Itchy or Irritating Eyes or Eyelids

This is a nuisance symptom which patients present with directly, or via their optician. It can be very difficult to ascertain whether the problem is arising from the eyelid or the eye itself. Often, the symptoms affect both and the causes overlap – which is why they’re considered together here.

Published: 2nd August 2022 | Updated: 15th August 2022

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 ConjunctivitisInfective ConjunctivitisDry EyesBlepharitisBlocked Tear Duct
Eyes RedYesYesPossibleNoNo
Eyelids RedPossibleNoNoYesNo

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.
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Website disclaimer

Pulse Reference is based on the best-selling book Symptom Sorter.

The experts behind Pulse Reference are Dr Keith Hopcroft who is the co-author of Symptom Sorter, a GP in Essex and Pulse’s editorial advisor and Dr Poppy Freeman, a GP in Camden and also a clinical advisor to Pulse.

This website is for clinical guidance only and cannot give definitive diagnostic information. Practitioners should work within the limits of their individual professional practice, seek guidance when necessary and refer appropriately.