previous episodes; no URTI; no joint problems
Trigger for resolution
- Responds positively if the GP directly names the blindness concern and addresses it
- Worried about the referral — asks: “Is it really necessary to go to hospital? I’ve got a busy afternoon.”
- Accepts plan when GP explains the specific risk of contact lens-related corneal infection clearly
- Asks about contact lenses: “Will I ever be able to wear them again?”
Resolution: The patient accepts the plan and becomes cooperative if: (1) the GP directly names and addresses the blindness concern rather than ignoring it, (2) the specific risk of contact lens-associated keratitis is explained in plain language, and (3) the patient is explicitly told she can wear lenses again safely in the future if she follows the right advice. Dismissal or generic responses will result in the patient becoming resistant.
- Severe pain + halos + vomiting + fixed dilated pupil (AACG)
- Chemical splash (alkali or acid) → irrigate immediately first
- Open globe / penetrating injury
- Hypopyon visible (endophthalmitis)
- Post-operative red eye within 6 weeks
- CL wearer + pain + photophobia + reduced VA (keratitis)
- Anterior uveitis: circumcorneal flush, photophobia, irregular pupil
- Dendritic ulcer on fluorescein (HSV keratitis)
- VA <6/12 unexplained
- Corneal opacity or white infiltrate visible
- Bacterial conjunctivitis: mucopurulent discharge, VA 6/6, no pain, no photophobia
- Viral conjunctivitis: watery, bilateral, URTI, follicles
- Allergic: bilateral itch, seasonal, atopy
- Dry eye, blepharitis, subconjunctival haemorrhage
✓ Pupil reactions (direct + consensual + RAPD)
✓ Pattern of injection (diffuse vs circumcorneal / ciliary flush)
✓ Cornea: opacity? infiltrate? (naked eye + torch)
✓ Lid eversion: follicles (viral) vs papillae (bacterial/allergic)
✓ Fluorescein if available: dendritic = HSV; ring = Acanthamoeba
✓ Preauricular lymph node: positive = viral (adenoviral)
Watery discharge + URTI + bilateral + follicles = viral conj
Bilateral itch + seasonal + atopy + no discharge = allergic
Pain + photophobia + CL wear + reduced VA = keratitis
Deep pain + circumcorneal flush + irregular pupil = uveitis
Severe pain + halos + vomiting + fixed pupil = AACG
Painless + sector red + VA 6/6 = subconj haemorrhage
Viral conj: Supportive only — cool compresses; hand hygiene; no antibiotics
Allergic: Olopatadine 0.1% BD or sodium cromoglicate 2% QDS
Dry eye: Hypromellose 0.3% QDS; preservative-free if >4×/day
Blepharitis: Lid hygiene (warm compress + lid scrubs) BD; fusidic acid to lid margin if infected
Subconj haemorrhage: Reassure; no treatment; check BP; resolves 2–3 weeks
Risk: steroid glaucoma, HSV dendritic ulcer expansion, fungal keratitis, cataract
✗ Combined antibiotic + steroid (Maxitrol, Tobradex)
Same risks; equally contraindicated in undifferentiated red eye
✗ Antibiotics before corneal scrapes in suspected keratitis
Masks organism; reduces diagnostic yield from >70% to <30%
| Condition / Drug | Monitor | Timing | Action threshold |
|---|---|---|---|
| Bacterial conj (chloramphenicol) | Symptom response | 48h call; 1 week if needed | No improvement → same-day ophth; consider chlamydial screen |
| HSV keratitis (aciclovir ointment) | VA + fluorescein (ophthalmology) | Daily initially | Ulcer not healing at 7 days → consider resistance; ophthalmology intensifies |
| Uveitis (topical steroids — ophth) | VA + IOP (ophthalmology) | Weekly until controlled | IOP >21 on steroids → add topical beta-blocker; switch steroid formulation |
| Allergic conj (olopatadine) | Symptom severity score | 4–6 weeks | Ongoing severe symptoms → add oral antihistamine; allergy referral |
| Systemic immunosuppression (recurrent uveitis) | FBC + LFTs (methotrexate) | Every 3 months | LFT elevation / cytopenia → dose reduction; haematology / rheumatology review |
| Contact lens-associated keratitis | VA + corneal clarity | Daily ophth initially | VA not recovering at 2 weeks → consider corneal scarring; contact lens restriction long-term |