Ophthalmology: Red emergencies

👁️ The red eye is one of the commonest eye presentations. Most cases are conjunctivitis or a harmless subconjunctival haemorrhage -but a few (acute glaucoma, keratitis, uveitis, scleritis, chemical injury, orbital cellulitis) can cause blindness within hours or days. Three questions sort most cases: Is vision reduced? Is there real pain or photophobia? Is the pupil abnormal? A "yes" to any means same-day eye casualty.
Your four questions for every patient: Is visual acuity reduced? Is it painful (not just gritty), with light sensitivity? Is the cornea clear and the pupil normal? Is there contact lens wear, trauma or a chemical?

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Assessing a Red Eye

Feature	What it suggests
Vision normal, gritty, discharge	Conjunctivitis
Painless bright red patch, vision normal	Subconjunctival haemorrhage
Sectoral redness, mild discomfort	Episcleritis
Severe, boring pain, worse at night, tender globe	Scleritis
Photophobia, ache, redness around the cornea, small pupil	Anterior uveitis
Severe pain, vomiting, haloes, fixed mid-dilated pupil, hazy cornea, hard eye	Acute angle-closure glaucoma
Pain, photophobia, white spot on the cornea, contact lens wearer	Bacterial keratitis
Branching (dendritic) ulcer on fluorescein	Herpes simplex keratitis
Swollen lids, painful eye movements, proptosis, fever	Orbital cellulitis

• Where is the redness?
  • Diffuse, including the inside of the lids -conjunctivitis.
  • Around the cornea (ciliary flush) -keratitis, uveitis, acute glaucoma.
  • Sectoral -episcleritis, scleritis.
• Always: Acuity, pupils, fluorescein, and ophthalmoscopy (or red reflex).

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Red Flags -Refer Today

• Reduced visual acuity.
• Moderate to severe pain (not just grittiness), or pain that wakes the patient.
• Photophobia.
• Abnormal pupil -fixed, irregular or mid-dilated.
• Corneal opacity or ulcer (fluorescein staining).
• Contact lens wearer with a painful red eye.
• Chemical injury -irrigate first, then refer.
• Penetrating or high-velocity injury.
• Recent eye surgery.
• Herpes zoster involving the eye or the tip of the nose.
• Neonate with red, sticky eyes.
• Proptosis or restricted, painful eye movements.

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Bacterial Conjunctivitis

• Features:
  • Red, gritty eye with sticky, purulent discharge; lids stuck together in the morning.
  • Often starts in one eye and spreads to both.
  • Normal vision, normal pupils, clear cornea.
• Organisms: Staphylococcus, Streptococcus pneumoniae, Haemophilus.
• Management (NICE CKS):
  • Usually self-limiting within 5–7 days.
  • Clean lids with cooled boiled water.
  • Chloramphenicol drops (0.5%, every 2 hours for 2 days then four times daily) or 1% ointment -if severe or not settling; or a back-up prescription. Fusidic acid as an alternative.
  • Children don't need to stay off school.
  • Contact lenses -stop wearing until resolved.
• Hyperacute (copious pus, rapid onset) -think gonococcal: urgent referral (corneal perforation risk), swab, systemic antibiotics, sexual health review.
• Chlamydial -chronic (weeks), follicular conjunctivitis in young sexually active adults; oral doxycycline or azithromycin; sexual health screen.

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Viral Conjunctivitis

• The commonest cause -usually adenovirus; very contagious.
• Features:
  • Red, gritty, watery eye; often both eyes.
  • Recent cold or sore throat.
  • Tender pre-auricular lymph node.
  • Follicles on the inner lid.
  • Can last 2–3 weeks.
• Management:
  • Cool compresses, lubricants.
  • Hygiene -hand washing, don't share towels.
  • No antibiotics.
  • Refer if vision falls or there is pain or photophobia (keratitis -small corneal spots).

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Allergic Conjunctivitis

• Features:
  • Itchy, red, watery eyes, both sides.
  • Swollen conjunctiva (chemosis) and lids.
  • Hay fever, eczema, asthma; seasonal (pollen) or year-round (dust mite, pets).
• Management:
  • Avoid triggers; cold compresses; don't rub.
  • Antihistamine drops (olopatadine, antazoline) or mast cell stabilisers (sodium cromoglicate -takes days to work).
  • Oral antihistamines.
• Vernal keratoconjunctivitis -severe allergic disease in boys with atopy: giant "cobblestone" papillae under the upper lid; can damage the cornea -refer.

