🩺 Ophthalmology in General Practice: Your Survival Guide
Retina-ready revision - no tears required (unless it's a blocked tear duct)
Date Updated: November 2025
Executive Summary: What You'll Master Today
Because you have 47 other things to do before lunch, and that's just the morning list
What This Page Covers:
- • Red flags & conditions not to miss
- • Diagnostic approach & investigations
- • Differential diagnosis frameworks
- • Common eye conditions management
- • Data-gathering & examination tips
- • Useful GP & patient resources
Quick Facts at a Glance:
6️⃣ Useful GP & Patient Resources
Essential resources for ongoing learning and patient support
📥 Downloads
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path: OPHTHALMOLOGY
- .listing
- acute conjuctivitis.ppt
- acute eye conditions - a guide for the occaisional ophthalmologist (excellent).doc
- acute red eye - summary table.doc
- acute red eye made simple.pdf
- acute red eye.ppt
- emergencies of the eye - common.pdf
- emergencies of the eye.pdf
- eye emergencies.pdf
- eye handbook - 01 anatomy of the eye.pdf
- eye handbook - 02 external disease.pdf
- eye handbook - 03 anterior segment anatomy.pdf
- eye handbook - 04 diseases of anterior segment.pdf
- eye handbook - 05 vitreous disease.pdf
- eye handbook - 06 post segment anatomy.pdf
- eye handbook - 07 diseases of post segment.pdf
- eye handbook - 08 orbit anatomy.pdf
- eye handbook - 09 strabismus and amblyopia.pdf
- eye handbook - 10 visual and pupillary pathways.pdf
- eye handbook - 11 lesions of sensory and motor pathways.pdf
- eye handbook - 12 visual acuity and electrodiagnostic tests.pdf
- eye handbook - 13 tumours of eye and orbit.pdf
- eye handbook - 14 injuries to eye eyelid and orbit.pdf
- eye handbook - 15 refraction.pdf
- eye handbook - 16 glossary index and acknowledgements.pdf
- eye osce teaching plan for gp trainees.doc
- eye problems in gp - with pictures.ppt
- eye trauma.pdf
- eyes - acute red eye made simple.pdf
- eyes in general practice - comprehensive.ppt
- eyes in primary care.doc
- ophthalmology - core curriculum.doc
- ophthalmology in primary care.pdf
- ophthalmology tutorial.doc
- quick tips for eye problems in gp.doc
- red eye diagnostic chart.jpg
- red reflex - the importance of.pdf
- retinoblastoma - would you recognise it.pdf
- sudden loss of vision.doc
- trauma of the eye.pdf
- visual acuity - testing.pdf
🌐 Web Resources
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NICE Clinical Knowledge Summaries - Eye Conditions
Primary source for UK GP guidance
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BMJ Best Practice - Red Eye
Evidence-based diagnostic algorithms
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RNIB Professional Resources
Support services and registration guidance
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College of Optometrists
Professional guidance and local pathways
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DVLA Eyesight Rules
Fitness to drive visual standards
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Patient.info Eye Care
Patient information leaflets
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NHS.uk Eye Problems
Patient-facing NHS guidance
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Royal College of Ophthalmologists
Clinical guidelines and standards
Brainy Bites: Essential Ophthalmology Wisdom
Key Questions for Data Gathering
ALWAYS check visual acuity first - it's your most important baseline
Ask about contact lens wear - think amoebic keratitis in any red painful eye
New onset floaters/flashes = same day referral until retinal detachment excluded
Painful red eye + contact lens = urgent ophthalmology - assume infection until proven otherwise
Red Flags – What Not to Miss!
Sudden visual loss + jaw claudication - giant cell arteritis
Painful red eye + haloes around lights - acute angle closure glaucoma
Orbital swelling + fever - orbital cellulitis
Post-op severe pain - endophthalmitis
🎯 Key Reminders - Don't Forget!
