🩺 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.