Dry eye, glaucoma and cataract: AU general practice eye screening

The major chronic eye conditions encountered in Australian general practice are dry eye disease, glaucoma, cataract, diabetic retinopathy, and age-related macular degeneration (AMD). The general practitioner’s role in eye health is not to be the treating ophthalmologist — it is to ask opportunistically about the last eye examination, identify high-risk patients, recognise emergencies, and coordinate appropriate referral.

RANZCO (the Royal Australian and New Zealand College of Ophthalmologists) and Glaucoma Australia recommend a comprehensive eye examination every two years from age 40, with annual review for people with family history of glaucoma, type 2 diabetes, Aboriginal and Torres Strait Islander background, or severe myopia. Approximately 50% of glaucoma in Australia remains undiagnosed at any point in time — making opportunistic identification by GPs one of the most impactful preventive actions in the consulting room.

A. Core clinical — the AU general-practice framework

Dry eye disease

Dry eye disease (DED) is the most common cause of chronic ocular surface symptoms in general practice, affecting a significant proportion of Australians — particularly postmenopausal women, those on anticholinergic medications, screen workers, and contact lens wearers.

The TFOS DEWS II report classifies DED into two principal mechanisms:

• Aqueous-deficient dry eye — insufficient tear volume; causes include Sjögren’s syndrome, lacrimal gland damage, and medications
• Evaporative dry eye — excessive evaporation due to meibomian gland dysfunction (MGD); the more common subtype; associated with blepharitis, rosacea, and prolonged screen use (reduced blink rate)

Symptoms: burning sensation, grittiness, fluctuating blurred vision that improves with blinking, photophobia, reflex tearing (paradoxically — the evaporative dry eye response), end-of-day worsening.

Causes to identify in the history:

• Age (most common single factor)
• Postmenopausal state and oestrogen changes
• Medications with anticholinergic burden — TCAs, antihistamines, oxybutynin, solifenacin; also beta-blockers, diuretics, isotretinoin
• Screen work with reduced blink rate
• Contact lens use
• Environmental factors — air conditioning, forced air heating, wind
• Sjögren’s syndrome (particularly when dry mouth and joint symptoms also present)
• Rosacea (a frequently missed cause of MGD)
• Post-refractive surgery (LASIK commonly disrupts corneal nerves and tear dynamics)

Sjögren’s screen: if dry eye is accompanied by dry mouth and arthralgia or joint swelling, send ANA, anti-Ro/La antibodies, RF, and ESR; refer to rheumatology if positive.

Glaucoma

Glaucoma is a progressive optic neuropathy characterised by damage to the optic disc and retinal nerve fibre layer, with corresponding visual field loss. Elevated intraocular pressure (IOP) is a major risk factor but not universal — normal-tension glaucoma exists, particularly in people of East Asian descent and those with vasoreactive disorders.

Types:

• Primary open-angle glaucoma (POAG) — most common; insidious onset; no symptoms until late
• Normal-tension glaucoma — POAG features with IOP ≤21 mmHg
• Primary angle-closure — see emergency section below
• Secondary glaucoma — steroid-induced (topical, inhaled, nasal, periocular, systemic), uveitic, pseudoexfoliative

Key risk factors:

• Age over 40 (risk rises sharply after 60)
• Family history (first-degree relative — approximately tenfold increased risk)
• Elevated IOP, severe myopia (POAG), severe hyperopia with shallow anterior chamber (angle closure)
• Type 2 diabetes, hypertension, vasospastic conditions
• Long-term corticosteroid use (any route)
• African or Caribbean descent (higher POAG risk); East Asian descent (higher angle-closure risk)
• Thin central corneal thickness

GP role in glaucoma:

• Ask at every health assessment: “When did you last have a comprehensive eye examination?”
• Identify risk factors and refer earlier if present
• Recognise that IOP alone is insufficient to screen for glaucoma — optic disc imaging (OCT), visual field testing, and gonioscopy are required for diagnosis
• Inform patients prescribed long-term corticosteroids of raised glaucoma risk and arrange regular eye review

Cataract

A cataract is opacity of the crystalline lens causing visual decline. Age-related nuclear sclerosis affects approximately 75% of Australians over 75. Additional causes include type 2 diabetes, prolonged steroid use (any route), trauma, prior uveitis, and post-vitreoretinal surgery.