ALWAYS Check Visual Acuity
It's the vital sign of ophthalmology - document it properly and compare to previous readings
Contact Lens Wearers
Remember amoebic keratitis - devastating if missed. Any red painful eye in contact lens user needs urgent referral
Floaters & Flashes
Might be retinal detachment - don't dismiss as "just age". New onset needs same-day assessment
1️⃣ Red Flags & Conditions Not to Miss
Life- or sight-threatening causes that require urgent recognition or same-day referral
Acute Angle-Closure Glaucoma
Classic triad: Sudden painful red eye, haloes around lights, nausea/vomiting
Examination: Fixed mid-dilated pupil, corneal oedema, raised IOP
Action: URGENT same-day ophthalmology referral - irreversible blindness within hours
Initial management: Lie patient flat, give analgesia, avoid mydriatics
Giant Cell Arteritis
Symptoms: Sudden visual loss, jaw claudication, temporal headache, scalp tenderness
Age: Usually >50 years, peak 70-80 years
Urgent tests: ESR >50, CRP >6, temporal artery biopsy
Action: Start prednisolone 60-80mg immediately if high suspicion - don't wait for biopsy
Orbital Cellulitis
Signs: Proptosis, restricted eye movements, reduced visual acuity, systemic illness
vs Pre-septal: No proptosis, normal eye movements, normal vision
Complications: Cavernous sinus thrombosis, meningitis, brain abscess
Action: URGENT hospital admission for IV antibiotics and imaging
Central Retinal Artery/Vein Occlusion
CRAO: Sudden painless profound visual loss, pale retina, cherry red spot
CRVO: Sudden visual loss, "blood and thunder" fundus, cotton wool spots
Risk factors: Hypertension, diabetes, glaucoma, cardiovascular disease
Action: URGENT ophthalmology referral - CRAO is "stroke of the eye"
Retinal Detachment
Symptoms: Flashing lights, shower of floaters, "curtain" visual field defect
Risk factors: Myopia, previous cataract surgery, trauma, family history
Examination: May be normal if peripheral - requires dilated fundoscopy
Action: URGENT same-day ophthalmology referral - posture patient to prevent macula involvement
Endophthalmitis
Post-operative: Severe pain, reduced vision, red eye within days of eye surgery
Endogenous: Immunocompromised patients, IV drug users, diabetes
Signs: Hypopyon, vitritis, severe anterior chamber reaction
Action: URGENT ophthalmology referral - intravitreal antibiotics needed within hours
Corneal Ulcer/Keratitis
Contact lens keratitis: Acanthamoeba - devastating if missed, resistant to treatment
Signs: Corneal epithelial defect, white/grey infiltrate, hypopyon
Bacterial: Rapid progression, purulent discharge, severe pain
Action: URGENT ophthalmology referral - corneal scraping and culture needed
Uveitis
Anterior uveitis: Painful red eye, photophobia, small irregular pupil, ciliary flush
Associations: Ankylosing spondylitis, IBD, Behçet's, sarcoidosis
Complications: Glaucoma, cataract, posterior synechiae
Action: URGENT ophthalmology referral - topical steroids needed to prevent complications
2️⃣ Diagnostic Approach & Investigations
Systematic approach to eye problems in primary care
History Framework
Structured approach to eye history taking
Core Symptoms
- • Visual acuity: Distance vs near, one or both eyes
- • Visual field: Central vs peripheral loss
- • Pain: Severity, character, associated with movement
- • Discharge: Purulent, watery, sticky
- • Photophobia: True vs discomfort in bright light
- • Diplopia: Horizontal, vertical, constant vs intermittent
Key Differentiators
- • Onset: Sudden (hours) vs gradual (days/weeks)
- • Unilateral vs bilateral: Infection often starts unilateral
- • Contact lens wear: Think Acanthamoeba keratitis
- • Recent surgery: Endophthalmitis risk
- • Trauma history: Even minor - penetrating injury
- • Systemic symptoms: Headache, nausea, jaw claudication
Eye Examination
What you can realistically achieve in primary care
