Problem Characteristic

features
Refer to
opthal?
Management
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Penetrating
Injury
Hx, +/- FB in eye, tear drop
pupil, +/-drips of aqueous.
Examine VERY carefully
(risk of irreversible eye
damage)
same day
assessment
same day assessment if ANY suspicion of penetrating eye injury or
embeded FB.
tear to lid
margins /
damage to
lacrimal duct.
same day
assessment

Corneal
abrasion
Hx, fluoro examination GP
management
Check no hyphaema/deep damage, chloro oint q2h for 24h then q4h
for 7d. Oral analgesics if sig pain. No evidence for the use of eye
pads. Should heal in <48h. Only refer if: large abrasion (>60%), Pain
does not resolve after use of antibiotic ointment, Patient continues to
experience blurred vision or a reduction in visual acuity, Patient
continues to experience considerable pain, despite analgesics
Conjunctival /
corneal FB
Hx, visible FB may need to
refer
conjunctival FB: give LA drops and attempt to remove with cotton
wool bud, refer if h/o metal/glasses exposure. Prophylac chloramph.
2d, reexamine at 24h with fluoro. Corneal FB: more difficult to
remove, and caution as the cornea is very thin = refer. Refer if ocular
pain not relived by LA/hyphaema/irreg pupil/deep orbital lacerations
(suggests deeper eye injury) or corneal opacities or dec vis acuity or
persistent rust rings. F/U at 24 and 48h (check vis acuity/rust
rings/fluorescein drops to assess healing).
Chemical burns Hx: cement, lime, caustic
soda, ammonia
immediate /
same day
assessment
Flush with saline for 20mins. Refer immediately if acid/alkali/cement.
Otherwise refer for same day assessment of severe conjunctivitis.
Prophylac ABx 2d, reexamine at 24h with fluoro
UV light burns
(arc eye)
Hx, severe pain and
watering may develop
several hours after
exposure. Redness, pain,
blepharospasm,
photophobia, blurred vision,
sensation of FB in eye.
Cornea may show areas of
gross opacification -
Fluorescein staining shows
punctate
erosions which cover most
of the cornea causing gross
uptake of fluorescein.
Usually GP
management
LA drops x once only, cyclopentolate 1% drops, chlor drops q2h for
24, then q4h, pad the worst affected eye.give po analgesics (opiods).
Refer if not healed in 24 - 48h. Give pt worsening advice (see Dr if inc
pain/ flashing lights/dec vision)
Blunt injuries : Hx O/E: look for bld in ant
chamber. Look for an irreg
pupil/iris, check PERLA.
Immediate
referral
all pts with vis impairment after blunt injury shouold be referred.
subconjunctival
haem
look for signs of orbital
fracture: diplopia, recessed
eye, ipsilat epistaxis,
may need to
refer
check BP, check for other bleeding/bruising, check INR if on warfarin.
Refer if ANY h/o trauma


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Stye a localised abcess on the
eyelid: may be internal
(around an eyelash follicle)
or external (in a meibomian
gland). Unlike a chalazion it
IS painful.
GP
management
if around an eyelash remove the lash to facillitate drainge. hot
compresses and analgesia. CKS only recommend topical antibiotics if
there is an associated conjunctivitis
Chalzion ie a meibomian cyst a
sterile, chronic,
inflammatory granuloma
caused by the obstruction of
a Meibomian gland -> firm
painless nodule in the
eyelid. The majority of cases
resolve spontaneously but
some require surgical
drainage
GP
management
warm compresses for 15-30mins bd, The majority of cases resolve
spontaneously -takes about 6wks, but some require surgical drainage
refer if persists >3m
Dacrocystitis watering eye (epiphora),
swelling and erythema at
the inner canthus of the eye
GP
management
Management is with systemic antibiotics. Intravenous antibiotics are
indicated if there is associated periorbital cellulitis