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Subconjunctival Haemorrhage

• Features: A bright red, flat patch on the white of the eye with a clear edge; painless; vision normal. Often noticed by others.
• Causes:
  • Spontaneous (most); coughing, straining, vomiting.
  • Hypertension.
  • Anticoagulants and antiplatelets.
  • Minor trauma or rubbing.
  • Bleeding disorders (if recurrent).
• Management:
  • Reassure -fades over 1–3 weeks (goes yellow like a bruise).
  • Check BP; check INR if on warfarin.
  • Refer if after significant trauma (can't see its back edge -possible orbital or skull base fracture), recurrent, or with other bleeding.

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Episcleritis

• What it is: Inflammation of the thin layer above the sclera. Benign and self-limiting.
• Features:
  • Sectoral redness (a wedge), mild discomfort, no real pain.
  • Vision normal.
  • Red vessels move over the sclera and blanch with phenylephrine drops (scleral vessels don't).
• Associations: Usually none; sometimes rheumatoid arthritis, IBD.
• Management: Reassurance, lubricants, cool compresses; oral NSAID if uncomfortable. Settles in 1–3 weeks. Refer if severe pain (consider scleritis) or recurrent.

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Scleritis

• What it is: Inflammation of the sclera itself -can be sight-threatening and is often linked to systemic disease.
• Features:
  • Severe, deep, boring pain that radiates to the head and face and wakes the patient at night.
  • Tender globe; deep red or purplish redness that doesn't blanch with phenylephrine.
  • Reduced vision in severe or posterior scleritis.
  • Scleromalacia perforans -painless thinning in long-standing rheumatoid arthritis (sclera turns blue-grey).
• Associations (about half):
  • Rheumatoid arthritis (the commonest).
  • ANCA vasculitis (GPA).
  • Lupus, relapsing polychondritis, IBD.
  • Infection (herpes zoster, after surgery).
• Management:
  • Same-day ophthalmology.
  • Screen for systemic disease (ANCA, rheumatoid factor, anti-CCP, ANA, CRP, urine dip).
  • Oral NSAIDs for mild disease; systemic steroids and immunosuppressants (methotrexate, rituximab) for severe disease.

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Anterior Uveitis

• What it is: Inflammation of the iris and ciliary body (iritis).
• Features:
  • Pain (dull ache), photophobia, red eye with ciliary flush (redness around the cornea).
  • Blurred vision; watering (not sticky).
  • Small, irregular pupil (the iris sticks to the lens -posterior synechiae).
  • Cells and flare in the anterior chamber on slit lamp; hypopyon (layer of pus) in severe cases.
  • Usually one eye; often recurrent.
• Associations:
  • HLA-B27 disease -ankylosing spondylitis (axial spondyloarthritis), reactive arthritis, psoriatic arthritis, IBD.
  • Sarcoidosis.
  • Behçet's disease (hypopyon).
  • Juvenile idiopathic arthritis (children -silent, needs screening).
  • Herpes viruses; syphilis; TB.
  • Drugs -checkpoint inhibitors, bisphosphonates.
• Management:
  • Same-day eye casualty.
  • Steroid drops (e.g. prednisolone acetate 1% hourly, then tapered over weeks).
  • Dilating drops (cyclopentolate) -relieve pain and stop the iris sticking.
  • Monitor pressure.
  • Investigate recurrent or bilateral disease; ask about back pain (refer to rheumatology).
• Intermediate and posterior uveitis -floaters and blurred vision with little redness; sarcoid, MS, toxoplasmosis, CMV (HIV), Behçet's.

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Acute Angle-Closure Glaucoma

• What it is: The iris suddenly blocks the drainage angle; eye pressure shoots up (often 50–70 mmHg). It can cause permanent blindness within hours.
• Who: Older, long-sighted people, women, East Asian ancestry. Often triggered in dim light (evening) or by dilating drugs (anticholinergics, sympathomimetics, dilating drops, topiramate).
• Features:
  • Severe eye pain and headache.
  • Nausea and vomiting -may be mistaken for a GI or neurological problem.
  • Blurred vision, haloes around lights.
  • Red eye; hazy cornea.
  • Fixed, mid-dilated pupil (often oval).
  • Rock-hard eye to gentle palpation through the lid.
• Emergency treatment (while arranging immediate ophthalmology review):
  • Lie the patient flat (supine, face up) -lets the lens fall back.
  • Acetazolamide 500 mg IV (or orally if IV not possible) -reduces aqueous production. Avoid in sulfonamide allergy; caution in kidney disease and sickle cell.
  • Pressure-lowering drops -timolol 0.5%, apraclonidine or brimonidine.
  • Pilocarpine 1–2% -constricts the pupil to pull the iris out of the angle (works better once pressure starts to fall).
  • Steroid drops to reduce inflammation (specialist).
  • Analgesia and antiemetics.
  • IV mannitol if pressure won't come down (specialist).
• Definitive treatment: Laser peripheral iridotomy in both eyes (the other eye is at high risk), or lens extraction.