Essential Checks
- • Visual acuity: Each eye separately, with/without glasses
- • Pupil reactions: Direct and consensual, RAPD test
- • Eye movements: Six cardinal directions
- • Visual fields: Confrontation testing
- • Red reflex: Ophthalmoscope at arm's length
External Examination
- • Lids: Swelling, erythema, lumps, position
- • Conjunctiva: Injection pattern, discharge, foreign bodies
- • Cornea: Clarity, epithelial defects (fluorescein)
- • Anterior chamber: Depth, hypopyon, hyphema
- • Proptosis: Compare both eyes from above
Investigations
When and what to test in primary care
Blood Tests
- • ESR & CRP: Giant cell arteritis (ESR >50)
- • FBC: Infection, malignancy
- • Glucose: Diabetic eye disease
- • Thyroid function: Thyroid eye disease
- • ACE: Sarcoidosis (if uveitis)
Specialist Tests
- • Fluorescein staining: Corneal epithelial defects
- • Intraocular pressure: Goldmann applanation (specialist)
- • Slit lamp examination: Anterior segment detail
- • Dilated fundoscopy: Retinal pathology
- • Visual field testing: Glaucoma, neurological
When to Refer
Clear referral criteria for ophthalmology
Same-Day Referral
- • Sudden visual loss (any cause)
- • Acute angle closure glaucoma
- • Giant cell arteritis
- • Orbital cellulitis
- • Endophthalmitis
- • Corneal ulcer/keratitis
- • New onset floaters/flashes
- • Penetrating eye injury
Routine Referral
- • Gradual visual loss
- • Suspected cataract
- • Chronic glaucoma
- • Macular degeneration
- • Persistent diplopia
- • Eyelid malposition
- • Suspected malignancy
- • Recurrent uveitis
3️⃣ Differential Diagnosis Frameworks
Systematic approaches to common eye presentations
Red Eye Differential
Pain is the key differentiator
Painful Red Eye
- • Acute angle closure: Haloes, nausea, fixed pupil
- • Anterior uveitis: Photophobia, small pupil, ciliary flush
- • Corneal ulcer: Contact lens history, white spot
- • Keratitis: Photophobia, reduced vision
- • Scleritis: Deep boring pain, worse at night
- • Foreign body: Sudden onset, history of trauma
Painless Red Eye
- • Conjunctivitis: Discharge, bilateral spread
- • Subconjunctival haemorrhage: Bright red, well-demarcated
- • Episcleritis: Sectoral redness, mild discomfort
- • Dry eye: Gritty sensation, worse evening
- • Blepharitis: Lid margin crusting, bilateral
- • Pterygium: Triangular growth from nasal side
Vision Loss Differential
Onset timing is crucial
Sudden Vision Loss
- • Central retinal artery occlusion: Profound loss, pale retina
- • Central retinal vein occlusion: Blood and thunder fundus
- • Retinal detachment: Curtain defect, floaters/flashes
- • Vitreous haemorrhage: Sudden floaters, red reflex loss
- • Giant cell arteritis: >50 years, jaw claudication
- • Acute angle closure: Pain, haloes, nausea
Gradual Vision Loss
- • Cataract: Glare, haloes, gradual clouding
- • Glaucoma: Peripheral field loss, asymptomatic
- • Macular degeneration: Central scotoma, metamorphopsia
- • Diabetic retinopathy: Background changes, maculopathy
- • Refractive error: Correctable with glasses
- • Optic neuritis: Pain on movement, RAPD
Watery Eye (Epiphora)
Overproduction vs poor drainage
Overproduction
- • Dry eye syndrome
- • Conjunctivitis
- • Corneal irritation
- • Foreign body
- • Trichiasis
- • Blepharitis
Poor Drainage
- • Nasolacrimal duct obstruction
- • Punctal stenosis
- • Canalicular obstruction
- • Ectropion
- • Facial nerve palsy
- • Nasal pathology
Simple Test
- • Fluorescein disappearance test:
- • Instil fluorescein drops
- • Normal: clears in 5 minutes
- • Delayed: drainage problem
- • Dye dilution test:
- • Persistent bright staining = obstruction
Eyelid Lumps
Benign vs malignant features
Common Benign
- • Chalazion: Painless, firm, slow-growing
- • Stye (hordeolum): Painful, red, at lash base
- • Sebaceous cyst: Mobile, smooth, central punctum
- • Xanthelasma: Yellow plaques, medial canthi