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Infective
Conjunctivitis

sore, red eyes associated
with a sticky discharge
(seroud d/c and preauric LN
suggests viral)

usually GP
management

normally a self-limiting condition that usually settles without treatment
within 1-2 weeks. topical antibiotic therapy is commonly offered to
patients, e.g. Chloramphenicol. Chloramphenicol drops are given 2-3
hourly initially where as chloramphenicol ointment is given qds
initially. If pt is a contact lens wearer refer to optometrist to r/o
keratitis. If chlamydial swabs positive refer to GUM.
Neonatal
conjunctivitis
<4wks old same day
assessment
if..
refer for same day assessment if neonatal conjunctivitis (ie baby
<4wks old)
Allergic
conjunctivtis
sore, red, bilat, tichy eyes,
+/- h/o atopy.
GP
management
topical or systemic antihistamines, topical mast-cell stabilisers, e.g.
Sodium cromoglicate and nedocromil
Blepharitis Anterior blepharitis the
bases of the eyelashes on
anterior eyelid margin are
inflamed (eg staph
infection/seborrhoeic).
Posterior blepharitis the
posteriorly located
Meibomian glands on the
eyelie margin are
imflammed (due to dec
meibomian gland function).
2 types can coexist and can
be difficult to distinguish.
GP
management
use fluoro to check for keratitis (if present refer to opthal).
Otherwise...warm compresses, clean eyelid margin, +/- massage
meibomian glands +/- 6/52 trial of chloroamph ointment (to erradicate
staph) +/- oxytetracycline (esp if pt has rosacea). Refer of no
improvement in wks. Urgent referral if unilat not responding to Rx
(?SCC eyelid margin), urgent referral if corneal disease/dec
vision/blepharitis sec to undelying systemic disease (eg sjogrens).
Dry Eye feelings of dryness,
grittiness, foreign body
sensation, red eyes, staining
of cornea, soreness in both
eyes, which get worse
throughout the day, eyes
water, particularly when
exposed to wind, and reflex
tearing or blurring whilst
reading or driving, eyelids
stuck together on waking.
BUT NO abnormalities O/E.
GP
management
For mild or moderate symptoms artificial tears alone are usually
sufficient: First line treatment hypromellose 0.3% QDS 1/12
(cheaper to buy the OTC). If treatment with artificial tears does not
completely resolve the irritation, the patient may
additionally wish to use liquid paraffin based eye ointment before
sleeping - Lacri-Lube
or Lubri Tears eye ointment (available over the counter). NB Eye
ointments containing
paraffin may be uncomfortable and blur vision - should only be used
at night, and never
with contact lenses.


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Acute glaucoma severe pain (may be ocular
or headache), decreased
visual acuity, patient sees
haloes, semi-dilated pupil,
hazy cornea, tender hard
eye. May be pptd by
adrenergic/antimusc drugs.
Often occurs in the evening.
Immediate
referral

Corneal ulcers
(Keratitis): HSV
or bacterial (or
Pseud. in lens
wearers)
red, painful eye,
photophobia, epiphora,
visual acuity may be
decreased, fluorescein
staining may show an
epithelial ulcer: feathery
pattern suggests HSV
keratitis. In bacterial keratitis
may have corneal ulcers
due to trauma eg contact
lenses.
Immediate
referral

Herpes zoster
ophthalmicus
vesicular rash around the
eye, which may or may not
involve the actual eye itself,
Hutchinson's sign: rash on
the tip or side of the nose.
Indicates nasociliary
involvement and is a strong
risk factor for ocular
involvement.
.conjunctivitis, keratitis,
episcleritis, anterior uveitis
Immediate
referral
ocular involvement requires urgent ophthalmology review, oral
antiviral treatment for 7-10 days, ideally started within 72 hours. Oral
CS.
Scleritis, severe deep pain (may be
worse on movement) and
tenderness, +/- dec vision.
may be underlying
autoimmune disease e.g.
rheumatoid arthritis
Same day
assessment

Ant Uvetis
(Iritis)
acute onset, pain, blurred
vision and photophobia,
small, fixed oval pupil, ciliary
flush
Immediate
referral

Episcleritis: localised area of redness +/-
mild irritation/photophobia.
Distinguish from
conjunctivitis by lack of
involvement of the palpebral
conjunctivae. 15% devlop a
mild irritis
GP
management
usually self limiting. oral NSAID (eg diclofenac) 2/52 +/- artificial tears
if sl irritated. If this treatment doesn't keep the eye comfortable patient
should be seen by opthal within 2-3days. Beware risk of iritis.