⚠️ Safety Pearl: An older person with headache, vomiting and a red eye may be sent for a CT head -look at the eye first. A fixed mid-dilated pupil and a hazy cornea point to acute glaucoma.

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Bacterial Keratitis and Contact Lens Ulcers

• What it is: Infection of the cornea -a sight-threatening emergency (scarring, perforation).
• Risk factors:
  • Contact lens wear -the biggest; especially sleeping in lenses, poor hygiene, swimming.
  • Corneal trauma; dry eye; exposure (facial palsy); steroid drops.
• Features:
  • Pain, photophobia, watering or discharge.
  • Reduced vision.
  • White spot (infiltrate) on the cornea that stains with fluorescein; ciliary flush; sometimes hypopyon.
• Organisms: Pseudomonas (contact lenses -fast and destructive), Staphylococcus, Streptococcus.
• Management:
  • Same-day eye casualty -don't treat in general practice.
  • Remove contact lenses; send the lenses and case for culture.
  • Corneal scrape for culture.
  • Intensive antibiotic drops -e.g. a fluoroquinolone (levofloxacin, ofloxacin) hourly day and night at first.
• Acanthamoeba keratitis -contact lenses rinsed in tap water or worn swimming; pain out of proportion to signs; ring infiltrate. Slow, hard to treat (specialist biguanide drops).
• Fungal keratitis -after plant or vegetable matter injury (gardening, farming).
• Contact lens wearer with a red painful eye -always refer the same day.

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Herpes Simplex Keratitis

• What it is: Reactivation of herpes simplex virus (HSV-1) in the cornea; a leading infectious cause of corneal blindness.
• Features:
  • Red, painful, watery eye; photophobia; blurred vision.
  • Often a history of cold sores or previous episodes.
  • Dendritic (branching) ulcer with fluorescein -diagnostic.
  • Reduced corneal sensation.
• Management:
  • Same-day ophthalmology.
  • Topical antiviral -ganciclovir 0.15% gel five times daily, or aciclovir 3% ointment; oral aciclovir in some cases.
  • Never give steroid drops for an active dendritic ulcer (they make it spread -a "geographic" ulcer).
  • Recurrent disease -long-term oral aciclovir prophylaxis.
• Stromal keratitis (deeper, immune-mediated) -specialists do use steroids with antiviral cover.

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Herpes Zoster Ophthalmicus

• What it is: Shingles in the ophthalmic division of the trigeminal nerve (V1) -forehead, upper lid, scalp.
• Hutchinson's sign -vesicles on the tip or side of the nose (nasociliary nerve) strongly predict eye involvement.
• Eye complications: Conjunctivitis, keratitis, uveitis, scleritis, raised pressure, optic neuritis, cranial nerve palsies; later corneal scarring and post-herpetic neuralgia.
• Management:
  • Oral antiviral within 72 hours of rash onset (or later if new lesions are still appearing) -aciclovir 800 mg five times daily or valaciclovir 1 g three times daily for 7 days.
  • Same-day ophthalmology if the eye is red, vision is reduced, or Hutchinson's sign is present; otherwise urgent review.
  • IV aciclovir if immunocompromised or severe.
  • Analgesia; consider early neuropathic pain treatment.
• Prevention -shingles vaccine (Shingrix) offered on the NHS to older adults and immunosuppressed people.

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Endophthalmitis

• What it is: Infection inside the eye -a sight-threatening emergency.
• Causes:
  • After eye surgery (cataract -usually within days to 2 weeks) or intravitreal injections (anti-VEGF).
  • Penetrating trauma.
  • Endogenous -spread from the blood: endocarditis, Candida (IV drug use, long-term lines, TPN), liver abscess (Klebsiella), immunosuppression.
• Features:
  • Pain, red eye, falling vision.
  • Hypopyon; poor red reflex.
• Management:
  • Immediate ophthalmology.
  • Vitreous tap for culture and intravitreal antibiotics (e.g. vancomycin and ceftazidime); sometimes vitrectomy.
  • Endogenous -blood cultures, echo, systemic treatment of the source; check the eyes of any patient with Candida bloodstream infection.