Symptoms: gradual painless visual decline; glare especially with oncoming headlights at night; fading or yellowing of colours; monocular diplopia; the “second-sight” phenomenon (temporary near vision improvement as nuclear sclerosis increases lens power — followed by continuing deterioration).

Treatment is phacoemulsification with intraocular lens (IOL) implantation — performed once the cataract is visually disabling. IOL options include monofocal (standard, most common), multifocal or EDOF (extended depth of focus — added cost, not universally suitable), and toric (for corneal astigmatism correction).

On the public list: wait times typically 1–2 years; no patient out-of-pocket cost. Privately: faster access with a gap fee. Important pre-operative alert: patients taking tamsulosin (Flomax) or other alpha-1 blockers for benign prostatic hyperplasia are at risk of intraoperative floppy iris syndrome — inform the referring ophthalmologist when writing the referral.

Diabetic retinopathy

All patients with type 2 diabetes require dilated fundus examination every 1–2 years. The KeepSight programme — a national diabetic retinopathy screening registry — provides automated reminders by SMS or email when examination is due. GPs should register all type 2 diabetes patients on KeepSight; registration is free and can be initiated by the GP, optometrist, or endocrinologist.

Retinopathy staging progresses from non-proliferative (mild, moderate, severe — dot haemorrhages, hard exudates, cotton-wool spots) to proliferative (neovascularisation, vitreous haemorrhage, tractional retinal detachment). Treatment for proliferative DR and diabetic macular oedema involves intravitreal anti-VEGF injections and retinal laser — all managed by an ophthalmologist.

Pregnancy and pre-existing diabetes: diabetic retinopathy can rapidly worsen in pregnancy. Women with pre-existing T1DM or T2DM require eye examination pre-conception and in each trimester of pregnancy.

Age-related macular degeneration

AMD is the leading cause of irreversible vision loss in Australians over 50. Two forms:

• Dry (atrophic) AMD: progressive atrophy of the retinal pigment epithelium; drusen on fundoscopy; gradual central vision loss; no approved pharmacological treatment to reverse it; AREDS2 supplements (vitamin C, E, zinc, copper, lutein, zeaxanthin) may slow progression in intermediate or advanced disease
• Wet (exudative/neovascular) AMD: subretinal neovascularisation with sudden central vision loss and metamorphopsia (distortion); urgent ophthalmology referral for intravitreal anti-VEGF — ranibizumab (Lucentis), aflibercept (Eylea), faricimab (Vabysmo), or brolucizumab (Beovu); PBS Section 100 Authority

Smoking is the most important modifiable risk factor — smokers have two to four times the age-matched risk. Smoking cessation is strongly recommended. The Amsler grid (checkerboard pattern for home monitoring of metamorphopsia) is a useful tool for patients with known dry AMD.

B. Evidence and controversies

Question	Position	Evidence	AU bottom line
Universal glaucoma screening	High prevalence, ~50% undiagnosed, treatable	USPSTF rates as insufficient evidence for asymptomatic adults; cost; false positives	Targeted opportunistic from age 40; earlier if risk factors
IOP measurement alone for glaucoma screening	Quick and cheap	Misses normal-tension glaucoma; ocular hypertension common without glaucoma	Inadequate alone — requires disc/OCT/fields
SLT versus drops as first-line for POAG	LiGHT trial 2019 showed non-inferiority to drops; more drug-free; possibly cheaper long-term	Specialist procedure; not all centres offer it; some still need adjunctive drops	Reasonable first-line choice; patient preference and access
Anti-VEGF for wet AMD	Highly effective; prevents major vision loss	Monthly injections; rare endophthalmitis; PBS cost	Standard of care
AREDS2 supplements	Modest benefit in intermediate to advanced AMD	No benefit in early AMD; smokers — caution with beta-carotene (use AREDS2 formulation without)	Selected use — not for all
Topical ciclosporin or lifitegrast for DED	Effective in moderate-severe refractory DED	Slow onset (months); stinging; cost	Specialist referral; reserve for refractory