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CRAO due to thromboembolism
(from atherosclerosis) or
arteritis (e.g. temporal
arteritis), features include
afferent pupillary defect,
'cherry red' spot on a pale
retina
Immediate
referral

ant isch optic
neuropathy due
to arteritis (TA)
or
atherosclerosis
altitudinal loss of vision. Sxs
of GCA/PMR or RFs for
atherosclerosis,
Immediate
referral
high dose pred for TA
CRVO/BRVO severe retinal
haemorrhages are usually
seen on fundoscopy, RFs:
glaucoma, polycythaemia,
hypertension
Immediate
referral

Vit Haem Large bleeds cause sudden
visual loss, Moderate
bleeds may be described as
numerous dark spot, Small
bleeds may cause floaters.
causes: diabetes, bleeding
disorders
Immediate
referral
[NB single longstanding floater with no flashes doesnt need urgent
ref, likely to be and old vit haem no acute threat]
Post vit detach flashes of light or floaters Immediate
referral

ret detach. Dense shadow that starts
peripherally progresses
towards the central vision,
A veil or curtain over the
field of vision, Straight lines
appear curved, Central
visual loss
Immediate
referral



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AACG severe pain: may be ocular
or headache, decreased
visual acuity, symptoms
worse with mydriasis (e.g.
watching TV in a dark
room), hard, red eye, haloes
around lights, semi-dilated
non-reacting pupil. corneal
oedema results in dull or
hazy cornea, systemic upset
may be seen, such as
nausea and vomiting and
even abdominal pain
Immediate
referral
reducing aqueous secretions with acetazolamide and inducing
pupillary constriction with topical pilocarpine
Optic neuritis unilateral decrease in visual
acuity over hours or days,
poor discrimination of
colours, 'red desaturation',
pain worse on eye
movement, relative afferent
pupillary defect, central
scotoma
refer neurol
post-op dec
pain and vision
Immediate
referral

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Wet ARMD reduced visual acuity:
'blurred', 'distorted' vision,
central vision is affected
first, central scotomas,
fundoscopy: drusen,
pigmentary changes
urgent
referral (to be
seen within
1wk)
stop smoking, consider vitamins, photocoag etc for wet ARMD



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Cataracts A dimming/blurring of vision.
Lights may appear too
bright, Glare from lamps or
the sun, Poor night vision.
Double vision or multiple
images in one eye, Dulled
colour vision,
Nearsightedness,
accompanied by frequent
changes in eyeglass
prescription
Refer to
optometrist
Refer children urgently, Young adults: look for DM/systemic disease,
then refer. In elderly refer to optician and then refer to opthal if no isg
improvement after new lens prescription (ie vis aciuty <6/9 after
correction with glasses)
ARMD asympt detected by
optometrist / gradual
painless blurring/loss of
central vision or c/o a
scotoma. O/E vis acuity, get
them to look at graph
paper/amsler chart
refer urgently
as per ARMD
fast track
pathway
should be seen within a week. Give pt worsening advice (if not seen
within one week or if worsening Sxs they shouod contact eye
casualty (or get in contact with you and you''ll chase it up!).. Advice
re diet/vitamins. Stop smoking.
COAG usually asympt until late in
the disease. Thus often
picked up incidentally on
eye testing (raised IOP and
large optic disc cup, visual
field loss.
refer
according to
the glaucoma/
ocular HTN
pathway