Protocol · WHO primary eye and ear care
Red eye, poor vision and ear problems
Most eye and ear problems seen at first-level care are minor and treatable, but a few threaten sight, hearing or life. Two simple habits catch them: measure distance vision in every eye complaint, and look behind the ear and at the face in every ear infection. Many cases of blindness and hearing loss are preventable.
- Based on WHO primary eye and ear care
- For doctors, clinical officers, nurses and community health workers
- Reviewed October 2026
1Who / when
- Adults and children with a red, painful, itchy or discharging eye, an eye injury, or difficulty seeing far or near.
- Anyone with ear pain, ear discharge, an itchy or blocked ear, something in the ear, or hearing loss. Children under 5: use the IMCI ear chart.
2Red flags: refer now
- Eye: sudden loss of vision; red eye with moderate or severe pain or reduced vision; chemical splash; penetrating injury or a foreign body you cannot remove; the whole eyelid or eyeball swollen; a baby under 3 months with swollen eyes and pus; a child whose eye looks abnormal (colour, shape, size, direction) or who does not follow a face or light; clouding of the cornea with measles.
- Ear: tender swelling behind the ear (mastoiditis); ear infection with severe headache, vomiting, drowsiness, stiff neck, fits, dizziness or facial weakness.
Irrigate firstChemical in the eye: wash it with clean water for at least 10 minutes before anything else, then refer urgently.
3Assess
Eye: measure distance vision first
- Use an E chart at 3 m, each eye separately, with the person's glasses on. Cannot see the 6/12 line: abnormal vision. Cannot see the 6/60 E: functionally blind.
- Ask: did it happen suddenly or gradually? Pain, discharge, itch, injury?
- Look at lids, lashes (turned in?), conjunctiva, cornea (clear?) and pupil. Near vision if they struggle to read.
Ear: look at both ears
- Ask about pain, discharge and for how long, hearing, dizziness. Feel behind the ear for tender swelling. Look at the face for weakness.
- With an otoscope or torch: wax, foreign body, swollen canal, pus, a red or bulging ear drum, or a hole in it. Dry-mop pus first to see.
- Check hearing once an infection has cleared (simple tests, or the WHO hearWHOpro app).
4Classify
| Finding | Classify as | Action |
|---|---|---|
| Red eye, vision normal, pus discharge | Conjunctivitis | Clean; antibiotic eye drops or tetracycline ointment; refer urgently if worse or unchanged in 2 days |
| Red, itchy, watering eye, vision normal | Allergic conjunctivitis | Cold water washes; allergy medicine |
| Red eye with mild pain, vision normal | Irritation | Painkiller, lubricating drops; refer urgently if worse or unchanged in 2 days |
| Red eye with moderate or severe pain, or vision reduced | Sight-threatening red eye | Painkiller and refer urgently |
| Vision below 6/12, gradual | Poor vision (refractive error, cataract, glaucoma) | Refer; reading glasses if only near vision is poor |
| Ear pain, or pus for less than 14 days | Acute ear infection | Antibiotic for 5 days, painkiller, dry the ear by wicking, review in 5 days |
| Pus from the ear for 14 days or more | Chronic ear infection (CSOM) | Wick, then quinolone ear drops 3 times a day for 2 weeks |
| Tender swelling behind the ear | Mastoiditis | First dose of antibiotic and painkiller; refer urgently |
5Treat
Eye
- Eye discharge: wash hands, wipe away pus with a clean wet cloth, then apply tetracycline eye ointment 4 times a day until the discharge stops (IMCI). Put nothing else in the eye.
- Foreign body you can see: remove with a moist cotton bud, then antibiotic drops. Cannot remove it: cover and refer urgently.
- Blow or knock to the eye: treat pain; if vision is abnormal or the eye is cut, shield it, give tetanus vaccine and refer urgently. Burns: ointment, cover, refer urgently.
- Lashes touching the eyeball: epilate or refer (in trachoma areas, for surgery). Crusted lid margins: clean the lashes, antibiotic ointment. Painful lid lump: warm compresses.