Clinical pearls

• Family history of glaucoma is the single biggest non-age risk modifier — first-degree relative warrants annual eye exams from age 40
• Do not miss acute angle-closure glaucoma presenting as headache, nausea, and vomiting without obvious eye signs — check the eye (hard globe, mid-dilated fixed pupil)
• Anticholinergic burden is a common treatable contributor to dry eye — review the medication list
• Tamsulosin before cataract surgery — document in referral every time
• Sudden monocular vision loss is not dry eye or cataract — this is a retinal emergency (retinal artery occlusion, vein occlusion, retinal detachment, optic neuritis)

C. First-line management — what GPs can do

Dry eye disease

Per eTG complete:

First-line (GP-managed):

• Preservative-free artificial tears — Refresh Plus, Systane Ultra Unit Dose, Hyalo-Vision, Optive Fusion UD; 4–6 times daily or as needed; preservative-free is preferable for frequent use (preserved drops can worsen surface toxicity)
• Lubricating gel or ointment at night — Polygel, Lacri-Lube, GenTeal Gel; reduces overnight epithelial drying
• Lid hygiene for MGD — warm compress 5–10 minutes daily; gentle expression of meibomian glands; commercial lid cleansers (Blephadex, OCuSOFT) or dilute baby shampoo on cotton wool
• Review and rationalise anticholinergic medications where possible

Refractory DED (ophthalmology referral):

• Topical ciclosporin 0.05% (Ikervis, Restasis) — reduces ocular surface inflammation; 3–6 months to full effect
• Lifitegrast 5% (Xiidra) — integrin antagonist; reduces T-cell mediated ocular surface inflammation
• Punctal plugs (aqueous-deficient DED) — reduces tear drainage; specialist procedure
• Autologous serum eye drops — specialist

Glaucoma

Medical management per eTG complete and PBS:

• Prostaglandin analogue (PGA) — first-line: latanoprost 0.005%, travoprost 0.004%, bimatoprost 0.03% — once daily nocte; reduces aqueous outflow resistance; General Schedule PBS; side effects include iris darkening, eyelash growth, periocular skin pigmentation
• Beta-blocker: timolol 0.25% or 0.5% — twice daily; adjunctive; caution in asthma, COPD, heart block, bradycardia, and depression (systemic absorption)
• Carbonic anhydrase inhibitor: dorzolamide 2% or brinzolamide 1% — adjunctive; twice to three times daily
• Alpha-2 agonist: brimonidine 0.15% — adjunctive; avoid in infants and young children (CNS depression from systemic absorption)
• Combination agents (Cosopt, Combigan, Duotrav, Ganfort) — improve adherence

Selective Laser Trabeculoplasty (SLT): increasingly used as first-line per the LiGHT trial (Lancet 2019); non-inferior to drops; can be repeated; specialist procedure.

Acute angle-closure glaucoma — immediate ED transfer:

• IV acetazolamide 500 mg plus topical pilocarpine 2%, timolol, apraclonidine, dorzolamide
• Definitive: YAG laser peripheral iridotomy (bilateral) — once acute IOP controlled

D. Australian operations

MBS items

• Optometry initial consultation (item 10907) — no GP referral required; Medicare bulk-billed at many practices
• Ophthalmology initial consultation (item 104); subsequent (item 105) — GP or optometrist referral required for Medicare rebate
• ATSI Health Assessment (item 715) — eye examination is a core component
• 75+ Annual Health Assessment (item 707) — includes vision review
• GPCCMP (items 965/967) — chronic eye condition management plans with allied health referral
• Cataract and glaucoma surgery — public hospital waitlist (1–2 years, no patient cost) or private (faster, gap fee applies)
• KeepSight diabetic retinopathy — optometry or ophthalmology consultations Medicare rebated; KeepSight registry tracks completion

MBS item lookup: mbsonline.gov.au.