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Preseptal and Orbital Cellulitis

Feature	Preseptal versus orbital
Where	Preseptal -skin and lids in front of the orbital septum. Orbital -behind it, around the eye.
Lid swelling and redness	Both
Pain on eye movement, restricted movement	Orbital only
Proptosis	Orbital only
Reduced vision, colour vision, RAPD	Orbital only -optic nerve compression
Fever, very unwell	More with orbital

• Causes:
  • Orbital -usually spread from ethmoid sinusitis (especially children).
  • Preseptal -skin injury, insect bite, stye, sinusitis.
• Management:
  • Preseptal (mild, adults or older children) -oral co-amoxiclav; review within 24–48 hours. Admit young children.
  • Orbital -emergency:
    • Admit; IV antibiotics (e.g. ceftriaxone with metronidazole, or co-amoxiclav, per local policy).
    • CT of the orbits and sinuses with contrast.
    • Joint ophthalmology and ENT review.
    • Monitor vision, colour vision and pupils regularly.
    • Surgical drainage for subperiosteal or orbital abscess.
• Complications of orbital cellulitis: Vision loss, cavernous sinus thrombosis (bilateral signs, cranial nerve palsies), meningitis, brain abscess.

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Neonatal Conjunctivitis

• Ophthalmia neonatorum -conjunctivitis in the first 28 days of life. A notifiable disease.
• Causes:
  • Gonococcal -days 1–5; hyperacute, copious pus; risk of corneal perforation. IV or IM ceftriaxone.
  • Chlamydial -days 5–14; can cause pneumonia. Oral azithromycin or erythromycin.
  • Other bacteria; herpes simplex.
• Management: Same-day ophthalmology or paediatric review; swabs (including for chlamydia and gonorrhoea PCR); treat the mother and partner (sexual health).
• Sticky eye from a blocked tear duct -common and harmless; lid cleaning, no antibiotics unless infected.

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Corneal Abrasion and Foreign Body

• Corneal abrasion:
  • Cause -fingernail, paper, branch, contact lens.
  • Features -pain, watering, foreign body sensation, photophobia; stains with fluorescein.
  • Management:
    • Topical anaesthetic for examination only.
    • Chloramphenicol ointment four times daily for a few days.
    • Oral analgesia; cyclopentolate for comfort if large.
    • No patching needed.
    • Heals in 24–72 hours; review if not improving.
    • Contact lens wearer -cover Pseudomonas; refer.
  • Vertical linear scratches suggest a foreign body under the upper lid -evert the lid.
• Corneal foreign body:
  • Remove superficial bodies with a cotton bud or needle under topical anaesthetic (if trained); a rust ring may need specialist removal.
  • Antibiotic ointment afterwards.
• High-velocity injury (hammering metal on metal, grinding, drilling) -suspect an intraocular foreign body even if the eye looks normal: X-ray or CT of the orbits (not MRI -metal).
• Arc eye (welding, sunbeds, snow) -UV keratitis: severe pain and watering 6–12 hours after exposure, both eyes. Lubricants, antibiotic ointment, analgesia; settles in 24–48 hours.

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Chemical Injury

• An ophthalmic emergency -alkalis (cement, lime, oven cleaner, ammonia, drain cleaner) are worse than acids, because they penetrate deeper.
• Immediate action -irrigate before anything else:
  • Topical anaesthetic drops, then irrigate with at least 1–2 litres of saline or Hartmann's (or tap water if nothing else) for at least 20–30 minutes.
  • Hold the lids open; use a Morgan lens if available.
  • Check pH with litmus paper 5 minutes after stopping; continue until the pH is 7.0–7.5.
  • Sweep the fornices and evert the lids to remove particles (cement).
• Then: Acuity; fluorescein; urgent ophthalmology review.
• Bad signs: A white, blanched eye (loss of blood supply to the limbus -worse than a red eye), corneal haze.
• Treatment (specialist) -antibiotics, steroids, vitamin C, doxycycline, lubricants, cycloplegics; amniotic membrane grafts.

⚠️ Safety Pearl: For a chemical splash, irrigate first and ask questions later. Every minute of delay increases damage -don't wait to check acuity or call for help.

