Benjamin Lin, M.D., Nicolas Yannuzzi, M.D., Jayanth Sridhar, M.D.
Here, you will find some of the most common eye complaints that present to primary care providers and emergency rooms and general guidelines on when ophthalmology should be consulted. This guide is NOT a comprehensive guide to all eye complaints that you will see. However, this is a good framework to get you thinking along the right lines.
These are the warning symptoms and history you should watch for when working up any eye patient:
- Acute loss of vision (either a partial visual field, or an entire eye)
- Sudden increase in flashers or floaters, curtain or shadow
- Eye pain
- Marked redness of eye
- Reduced visual acuity
- Photophobia
- Suspected foreign body or trauma
- Diplopia (double vision)
- Metamorphopsia (distortion of straight lines)
- Proptosis
- Ophthalmoplegia (incomplete movement of the eyes)
- Nystagmus
- Possibility of foreign bodies in the eye (e.g. patient was working with power tools – especially with metal on metal contact, under cars, or was in a very dusty environment)
Fundamentals for every patient
- Check the visual acuity!
- This is the key vital sign of ophthalmology. If you know nothing else about a patient, please check the visual acuity for your friendly neighborhood ophthalmology consultant. This is ideally done with a handheld or wall mounted eye chart, but it does not have to be perfect. In a pinch, document whether or not they can read printed text on a paper nearby or the distance at which they can count your fingers reliably. You can also use an app like EyeHandbook or print an offline near card to have a patient read, with reading glasses if they use them normally.
- Check the pupils for symmetry and responsiveness.
- Check extraocular muscles for full range of motion.
- Ask if they usually use glasses/contacts.
- Many people, especially in the emergency room, simply have blurry vision because they didn’t have time to grab their glasses or put in contacts before they came. Make sure to ask!
- Ask about and characterize the warning symptoms and history listed above
- Gather key history: See appropriate points below for each chief complaint
Chief complaint: “Red Eye”
Key history:
- Time course?
- Recent coughs/colds?
- Sick contacts?
- Light sensitivity?
- Contact lens use?
- Contact lens habits? (especially if they sleep in them or use them for longer than suggested if they use weekly or monthly lenses)
| Diagnosis | Key findings | Basic management |
| Viral conjunctivitis Viral infection of the eye (most commonly adenovirus) | Unilateral, diffuse conjunctival injection that can become bilateral. Profuse, watery discharge. May have recent cough/cold or sick contacts. Check for pseudomembranes. | Viral conjunctivitis is extremely contagious! Make sure to wear gloves during the exam, and wipe down the room and any exam equipment used. Educate patient about taking precautions to prevent spread of viral conjunctivitis. Look for mucous membranes by pulling down the lower lid. Refer urgently if pseudomembranes present. Otherwise, elective referral. |
| Allergic conjunctivitis IgE mediated hypersensitivity reaction | Diffuse, bilateral conjunctival injection with pruritis. Worsens with allergen exposure. History commonly positive for other allergic signs/symptoms (rhinorrhea, allergic shiners) or atopic disease (eczema). | Prescribe oral or topical antihistamines. Refer electively. |
| Bacterial conjunctivitis Bacterial infection of the conjunctiva | Diffuse conjunctival injection with mucopurulent discharge, most commonly unilateral. | Prescribe antibiotic drops. Consider elective referral if severe. |
| Subconjunctival hemorrhage Ruptured conjunctival vessel, commonly with a Valsalva or cough | Very well demarcated area of extravasated blood overlying the sclera. | Reassure patient that it usually self-resolves in 1-2 weeks. Refer electively. |
| Iritis Inflammation of the iris | Extreme photophobia. Patients often present wearing sunglasses while indoors. Pupils may be asymmetric or abnormally shaped due to iris adhesions (posterior synechiae). Often will have a history of prior episodes of eye inflammation. | Refer urgently. |
| Episcleritis Inflammation of superficial episcleral vessels of the eye | Dilated conjunctival vessels. Diagnosis can be confirmed by instilling phenylephrine drops (usually 2.5%) into the eye, which will blanch these superficial vessels. | Reassure patient and use trial of oral NSAIDS. Refer electively. |
| Scleritis Inflammation of the deeper sclera | Severe tenderness to palpation and bluish hue. Pt frequently has underlying autoimmune disease. | Refer urgently. |
| Acute angle closure glaucoma Acute obstruction of drainage from the eye causing high pressures | Severe ocular pain and blurry vision with a rock-hard eye on palpation. | Start oral acetazolamide and pressure lowering eye drops as soon as possible. Refer emergently. |
Chief complaint: “Blurry vision”
Key History:
- Constant or intermittent?