- Children: give vitamin A with measles or persistent diarrhoea (IMCI doses). Newborn eye discharge: clean, start antibiotic, refer.
Ear
- Dry wicking: roll clean soft tissue into a wick, insert it gently, remove when wet, repeat until dry. Do it 3 times a day. Do not wick if there is acute pain.
- Acute ear infection, child under 5: oral amoxicillin twice daily for 5 days (250 mg tablets: 4 to under 10 kg one, 10 to under 14 kg two, 14 to 19 kg three). Older children and adults: an antibiotic for 5 to 7 days if the drum bulges or has a hole, there is discharge or high fever, or no better after 2 days; dose per national formulary.
- Chronic discharge: wick, then quinolone drops (ciprofloxacin, norfloxacin or ofloxacin), or an antiseptic drop; keep the ear dry.
- Wax needs removal only if it blocks the canal: soften for 2 to 3 days, then wash out. Foreign body: wash out; drown an insect first with clean oil; refer seeds (they swell with water) and anything you cannot remove. Never use hooks or sharp instruments.
- Paracetamol for pain. Never put hot oil or home remedies in a painful ear.
6Follow-up
- Red eye or discharge: review in 2 days; refer urgently if worse or unchanged. Newborn and child eye discharge: refer if not improving in 3 days.
- Acute ear infection: review in 5 days; if still painful or discharging, 5 more days of the same antibiotic and keep wicking.
- Chronic ear infection: review in 1 week; check that the family is wicking correctly. Check hearing once the ear is dry.
7Counsel
- Do not put traditional medicines, oil or sticks in the eye or ear.
- Keep a discharging or perforated ear dry: water entering the ear can restart the infection.
- Children need their vision and hearing checked if they struggle at school or do not respond to sounds.
- Wear eye protection for welding, chemicals and other work that could injure the eyes.
Your child's ear is full of pus. Dry it three times a day with a clean tissue wick until the wick comes out dry, and then put in the drops. Come back in five days, or at once if the ear swells behind or your child becomes very sleepy.
8When to refer
- Urgently: any red flag above; chemical, burn or penetrating eye injury; sudden loss of vision; vision cannot see 6/60.
- Gradual loss of vision (below 6/12) for refraction, cataract or glaucoma assessment.
- Ear discharge that persists after treatment or smells foul; dizziness; hearing loss; a dry hole in the ear drum unchanged after 3 months.
- Ear canal infection spreading to the skin around the ear, or not responding to treatment.
- A child who fails a hearing check, or whose parents are worried about hearing.
9Sources
- World Health Organization Regional Office for Africa. Primary eye care training manual: a course to strengthen the capacity of health personnel to manage eye patients at primary-level health facilities in the African Region. 2018 (ISBN 9789290234067). Algorithms 1 to 5 (loss of vision, red eye, swelling and lashes, trauma, children 5 and under); 3 m E chart with 6/12 and 6/60 thresholds; 10-minute irrigation for chemical injury.
- World Health Organization. Primary ear and hearing care: training manual. 2023 (ISBN 9789240069152). Acute otitis media, CSOM, dry perforation, mastoiditis, complications needing urgent referral, dry mopping and wicking, wax, foreign bodies, otitis externa, hearWHO.
- World Health Organization. Integrated Management of Childhood Illness (IMCI) chart booklet. 2014. Ear problem classification; amoxicillin weight bands; wicking and quinolone drops; tetracycline eye ointment; vitamin A treatment with measles.
Adapted from WHO guidance; not endorsed by WHO. This page paraphrases and adapts the WHO publications listed under Sources, which are licensed CC BY-NC-SA 3.0 IGO; the adapted text is shared under the same licence for non-commercial education. Reasoning GP is not affiliated with WHO or any other organisation named here. Use it alongside your national guidelines, essential medicines list and formulary, and your clinical judgement. Doses are given only where they come from a WHO source; otherwise follow your national guideline or formulary.