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Blunt Trauma and Blowout Fracture

• Hyphaema -blood in the anterior chamber (a fluid level):
  • Same-day ophthalmology.
  • Rest with head up; steroid and dilating drops; check pressure.
  • Risk of rebleeding and raised pressure; extra care in sickle cell disease.
  • Avoid NSAIDs and anticoagulants if possible.
• Orbital blowout fracture -a blow from a fist or ball breaks the thin orbital floor:
  • Double vision on looking up (inferior rectus trapped).
  • Numb cheek and upper lip (infraorbital nerve).
  • Sunken eye (enophthalmos); surgical emphysema -advise no nose blowing.
  • CT orbits; maxillofacial and ophthalmology review.
  • Children -"white-eyed blowout": trapped muscle with little bruising, nausea and vomiting, slow heart rate (oculocardiac reflex) -urgent surgery.
• Retrobulbar haemorrhage -orbital compartment syndrome:
  • After trauma or eye surgery, or on anticoagulants.
  • Painful, tense proptosis, falling vision, RAPD, restricted movements, hard eye.
  • Emergency lateral canthotomy and cantholysis within about 90–120 minutes to save the sight.
• Other -commotio retinae (retinal bruising), retinal detachment, lens dislocation, traumatic optic neuropathy.

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Penetrating Injury

• Clues:
  • Mechanism -sharp object, glass, high-velocity metal.
  • Reduced vision; teardrop or irregular pupil (pointing to the wound).
  • Shallow anterior chamber; prolapsed dark tissue (iris).
  • Seidel test -fluorescein streams away from a leaking wound.
  • Severe subconjunctival haemorrhage hiding a scleral rupture.
• Management:
  • Don't press on the eye; don't remove an impaled object.
  • Rigid eye shield (not a pad).
  • Keep nil by mouth (surgery); antiemetic (vomiting raises eye pressure); analgesia.
  • Tetanus status; IV or oral antibiotics (e.g. a fluoroquinolone) to prevent endophthalmitis.
  • CT orbits to look for a foreign body.
  • Immediate ophthalmology for surgical repair.
• Sympathetic ophthalmia -rare inflammation in the uninjured eye weeks to years after a penetrating injury.

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Drug Reference Table

Drug	Key points
Chloramphenicol 0.5% drops / 1% ointment	Bacterial conjunctivitis; corneal abrasion (ointment four times daily).
Levofloxacin / ofloxacin drops	Bacterial keratitis and contact lens wearers (Pseudomonas); intensive dosing on specialist advice.
Ganciclovir 0.15% gel / aciclovir 3% ointment	Herpes simplex dendritic ulcer, five times daily.
Aciclovir 800 mg five times daily or valaciclovir 1 g three times daily	Herpes zoster ophthalmicus for 7 days, within 72 hours.
Acetazolamide 500 mg IV	Acute angle closure. Avoid in sulfonamide allergy; caution in kidney disease and sickle cell.
Pilocarpine 1–2%	Acute angle closure -constricts the pupil.
Timolol 0.5% / apraclonidine	Lower pressure in acute glaucoma; timolol avoided in asthma.
Prednisolone acetate 1% drops	Anterior uveitis (specialist); tapered; check pressure.
Cyclopentolate 1%	Uveitis pain and synechiae; large abrasions.
Olopatadine / sodium cromoglicate	Allergic conjunctivitis.
Co-amoxiclav oral	Preseptal cellulitis.
Ceftriaxone + metronidazole IV	Orbital cellulitis (per local policy); gonococcal neonatal conjunctivitis (ceftriaxone).
Saline / Hartmann's irrigation	Chemical injury -at least 1–2 L until pH 7.0–7.5.

