Intended for healthcare professionals

Practice Practice Pointer

Assessing the painful, uninflamed eye in primary care

BMJ 2015; 351 doi: (Published 04 August 2015) Cite this as: BMJ 2015;351:h3216
  1. Lucia Kuffova, senior clinical lecturer, University of Aberdeen; honorary consultant ophthalmologist, NHS Grampian1,
  2. John V Forrester, emeritus professor, University of Aberdeen; clinical professor, University of Western Australia2,
  3. Andrew Dick, professor of ophthalmology3
  1. 1Section of Immunity, Infection and Inflammation, Division of Applied Medicine, University of Aberdeen, School of Medicine and Dentistry, Aberdeen AB25 2ZD, UK
  2. 2Ocular Immunology Program, Centre for Ophthalmology and Visual Science, University of Western Australia, Western Australia, 6009 Australia; and Centre for Experimental Immunology, Lions Eye Institute, Nedlands, WA 6009, Australia
  3. 3Academic Unit of Ophthalmology, School of Clinical Sciences, University of Bristol, Bristol BS8 1TD; National Institute for Health Research (NIHR) Biomedical Research Centre at Moorfields Eye Hospital and University College London Institute of Ophthalmology, London EC1V 2PD, UK
  1. Correspondence to: J V Forrester j.forrester{at}

The bottom line

  • For the patient with a painful, uninflamed eye, it is crucial to check vision—reduced visual acuity is the major alarm signal of serious eye disease

  • Refer all patients with eye pain who have reduced vision

  • Eye pain without visual loss or redness is most often due to non-sight threatening conditions. A careful history and simple, direct examination will differentiate serious from less serious conditions

  • Be alert to potentially sight threatening or life threatening conditions (such as giant cell arteritis, intracranial aneurysm, optic neuritis, and raised intracranial pressure).

  • Be alert to occult eye disease (such as chronic glaucoma, chronic uveitis, and unsuspected trauma)

Eye pain is common. Around 2-5% of general practice patients have an eye complaint featuring pain in and around the eye (ocular, periocular, and periorbital pain, described here collectively as eye pain).1 Among patients attending an ophthalmic emergency department in New Zealand, more than 50% of new referrals were from general practices,2 with eye pain being the most common symptom. The authors suggested that referrals could be reduced with better initial diagnosis.

Eye pain with an inflamed, red eye is common and can be readily triaged for a management plan, in most cases by simple examination with a direct ophthalmoscope3 or pen torch. This is discussed elsewhere in relation to the differential diagnosis and treatment of conjunctivitis4 and when to refer for slit-lamp examination for sight threatening ocular surface inflammation or uveitis.5 Eye pain in an uninflamed (white) eye is less common.6

Guidelines for the diagnosis of conjunctivitis have been produced by the Dutch College of General Practitioners,7 and evidence based summaries on management of the red eye are available (, but no validated guidelines for the painful, inflamed or uninflamed, eye have been developed. The present advice is based on …

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