- • Papilloma: Pedunculated, rough surface
- • Molluscum contagiosum: Central umbilication
Malignant Features
- • Basal cell carcinoma: Pearly, rolled edge, telangiectasia
- • Squamous cell carcinoma: Keratotic, irregular, rapid growth
- • Melanoma: Pigmented, irregular, changing
- • Red flags: Ulceration, bleeding, lash loss
- • Growth pattern: Rapid, irregular, destructive
- • Age: Usually >60 years, sun exposure
Diplopia (Double Vision)
Monocular vs binocular is key
Monocular Diplopia
- • Cataract: Most common cause
- • Corneal irregularity: Astigmatism, scarring
- • Lens dislocation: Trauma, Marfan syndrome
- • Macular pathology: Metamorphopsia
- • Refractive error: Uncorrected astigmatism
- • Test: Persists when other eye covered
Binocular Diplopia
- • Cranial nerve palsy: III, IV, VI
- • Thyroid eye disease: Restrictive myopathy
- • Myasthenia gravis: Fatigable, ptosis
- • Orbital fracture: Trauma, restriction
- • Stroke: Brainstem, cortical
- • Test: Resolves when either eye covered
Eye Problems + Headache
Urgent vs common causes
Urgent Causes
- • Giant cell arteritis: Temporal headache, jaw claudication
- • Acute angle closure: Severe pain, nausea, haloes
- • Optic neuritis: Pain on eye movement, RAPD
- • Orbital cellulitis: Proptosis, restricted movements
- • Cavernous sinus thrombosis: Bilateral signs, systemic illness
- • Raised ICP: Papilloedema, morning headaches
Common Causes
- • Refractive error: Eye strain, worse with near work
- • Dry eye: Gritty sensation, worse evening
- • Migraine: Visual aura, photophobia
- • Tension headache: Band-like, stress-related
- • Sinusitis: Facial pain, nasal congestion
- • Cluster headache: Unilateral, lacrimation, rhinorrhoea
4️⃣ Common Eye Conditions
Practical management for everyday eye problems
Bacterial Conjunctivitis
Features: Purulent discharge, crusting, usually unilateral initially
Organisms: Staph aureus, Strep pneumoniae, H. influenzae
Treatment: Chloramphenicol drops QDS for 7 days
Advice: Highly contagious, avoid sharing towels, hand hygiene
Allergic Conjunctivitis
Features: Itching (key symptom), watery discharge, bilateral
Seasonal: Hay fever, tree/grass pollen
Perennial: House dust mite, pet dander
Treatment: Antihistamine drops (olopatadine), avoid allergens, cool compresses
Blepharitis & Meibomian Gland Dysfunction
Symptoms: Gritty eyes, burning, crusting, worse in morning
Signs: Lid margin erythema, scales, blocked meibomian glands
Treatment: Lid hygiene (warm compresses, lid massage), artificial tears
Severe cases: Oral doxycycline 100mg OD for 6-12 weeks
Advice: Chronic condition, requires ongoing management
Dry Eye Syndrome
Symptoms: Gritty sensation, burning, paradoxical watering
Risk factors: Age, female, medications (antihistamines, antidepressants)
Associations: Sjögren's syndrome, rheumatoid arthritis
Treatment: Artificial tears, avoid preservatives, humidify environment
Severe: Ciclosporin drops, punctal plugs (specialist)
Subconjunctival Haemorrhage
Appearance: Bright red, well-demarcated, painless
Causes: Coughing, straining, hypertension, anticoagulants
Management: Reassurance, resolves in 1-2 weeks
Check BP: If recurrent or no obvious cause
Red flags: Pain, visual loss, trauma (exclude globe rupture)
Chalazion (Meibomian Cyst)
Features: Painless, firm, slow-growing lump in eyelid
Cause: Blocked meibomian gland, chronic inflammation
Treatment: Warm compresses, lid massage, topical antibiotics
Referral: If large, affecting vision, or not resolving after 6 weeks
Stye (Hordeolum)
Features: Painful, red, tender lump at lash base
Cause: Bacterial infection of lash follicle (usually Staph aureus)
Treatment: Warm compresses, topical antibiotics, may point and drain
Advice: Don't squeeze, good lid hygiene, usually resolves in 1 week
Cataract
Symptoms: Gradual visual loss, glare, haloes around lights
Risk factors: Age, diabetes, steroids, UV exposure, smoking