- Age?
- History of diabetes?
| Diagnosis | Key findings | Basic management |
| Corneal ulcer Most commonly a bacterial etiology | Commonly a history of contact lens use. Can frequently see a small grayish/white ulcer near the center of the cornea on careful penlight exam. | Refer emergently. |
| Vitreous hemorrhage Poorly controlled diabetes leads to newly proliferative blood vessels that easily bleed | Constant blurry vision with a history of longstanding diabetes. Sometimes patient will see one large floater that seems to move around as they shift their gaze. | Refer emergently, especially if the patient is not a diabetic. This can be the initial presentation of a retinal detachment/tear. Ask the patient to reduce activities that result in Valsalva. Check A1c if there is no recent one on file. |
| Cataracts Lens becomes cloudy with age, preventing transmission of light | Constant blurry vision. You may see leukocoria. Note that leukocoria in a child is always abnormal and should be referred urgently. | Refer non-urgently for cataract evaluation. |
| Glaucoma Aqueous outflow tract from the anterior chamber is impaired | Constant blurry vision. More moderate to advanced glaucoma may present with peripheral visual field deficits. Glaucoma can present chronically (painless) or acutely (painful angle closure). Both can cause blurry vision. Acute angle closure glaucoma is an ophthalmic emergency! | Refer urgently if the visual acuity is lower than baseline. Refer emergently if you suspect angle closure. |
| Refractive error Cornea or lens of the eye isn’t focusing light properly onto the retina | Constant blurry vision. Most commonly near-sighted and will need to hold fine print close to their face to read. | Refer non-urgently (to optometry) for refraction and glasses. |
| Presbyopia Loss of the ability of the lens to focus with increasing age | New onset difficulty focusing on near objects in an individual older than 50. Classically, the patient will hold text at arm’s length to read. | Instruct patient to purchase reading glasses from grocery or convenience store. Refer non-urgently. Presbyopia is associated with cataract development. |
| Dry eye Aqueous tear deficiency, either due to decreased production or increased evaporation | Intermittent blurry vision, on the order of seconds to minutes. Eye may feel scratchy. | Prescribe preservative free artificial tears q4h. Consider prescribing ointment for use right before bed (e.g. lacrilube). Recommend the patient to apply warm compresses to the eyelids to improve oil production. Also recommend baby shampooing their eyelashes twice a day improve lid hygiene and decrease blepharitis. Refer electively or non-urgently. |
Chief complaint: “Flashers and floaters”
Key history:
- How many flashers/floaters?
- Which eye?
- Any acute loss of vision?
| Diagnosis | Key findings | Basic management |
| Retinal detachment/tear/hole A break in the retina that can lead to permanent vision loss | Hundreds or more flashers/floaters, acute vision loss, or a “curtain” or “shade” in part of their vision. | Refer emergently. |
| Posterior vitreous detachment (PVD) Vitreous shrinks with age and physiologically pulls off the retina | A few solitary flashers/floaters. | Refer urgently to emergently. An early retinal detachment can also present with these symptoms and a dilated retinal exam is necessary. |
Chief complaint: “Something in the eye”
Key history:
- Ongoing scratchiness/irritation?
- What got in the eye and how long ago?
- Wearing eye protection?
- What type of material is likely in the eye (wood, metal, plastic, etc.)?
- Any chance of organic material in the eye?
