Itchy or Irritating Eyes or Eyelids
Differential Diagnosis
Common Diagnoses
- Allergic Conjunctivitis (Usually Hay Fever)
- Infective Conjunctivitis
- Dry Eyes
- Blepharitis
- Blocked Tear Duct
Occasional Diagnoses
- Ectropion
- Entropion
- Eczema of the Eyelids
- Effect of Contact Lenses or Solutions
- Iatrogenic (Oral or Local Medication)
- Foreign Body (Though Usually Presents with Pain and Redness)
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 Conjunctivitis | Infective Conjunctivitis | Dry Eyes | Blepharitis | Blocked Tear Duct | |
|---|---|---|---|---|---|
| Bilateral | Yes | Possible | Yes | Yes | Possible |
| Eyes Red | Yes | Yes | Possible | No | No |
| Eyelids Red | Possible | No | No | Yes | No |
| Seasonal | Possible | No | No | No | No |
| Discharge | Yes | Yes | Possible | No | Yes |
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.