Examination: Reduced red reflex, lens opacity on direct ophthalmoscopy
Referral criteria: Visual symptoms affecting daily activities
Surgery: Phacoemulsification with IOL implant, day case procedure
Chronic Open Angle Glaucoma
Pathophysiology: Raised IOP causing optic nerve damage
Symptoms: Usually asymptomatic until advanced
Risk factors: Age >40, family history, Afro-Caribbean, myopia
Screening: Optometrist - IOP, optic disc, visual fields
Management: Topical drops (prostaglandins first-line), regular monitoring
Dry AMD (90%)
Features: Gradual central visual loss, drusen, geographic atrophy
Symptoms: Difficulty reading, recognizing faces, metamorphopsia
Management: AREDS2 vitamins, lifestyle advice, low vision aids
Monitoring: Amsler grid, urgent referral if sudden change
Wet AMD (10%)
Features: Rapid central visual loss, choroidal neovascularization
Symptoms: Sudden distortion, central scotoma, metamorphopsia
Treatment: Anti-VEGF injections (ranibizumab, aflibercept)
Referral: URGENT - treatment most effective within 3 months
Diabetic Retinopathy & Maculopathy
Screening: Annual digital photography for all diabetics
Background: Microaneurysms, dot/blot haemorrhages, hard exudates
Pre-proliferative: Cotton wool spots, venous beading, IRMA
Proliferative: Neovascularization, vitreous haemorrhage
Maculopathy: Exudates/oedema within 1 disc diameter of fovea
Prevention: Good glycaemic control, BP control, lipid management
5️⃣ Data-Gathering & Examination Tips
Practical skills for effective eye assessment
History Tips
Efficient questioning techniques for eye problems
Essential Openers
- • "Tell me about your eye problem"
- • "When did you first notice this?"
- • "Is it affecting one or both eyes?"
- • "How has it changed since it started?"
- • "What does it stop you from doing?"
- • "Have you had anything like this before?"
Red Flag Questions
- • "Did this come on suddenly?" (hours vs days)
- • "Do you wear contact lenses?" (keratitis risk)
- • "Any recent eye surgery?" (endophthalmitis)
- • "Any headache or jaw pain?" (GCA)
- • "Seeing flashing lights or floaters?" (retinal detachment)
- • "Any nausea or vomiting?" (acute glaucoma)
Pain Assessment
Painful red eye = urgent until proven otherwise
- • Severity: 0-10 scale
- • Character: Sharp, dull, gritty, burning
- • Triggers: Light, movement, blinking
- • Associated: Headache, nausea, visual symptoms
Examination Essentials
What you can realistically achieve with basic equipment
Visual Acuity Testing
- • Use Snellen chart at 6 metres (or 3m with mirror)
- • Test each eye separately with glasses/contacts if worn
- • If can't see top letter, try counting fingers, hand movements, light perception
- • Near vision with reading card if distance vision affected
- • Document as 6/6, 6/12, 6/60 etc.
Pupil Examination
- • Check size, shape, and direct light reaction
- • RAPD test: Swinging flashlight test - pupil dilates when light swings to affected eye
- • RAPD suggests optic nerve or severe retinal pathology
- • Fixed dilated pupil = acute glaucoma or neurological cause
Fundoscopy Tips
- • Start with red reflex - should be bright and equal
- • Dim room lights, use right eye for patient's right eye
- • Look for optic disc swelling, haemorrhages, exudates
- • Don't worry about perfect view - gross abnormalities are usually obvious
- • If you can't see anything clearly, that's still useful information!
Fluorescein Staining
- • Use for suspected corneal abrasion or foreign body
- • Wet fluorescein strip with saline, touch to lower lid
- • Use blue light (or Wood's lamp) to see green staining
- • Dendritic pattern suggests viral keratitis
How to Use a Direct Ophthalmoscope
The direct ophthalmoscope is useful but often under-utilized by non-ophthalmologists. Follow these steps for a good fundal view (requires clear media without corneal, lens, or vitreous opacities).