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Spot the Emergency

Clue	Diagnosis / action
Sticky discharge both eyes, normal vision	Bacterial conjunctivitis -self-care ± chloramphenicol
Watery red eyes after a cold, tender pre-auricular node	Adenoviral conjunctivitis
Painless bright red patch on the sclera on warfarin	Subconjunctival haemorrhage -check BP and INR
Severe eye pain waking her at night, rheumatoid arthritis	Scleritis -same day
Photophobia and small pupil in a man with back stiffness	Anterior uveitis (ankylosing spondylitis)
Vomiting, haloes, fixed mid-dilated pupil, hard eye	Acute angle-closure glaucoma
Contact lens wearer with a painful eye and white corneal spot	Bacterial keratitis (Pseudomonas)
Branching ulcer on fluorescein	HSV keratitis -no steroids
Vesicles on the forehead and tip of the nose	Herpes zoster ophthalmicus (Hutchinson's sign)
Painful red eye with hypopyon 4 days after cataract surgery	Endophthalmitis
Child with swollen lid, proptosis and painful eye movements	Orbital cellulitis
Cement in the eye	Alkali injury -irrigate now
Double vision looking up and numb cheek after a punch	Orbital floor blowout fracture
Tense proptosis and falling vision after facial trauma on apixaban	Retrobulbar haemorrhage -lateral canthotomy
Hammering metal, gritty eye, normal-looking eye	Possible intraocular foreign body -X-ray/CT, not MRI
Copious pus in a 3-day-old baby	Gonococcal ophthalmia neonatorum

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Exam-style Scenarios

1. A 68-year-old woman has a severe headache, vomiting and a red left eye that started in a dark cinema. The left pupil is fixed and mid-dilated, the cornea is hazy and the eye feels hard.
Answer: Acute angle-closure glaucoma.

• Immediate ophthalmology; lie flat.
• Acetazolamide 500 mg IV; timolol and apraclonidine drops; pilocarpine; analgesia and antiemetic.
• Laser iridotomy to both eyes once settled.

2. A 24-year-old contact lens wearer has a painful, photophobic right eye. Vision is 6/18 and there is a white spot on the cornea that stains with fluorescein.
Answer: Bacterial keratitis.

• Same-day eye casualty; remove lenses; send lenses and case for culture.
• Corneal scrape; intensive fluoroquinolone drops.
• Advice on lens hygiene; no sleeping or swimming in lenses.

3. A builder gets wet cement in his eye. He arrives at ED in pain.
Answer: Alkali chemical injury.

• Immediate topical anaesthetic and irrigation with at least 1–2 L of saline.
• Check pH after 5 minutes; continue until 7.0–7.5; remove particles from the fornices.
• Then acuity and fluorescein; urgent ophthalmology.

4. A 32-year-old man with ankylosing spondylitis has a painful, light-sensitive red eye with blurred vision and a small, irregular pupil.
Answer: Acute anterior uveitis (HLA-B27).

• Same-day ophthalmology.
• Steroid drops and cyclopentolate; monitor pressure.
• Advise early review for future attacks.

5. A 6-year-old has a swollen, red left upper lid after a cold. She has a fever, the eye is pushed forward and eye movements are painful.
Answer: Orbital cellulitis from ethmoid sinusitis.

• Admit; IV antibiotics; CT orbits and sinuses.
• Ophthalmology and ENT review; monitor vision and pupils.
• Surgical drainage if an abscess is present.

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Key Points

• Red eye red flags: reduced vision, real pain, photophobia, abnormal pupil, corneal opacity, contact lenses, trauma or chemicals.
• Conjunctivitis: normal vision; bacterial (sticky -often self-limiting), viral (watery, contagious), allergic (itchy).
• Subconjunctival haemorrhage: painless; check BP and INR.
• Episcleritis is benign; scleritis is painful, sight-threatening and linked to rheumatoid arthritis and vasculitis.
• Anterior uveitis: photophobia, ciliary flush, small pupil -steroid and dilating drops; think HLA-B27 and sarcoid.
• Acute angle closure: vomiting, haloes, fixed mid-dilated pupil, hard eye -acetazolamide, drops, laser to both eyes.
• Contact lens wearer with a painful red eye: refer the same day (Pseudomonas keratitis).
• Dendritic ulcer = HSV: topical antiviral, never steroid drops.
• Hutchinson's sign predicts eye involvement in zoster; oral antiviral within 72 hours.
• Orbital cellulitis: proptosis, painful restricted movements, reduced vision -IV antibiotics and CT.
• Chemical injury: irrigate immediately until pH is neutral; alkali is worse than acid.
• High-velocity injury: image for an intraocular foreign body (CT, not MRI).
• Retrobulbar haemorrhage needs urgent lateral canthotomy.

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Guidelines and Further Reading

• NICE Clinical Knowledge Summaries: Red eye; Conjunctivitis -infective and allergic; Corneal superficial injury; Herpes zoster
• College of Optometrists -Clinical Management Guidelines
• The Royal College of Ophthalmologists -guidance on ophthalmic emergencies and referral urgency
• RCEM -guidance on eye injuries in the emergency department
• BNF -for current doses

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