| Diagnosis | Key findings | Basic management |
| Corneal foreign body Foreign body on the surface of the cornea | Recent work with power tools or working underneath cars, etc. A fluorescein stain may show green staining (abnormal) on a background of blue (normal). | Evaluate for open globe secondary to full thickness penetrations. Stain the eye with fluorescein to check for corneal abrasions. Flip the eyelids to check for hidden foreign bodies. If you have a slit lamp and are experienced using it, instill numbing drops and attempt to gently remove the particle with first a cue tip and then a 25 to 30 gauge needle if needed. Remember to approach the eye tangentially so you don’t accidentally puncture the eye! Refer electively to emergently, depending on concern for full thickness penetration causing open globe and ability to remove foreign body. |
| Corneal abrasion Small scratch to the cornea that can feel like sand or grit | Minor trauma to the eye, corneal foreign body, or a contact lens user. If large enough to be symptomatic, you can frequently see these with the naked eye on fluorescein stain. | Stain the eye with fluorescein to check for corneal abrasions. Flip the eyelids to check for hidden foreign bodies. Prescribe erythromycin ointment for most small abrasions. If the abrasion is large or from organic matter, prescribe moxifloxacin or gatifloxacin and refer. Refer non-urgently to emergently, depending on size/type of abrasion. All abrasions in contact lens users should be evaluated by an ophthalmologist for subtle ulcers. |
Chief complaint: “Eyelid bump/lump/inflammation”
Key history:
- How long has it gone on for?
- Any other recent illness?
- Any pain with eye movement?
| Diagnosis | Key findings | Basic management |
| Orbital cellulitis Infection of soft tissues posterior to the orbital septum | Classically from extension of sinus or dental infections. Swollen eyelids and conjunctival hyperemia, chemosis, and pain with eye movements. Recent sinus infection, or longstanding preseptal cellulitis. Eschar in a diabetic is concerning for deadly mucormycosis. | Obtain CT with contrast of orbits. Refer emergently. |
| Preseptal cellulitis An infection of the soft tissues anterior to the orbital septum | Usually from local spread of infection from periorbital trauma or insect bites. Swollen eyelids, but the eye underneath appears white and quiet. | Consider using either IV or oral antibiotics, depending on the severity of presentation. Consider obtaining CT with contrast of orbits. Refer emergently if orbital cellulitis is suspected |
| Stye (AKA hordeolum) An acute, localized infection of either an external gland on the lid margin or an internal abscess of a meibomian gland | Localized erythema and swelling of the eyelid margin. Usually painful. May have purulent discharge. | Instruct patient to use warm compresses for 10 minutes QID. Consider topical antibiotics if larger and purulent. Refer electively. |
| Chalazion An uninfected, obstructed meibomian gland causing secondary granulomatous formation | Localized swelling a few millimeters posterior from the eyelid margin. Usually painless. | Instruct patient to use warm compresses for 10 minutes QID. Refer electively. If chronically nonhealing or ulcerated, consider referral for evaluation for eyelid carcinomas. |
Chief complaint: “Eye trauma”
Key history:
- What trauma?
- Any risk for penetrating injury?
| Diagnosis | Key findings | Basic management |
| Open globe The eye is either ruptured or punctured, which can allow fluid to extrude from the eye | Commonly penetrating trauma to the eye. Can also occur with blunt trauma and severe, full thickness corneal ulcers. Extra concerning signs include iris coming out of the eye (uveal show) leading to a “keyhole” pupil, and 360 degree chemosis (swelling/ballooning of the conjunctiva). | Do NOT put any pressure on the eye including with ocular ultrasound. Cover the eye with an eye shield. Start oral antibiotics and ensure patient is up to date on tetanus shots. Refer emergently. |
| Eyelid/periorbital laceration Laceration around the eye/eyelids. | Commonly will have recent trauma. Pay attention to the location of the laceration. Lacerations in the inner corner of the eye commonly involve the nasal canaliculi which are difficult to repair when presenting late after injury. | Refer urgently to emergently if involving the inner corner of the eye (canaliculus) or lid margin, which should be repaired within 24 hours. Suture other lacerations at the presenting location (ED or PCP office) if you feel comfortable.
|
| Orbital fracture Bones of the orbit fractured.
| Trauma. Make sure to check extraocular movements. Evaluate for size of the fracture with CT of orbits. Muscle entrapment can lead to muscle ischemia and necrosis. If extraocular muscles have full range of motion, the chance of entrapment is extremely low. Minor, nondisplaced orbital fractures are frequently managed nonoperatively. | Reasons to repair fractures include: large fractures (>50%) of the floor, restricted extraocular movements, diplopia, and endophthalmos (posterior displacement of the eye). Refer emergently if eye movements are restricted or if any vision related complaints: flashers, floaters, blurry vision, etc. Otherwise, refer urgently or non-urgently if eye movements are full, eye looks white and quiet, and patient has no visual symptoms. |
Why is VZV not in here somewhere?