Itchy or Irritating Eyes or Eyelids

Differential Diagnosis

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
Eyes RedYesYesPossibleNoNo
Eyelids RedPossibleNoNoYesNo

Possible Investigations


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.
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