PBS items for glaucoma

Prostaglandin analogues (latanoprost, travoprost, bimatoprost), timolol, dorzolamide, brinzolamide, and brimonidine are General Schedule PBS items. Combination preparations are also General Schedule. Anti-VEGF agents for wet AMD (ranibizumab, aflibercept, faricimab, brolucizumab) are PBS Section 100 Authority Required — specialist ophthalmologist prescribing. Details: pbs.gov.au.

Referral pathways

• Routine optometry: all adults from age 40 for glaucoma screening; annual for high-risk patients; annual diabetic retinopathy screen
• Ophthalmology routine: cataract once visually disabling; stable glaucoma requiring drug adjustment or monitoring; dry AMD monitoring
• Ophthalmology urgent (within days): new visual field loss, worsening glaucoma on treatment, suspected wet AMD with new distortion or rapid decline
• Ophthalmology emergency: acute angle-closure glaucoma (ED transfer), sudden monocular vision loss (retinal artery occlusion, retinal detachment, vitreous haemorrhage)
• Rheumatology: Sjögren’s screen positive

E. Special populations

Postmenopausal women. Both dry eye disease and cataract are more prevalent in postmenopausal women. Oestrogen deficiency may alter tear film composition. Menopausal hormone therapy may modulate dry eye but this is not a primary indication for HRT.

Patients on long-term corticosteroids. Any route of corticosteroid administration — topical, inhaled, nasal, periocular, or systemic — can raise IOP and accelerate cataract formation. Patients on long-term steroids should have regular eye examinations; document steroid use prominently in the ophthalmology referral.

Type 2 diabetes patients. Annual or two-yearly diabetic retinopathy screening via KeepSight is standard of care; accelerated cataract onset; IOP and optic disc review are also important given diabetes is a glaucoma risk factor.

Aboriginal and Torres Strait Islander patients. Higher rates of diabetes-related eye disease, trachoma in some remote communities, and limited access to specialist eye services. The ATSI Health Assessment (item 715) mandates vision and eye health review. Vision 2020 Australia co-ordinates outreach eye health programmes for ATSI communities.

When to escalate

Same-day emergency (ED): acute angle-closure glaucoma (sudden severe eye pain, halos, hard globe, mid-dilated pupil, nausea/vomiting), sudden monocular vision loss of any cause, retinal detachment (curtain or shadow across visual field, new floaters or flashes), chemical eye injury.

Urgent ophthalmology (within days): new wet AMD symptoms (sudden distortion or central scotoma), rapidly worsening visual field in established glaucoma, post-operative eye complications.

Routine ophthalmology: glaucoma requiring initiation or adjustment of treatment, cataract for surgical planning, moderate-to-severe refractory dry eye disease.

What this article is and is not

This article is general health information based on RANZCO, Glaucoma Australia, NHMRC glaucoma guidelines, KeepSight, eTG complete, TFOS DEWS II, and the LiGHT trial (Lancet 2019). It is not personal medical advice and does not create a doctor–patient relationship.

For Australian consumer information: Glaucoma Australia, Vision 2020 Australia, HealthDirect — Eye conditions.

---

Sources cited

1. RANZCO — Adult eye examination, glaucoma, cataract, AMD
2. Glaucoma Australia — Patient and GP resources
3. NHMRC — Primary Open Angle Glaucoma management guideline
4. Vision 2020 Australia
5. KeepSight — Diabetic retinopathy screening registry
6. eTG complete — Eye conditions, dry eye, glaucoma
7. TFOS DEWS II report on dry eye disease
8. LiGHT trial — SLT vs drops first-line for POAG (Lancet 2019)
9. PBS Australia — Glaucoma drops, anti-VEGF Section 100
10. MBS Online — optometry and ophthalmology items
11. HealthDirect — Eye conditions