8th December 2023

Clinical examination

The non-affected eye should also be examined as it gives an idea of the baseline appearance of the patient’s eyes. Clinical examination should include:

• Visual acuity check using a Snellen chart at 6 metres
• Examine the pupils
  • Check for asymmetry in dim and bright light
  • Check for abnormalities of shape or size
  • Check pupillary reactions to light – direct, consensual and presence of a relative afferent pupillary defect
• Examination of the eyelids looking for redness, swelling, lumps, trichiasis, abnormalities of position such as ptosis, entropion and ectropion, and abnormal shapes
• Examination of the conjunctiva to include eversion of the upper lid, checking for foreign bodies, if available, stain with fluorescein and examine under a blue filter on the ophthalmolscope. Check for redness, including location and pattern, such as ciliary (pattern of dilated vessels around the cornea indicating uvea pathology) or conjunctival which is more diffuse
• Examine the cornea for cloudy areas and staining epithelial defects

Based on NICE guidelines, red flag signs and symptoms which may indicate a serious and potentially sight-threatening cause of the person’s red eye include:

• Reduced visual acuity.
• Moderate to severe pain.
• Headache.
• Photophobia — this can be a symptom of acute uveitis, corneal ulcer, contact lens-related red eye, or corneal foreign body. However, systemic causes of photophobia, such as meningitis, should also be considered.
• Significant ciliary injection.
• Fluorescein staining indicating a significant corneal ulcer.
• Unequal or misshapen pupils, or abnormal pupillary reactions.
• Pain on pupillary constriction.
• Loss of red reflex.
• Corneal defect/haze.
• Hyphaema (blood in the anterior chamber) or hypopyon (pus in the anterior chamber).

Other red flag features include:

• A high-velocity injury (for example, injuries occurring while hammering or chiselling), or injuries involving glass.
• Foreign body or penetrating lesion.
• Serious chemical eye injury.
• Contact lens use.
• Conjunctivitis in an infant in the first 28 days of life.