Delwar Hussain
Learning points
- Visual acuity is essential to ophthalmic examination – significant reduction in a patient’s visual acuity is a good indicator for referral (1)
- A safe primary care eye exam can be built around a systematic eye examination: Visual acuity (VA) → pupil assessment → eye movements → visual fields → anterior segment examination with fluorescein (1-2).
- Pain, photophobia, reduced VA, contact lens wear, corneal symptoms, trauma/chemical injury are common “red flags” that should lower your threshold for urgent referral (2-3).
Background
Eye presentations are frequent in general practice, but many referrals are delayed or less effective because key examination findings aren’t documented. Particularly visual acuity and “red flag” features. Quality improvement work in primary care shows that simple prompts and a standardised approach can markedly improve documentation of high-yield findings (4-5).
The aim of this article is to give FY2 doctors in GP a practical, quick, and defensible ophthalmic exam you can apply to most acute presentations.
The 5 minute eye examination in GP
1) Visual acuity (VA): do it first, every time
Moorfields’ primary care guidance explicitly advises recording best corrected VA (with glasses/contact lenses if used) and notes that significant VA reduction is a good indicator for referral urgency (1).
How to document
- Test one eye at a time (occlude without pressing).
- Record with correction (if worn) and consider pinhole if available.
Example:
VA: R 6/6 (with glasses), L 6/18 → 6/9 (pinhole).
2) Pupils
Check:
- size and symmetry
- direct and consensual responses
- swinging light test if unilateral visual loss/asymmetry (RAPD suggests optic nerve/retinal pathology) (1)
3) Eye movements
Assess extraocular movements in 6 directions and ask about:
- Diplopia
- Pain on movement
- Look for nystagmus
4) Confrontation visual fields
Quickly screen each eye. This supports triage in:
- Sudden visual loss
- Suspected retinal detachment symptoms (flashes/floaters + “curtain”)
- Neuro-ophthalmic concerns
5) Anterior segment inspection + fluorescein (high yield in GP)
NICE CKS red eye guidance recommends examination including inspection, VA, fluorescein examination, and pupil reactions (2).
Do this particularly for: red eye, pain, foreign body sensation, contact lens wear, trauma. Technique
- Inspect lids/lashes, conjunctiva, cornea clarity.
- Apply fluorescein and view with blue light (ophthalmoscope blue filter / Wood’s lamp).
What staining can mean
- Abrasion or ulcer: corneal staining can indicate abrasion/ulcer and warrants appropriate escalation depending on context (especially contact lens wear) (2).
- Trauma: NICE CKS corneal superficial injury highlights that fluorescein findings suggesting penetrating injury (e.g., streaming/positive seidel test) require immediate referral (6).
Lid eversion can reveal a retained subtarsal foreign body in persistent foreign body sensation.
Red flags: findings that should prompt urgent same-day escalation
Primary care guidance and QI work on red eye consistently emphasise that the following should lower your threshold for urgent ophthalmology/urgent eye care assessment:
- Reduced visual acuity (especially if new or unexplained) (2,1).
- Moderate to severe pain and/or photophobia (2-3).
- Contact lens wearer with red/painful eye or corneal staining (high risk microbial keratitis) (2-3).
- Corneal opacity/ulcer appearance, dendritic pattern, or significant corneal staining (2-3).
- Trauma (especially reduced VA, irregular pupil, suspected penetrating injury) (6).
- Chemical injury (irrigate immediately + emergency referral).
- Suspected acute angle-closure glaucoma (pain, headache, halos, nausea, fixed mid-dilated pupil).
- New field defect, RAPD, or sudden vision loss symptoms (1,3).
When referring, Moorfields’ “red eyes and red flags” article notes that the gross assessment of vision helps govern urgency and that worse vision with an inflamed eye should be referred more acutely (3).
Documentation that makes referrals safer (and faster)
Good ophthalmic documentation is not about writing more; it’s about writing the right things. Professional record keeping guidance emphasises full and accurate records made at the time (or as soon as possible after), including relevant history, findings, and actions/advice (7).
A GP-ready template
- Laterality, onset, trauma/chemical exposure, contact lens use
- Pain, photophobia, discharge, systemic symptoms
- VA (each eye; with correction; pinhole if used)
- Pupils (+/− RAPD), eye movements, confrontation fields
- Anterior segment findings + fluorescein result
- Working diagnosis, treatment given, safety netting, and referral destination/urgency
Practical kit list for GP
A small eye kit dramatically improves exam quality (1):
- Distance VA chart + pinhole
- Fluorescein strips + saline
- Direct ophthalmoscope with blue filter
- Access to topical anaesthetic if locally permitted and appropriately governed
- Cotton buds, eye pads and tape
Conclusion
As an FY2 in general practice, you don’t need specialist equipment to examine eyes safely; you need a repeatable method. Start with visual acuity, then pupils, movements, fields, and fluorescein anterior segment assessment. Combine this with clear documentation and a low threshold for referral when red flags are present. Your eye consultations become faster, safer, and more defensible.
References
- Moorfields Eye Hospital NHS Foundation Trust. For primary care providers. [cited 2025 Dec 18]. Available from: https://www.moorfields.nhs.uk/for-health-professionals/for-primary-care-providers
- NICE Clinical Knowledge Summaries. Red eye: Diagnosis. NICE; [cited 2025 Dec 18]. Available from: https://cks.nice.org.uk/topics/red-eye/diagnosis/diagnosis/
- Moorfields Eye Hospital NHS Foundation Trust. Red eyes and red flags – when to refer. [cited 2025 Dec 18]. Available from: https://www.moorfields.nhs.uk/private/refer-to-us/for-healthcare-professionals/news-and-articles/red-eyes-and-red-flags-when-to-refer
- Teo MAL. Improving acute eye consultations in general practice: a practical approach. BMJ Qual Improv Rep. 2014 Dec 10;3(1):u206617.w2852. doi:10.1136/bmjquality.u206617.w2852.
- Kilduff C, Lois C. Red eyes and red-flags: improving ophthalmic assessment and referral in primary care. BMJ Qual Improv Rep. 2016 Jun 29;5(1):u211608.w4680. doi:10.1136/bmjquality.u211608.w4680.
- NICE Clinical Knowledge Summaries. Corneal superficial injury: Assessment. NICE; [cited 2025 Dec 18]. Available from: https://cks.nice.org.uk/topics/corneal-superficial-injury/diagnosis/assessment/
- College of Optometrists. What to record. [cited 2025 Dec 18]. Available from: https://www.college-optometrists.org/clinical-guidance/guidance/knowledge%2C-skills-and-performance/patient-records/what-to-record