Itchy or Irritating Eyes or Eyelids

Differential Diagnosis

Common Diagnoses

Occasional Diagnoses

Rare Diagnoses

  • Pubic Lice (Can Affect Eyelashes)
  • Floppy Eyelid Syndrome (Chronic Conjunctivitis with Lax Eyelids in Obese, Middle-Aged Men)
  • Sebaceous Gland Carcinoma
  • Thyroid Eye Disease

Ready Reckoner

Key distinguishing features of the most common diagnoses

Allergic ConjunctivitisInfective ConjunctivitisDry EyesBlepharitisBlocked Tear Duct
BilateralYesPossibleYesYesPossible
Eyes RedYesYesPossibleNoNo
Eyelids RedPossibleNoNoYesNo
SeasonalPossibleNoNoNoNo
DischargeYesYesPossibleNoYes

Possible Investigations

Likely:None.

Possible:Swab, Schirmer’s test.

Small Print:TFT, thyroid autoantibodies, MRI orbits, biopsy.

  • Swab: May be necessary in persistent discharge; essential in neonates who’ve had sticky eyes since birth.
  • Schirmer’s test: To assess for dry eye – may be performed by the optician.
  • TFT, thyroid autoantibodies, MRI orbits – may be required in suspected thyroid eye disease.
  • Biopsy: Rarely, if sebaceous gland carcinoma suspected.

Top Tips

  • Diagnosis can be difficult and an optician’s input may be invaluable.
  • Enquire about the use of OTC drops and their effect: This may give clues to the underlying problem. Sometimes, the drops themselves may be the cause.
  • It can be easy to overlook entropion – ask the patient to squeeze the eyes shut, then suddenly open them, in which case a subtle entropion should be revealed.
  • Bear in mind that patients with dry eyes sometimes paradoxically complain of a stringy discharge.

Red Flags

  • Remember that thyroid eye disease can present before biochemical dysfunction – if in doubt, refer.
  • Do not overlook a foreign body as a possible cause, especially if the history is vague and the symptoms unilateral.
  • Chlamydia and gonorrhoea must be excluded in the neonate with a sticky eye or eyes from birth.
  • The rare sebaceous gland carcinoma causes blepharitis-type symptoms, but with localised inflammation and localised loss of lashes.

Published: 2nd August 2022 Updated: 10th April 2024

Report errors, or incorrect content by clicking here.

What is Nursing in Practice Reference?

Based on the best-selling book Symptom Sorter, Nursing in Practice Reference is designed to help nurses working in primary and community care make sense of patient presentations. Written by GPs and adapted by nurses, it covers the vast majority of symptoms seen in primary care to inform different nursing disciplines with a range of responsibilities. Each symptom is organised into common, occasional or rare differentials, with distinguishing features, possible investigations and key points. It also provides guides on managing more than 350 conditions. The perspective is very much grass roots primary care, informed by the latest evidence and guidance.

Learn More

Disclaimer

Nursing in Practice Reference is based on the best-selling book Symptom Sorter. The experts behind Nursing in Practice Reference are Marilyn Eveleigh who is Nursing in Practice’s editorial advisor and a primary care nurse in East Sussex, Dr Keith Hopcroft who is the co-author of Symptom Sorter, a GP in Essex and Pulse editorial advisor and Dr Poppy Freeman, a GP in Camden and also a clinical advisor to Pulse.