When should I refer patients with sore eyes to an ophthalmology specialist, considering their symptoms, medical history, and risk of morbidity or mortality?

When to Refer Patients with Sore Eyes to Ophthalmology

Refer immediately (within 24 hours) if the patient has any vision-threatening red flags: visual loss, moderate-to-severe pain, corneal involvement, severe purulent discharge, or photophobia. 1, 2

Immediate/Emergency Referral (Within 24 Hours)

Refer urgently to ophthalmology or the emergency department if any of the following are present:

• Visual loss or significant blurred vision - indicates potential corneal damage, uveitis, or other sight-threatening pathology 3, 1, 4
• Moderate or severe eye pain - suggests keratitis, uveitis, acute angle-closure glaucoma, or corneal ulceration 3, 1
• Corneal involvement - identified by fluorescein staining showing epithelial defects or corneal infiltration/ulceration 3, 1, 2
• Severe purulent discharge - particularly concerning for gonococcal conjunctivitis requiring systemic antibiotics 1, 2
• Photophobia with redness - indicates potential corneal or intraocular inflammation beyond simple conjunctivitis 1, 4
• Conjunctival scarring - suggests severe or chronic disease requiring specialist management 1, 2
• History of herpes simplex virus (HSV) eye disease - increases risk of recurrence and serious complications 1, 2
• Immunocompromised state - increases risk of atypical or severe infections 1, 2

Urgent Referral (Within 4 Weeks)

For adults with mild-to-moderate symptoms who fail initial treatment with lubricants and lid hygiene, refer within 4 weeks. 3

Specific scenarios requiring urgent (but not emergency) referral include:

• Lack of response to therapy after 3-4 days - particularly for bacterial conjunctivitis or blepharitis 3, 1, 2
• Recurrent episodes - suggests underlying chronic condition requiring specialist evaluation 3, 1, 2
• Severe dry eye unresponsive to treatment - particularly when systemic disease is suspected 3
• Orbital involvement - eyelid swelling with pain, restricted eye movement, or proptosis 3, 4

Special Population Considerations

Children and Young People (7-17 years)

• Severe symptoms require emergency assessment within 24 hours 3
• Mild-to-moderate symptoms unresponsive to lubricants or antihistamines require standard referral 3
• Children under 7 years should be discussed with ophthalmology for severity grading 3
• Pediatric patients should generally be referred sooner than adults 3

Patients on Dupilumab

For patients with atopic dermatitis on dupilumab therapy who develop ocular symptoms:

• Severe cases: refer for assessment within 24 hours or within 4 weeks based on clinical judgment 3
• Mild-to-moderate cases: refer within 4 weeks 3
• Any patient started on tacrolimus ointment to lid margins requires ophthalmology assessment within 4 weeks 3

Critical Pitfalls to Avoid

Do not initiate topical corticosteroids before ophthalmology evaluation if red flags are present - steroids can worsen infectious keratitis, prolong adenoviral infections, and mask HSV infections. 1, 2, 4

Always measure visual acuity - reduced visual acuity is an important diagnostic sign that is frequently missed in primary care, yet was present in eight of 15 seriously misdiagnosed cases in one study. 5

Consider child abuse - sexually transmitted conjunctivitis in children mandates consideration of abuse and appropriate reporting. 1

Conditions Safe to Manage Without Immediate Referral

You can manage the following in primary care with routine follow-up:

• Mild bacterial conjunctivitis - can resolve spontaneously; if treating, reassess in 3-4 days 1, 2
• Viral conjunctivitis without red flags - supportive care with artificial tears and cold compresses 1, 2
• Allergic conjunctivitis - topical antihistamines with mast cell stabilizers, cold compresses 1, 2
• Mild blepharitis - lid hygiene and warm compresses 3
• Mild dry eye - preservative-free lubricants 3

However, advise these patients to return immediately if symptoms worsen or if they develop any red flag features. 3