Initial Setup
- • Position: Sit/stand at patient's right side to examine right eye
- • Settings: Select "0" on lens disc, start with small aperture
- • Grip: Hold vertically in right hand, place in front of your right eye
- • Finger position: Right index finger on lens dial edge for easy adjustment
Patient Preparation
- • Lighting: Dim room lights
- • Fixation: Patient looks straight ahead at distant object
- • Important: Patient must NOT look at the light (causes pupil constriction)
Step-by-Step Examination
- 1. Initial approach: Position 6 inches (15cm) in front and slightly right (25°) of patient
- 2. Red reflex: Direct light beam into pupil - red reflex should appear
- 3. Move closer: Keep reflex in view, slowly approach patient
- 4. Find optic disc: Should come into view at 1.5-2 inches (3-5cm) from patient
- 5. Focus: Rotate lenses until optic disc is clearly visible
- 6. Examine disc: Check clarity, colour, elevation, vessel condition
- 7. Follow vessels: Trace each vessel as far peripherally as possible
Lens Adjustments
- • Hypermetropic eye: Requires more plus lenses for clear focus
- • Myopic eye: Requires minus lenses for clear focus
- • No red reflex: Suggests dense cataract or scarred cornea
Examining the Macula
- • Method 1: Focus on disc, then move light 2 disc diameters temporally
- • Method 2: Have patient look at ophthalmoscope light (automatically centers macula)
- • Red-free filter: Facilitates viewing of macular center
If Patient Has Visual Loss - Look For:
Disc abnormalities:
- • Swelling (anterior ischaemic optic neuropathy, CRVO)
Vessel changes:
- • Tortuosity/dilatation (CRVO)
- • Narrowing (CRAO)
Retinal changes:
- • Paleness (retinal artery occlusion)
- • Haemorrhages (CRVO, diabetic retinopathy)
Peripheral Examination
Instruct patient to look in different directions:
- • Up: Examine superior retina
- • Down: Examine inferior retina
- • Temporally: Examine temporal retina
- • Nasally: Examine nasal retina
Overcoming Corneal Reflection
- • Polarized filter: Use if available on ophthalmoscope
- • Small aperture: Reduces reflection but limits illuminated area
- • Angle technique: Direct light toward pupil edge rather than center
Dealing with Small Pupils (Elderly Patients)
- • Best combination: Tropicamide 1% + Phenylephrine 2.5% (act on different iris muscles)
- • Single drop option: Tropicamide 1% (more efficient than phenylephrine alone)
- • Benefit: Short-acting dilating drops increase fundal examination area
Communication & Accessibility
Consulting with visually impaired patients
Communication Strategies
- • Introduce yourself - say your name and role clearly
- • Speak directly to the patient, not their companion
- • Use normal tone - visual impairment doesn't affect hearing
- • Describe what you're doing - "I'm going to shine a light in your eye"
- • Use specific directions - "to your left" not "over there"
- • Ask before helping - don't grab their arm
Accessible Information
- • Provide information in large print (minimum 14pt font)
- • Offer audio formats or digital copies for screen readers
- • Use high contrast (black text on white background)
- • Avoid glossy paper that creates glare
- • Consider Braille for profoundly blind patients
Practical Consultation Tips
- • Good lighting is essential - position patient facing window
- • Reduce glare - avoid bright lights behind you
- • Allow extra time for explanations and questions
- • Confirm understanding: "Can you tell me what you'll do with these drops?"
- • Arrange follow-up - visual problems often need monitoring
You've Got This! 💪
Remember, you don't need to be an ophthalmologist to provide excellent eye care in general practice. Focus on recognizing red flags, taking a good history, and knowing when to refer. Your patients will thank you for catching that sight-threatening condition early.
Most eye problems you'll see are straightforward - conjunctivitis, dry eyes, and the occasional foreign body. But when you do encounter something serious, you'll know exactly what to do.
thank you so much for this excellent concise presentation of eye conditions