Red eye and conjunctivitis: triage and treatment in Australian general practice

Red eye in general practice — what’s at stake

Red eye is one of the most common acute presentations in Australian general practice. The overwhelming majority are benign and self-limiting — viral conjunctivitis, bacterial conjunctivitis, allergic conjunctivitis, episcleritis, or subconjunctival haemorrhage. A small proportion, however, are vision-threatening emergencies: acute angle-closure glaucoma, anterior uveitis, scleritis, bacterial keratitis, herpetic keratitis, hyperacute gonococcal conjunctivitis, and orbital cellulitis.

The critical GP skill is rapid triage. Missing a vision-threatening presentation can result in permanent visual impairment. Getting triage right means confidently managing benign conditions without over-referring, while reliably identifying the minority that require same-day ophthalmology or emergency department care.

This article outlines the diagnostic framework used in Australian general practice, describes the common presentations, and maps the treatment and referral pathways, drawing on RANZCO guidance, Therapeutic Guidelines, AMH, and ASHM Australasian STI Management Guidelines.

A. Core clinical — the AU general-practice framework

The mandatory triage question

Before reaching for the chloramphenicol prescription, every red eye assessment must answer: is this an intraocular or corneal emergency?

Vision-threatening red flags — refer urgently to ophthalmology or ED:

• Vision loss or change — any blurring, scotoma, or distortion not relieved by blinking
• Severe eye pain — deep aching or pressure (distinct from the gritty discomfort typical of conjunctivitis)
• True photophobia — intolerance of normal indoor light, not merely glare
• Pupil abnormality — fixed, irregular, mid-dilated, miotic, or anisocoria
• Hypopyon — visible pus layering in the anterior chamber
• Hyphaema — visible blood in the anterior chamber
• Corneal haziness or opacity — inability to see iris detail clearly through the cornea
• Recent ocular surgery, significant trauma, or chemical exposure
• Contact-lens wearer with red eye — risk of bacterial keratitis (particularly Pseudomonas aeruginosa) and Acanthamoeba; standard topical chloramphenicol is insufficient

Specific emergencies to recognise:

Acute angle-closure glaucoma presents as sudden severe unilateral pain, coloured halos around lights, a mid-dilated fixed pupil, a hard (“rocky”) globe on palpation, decreased vision, nausea, and vomiting. This is an ophthalmic emergency — refer to the emergency department immediately for intraocular pressure reduction.

Anterior uveitis (iritis) — ciliary flush (perilimbal redness concentrated around the corneal limbus), true photophobia, miotic or irregular pupil, and pain that worsens with accommodation or light. Refer same-day to ophthalmology.

Scleritis — deep boring eye pain, severe redness that often fails to blanch with phenylephrine, globe tenderness on palpation. Associated with systemic autoimmune disease including rheumatoid arthritis and systemic vasculitis. Refer same-day.

Herpetic keratitis — painful red eye with photophobia; fluorescein staining under cobalt blue light reveals a dendritic (branching) epithelial ulcer pathognomonic of herpes simplex virus corneal infection. Hutchinson’s sign — vesicles on the tip of the nose or forehead indicating involvement of the nasociliary branch of V1 — signals herpes zoster ophthalmicus with high risk of ocular involvement. Start oral valaciclovir and refer urgently to RANZCO-trained ophthalmology.

Hyperacute gonococcal conjunctivitis — profuse purulent discharge developing within 24 hours, marked lid oedema and chemosis. Sight-threatening — corneal perforation can occur rapidly without treatment. Requires emergency department referral, intramuscular ceftriaxone, and full STI workup per ASHM.

Orbital cellulitis — proptosis, restricted or painful eye movements, severe lid swelling, fever, and decreased vision distinguish orbital (postseptal) from preseptal cellulitis. Orbital cellulitis is a systemic emergency requiring hospital admission, IV antibiotics, and imaging.

Visual acuity assessment

Document visual acuity using a Snellen chart (or equivalent distance chart) in every patient presenting with a red eye. This identifies vision loss that may be missed by history alone, establishes the baseline, and is essential for the referral record. Even rough assessment — count fingers, hand movements — is valuable when a chart is unavailable.

Fluorescein examination

Fluorescein strips and cobalt blue light should be used whenever pain, foreign-body sensation, contact-lens wear, or any suspicion of corneal pathology is present. A dendritic ulcer (HSV), punctate epithelial erosions (dry eye, toxic conjunctivitis), traumatic abrasion, or retained foreign body will be missed without this step. A Seidel test — aqueous leaking through a corneal wound producing a streaming sheen under blue light — identifies open globe injury, which is a surgical emergency.

B. Conjunctivitis by type — the common presentations

Viral conjunctivitis

Viral conjunctivitis — most commonly adenoviral — is the most frequent cause of infectious red eye. Features include watery or mucoid discharge, often starting unilateral and progressing to bilateral involvement within one to two days, and a preceding or concurrent upper respiratory tract infection. Preauricular lymphadenopathy may be palpable.

Management: supportive only. Cool compresses, preservative-free lubricant drops (hypromellose, Systane), and strict hand hygiene. Antibiotics are not effective and are not indicated per eTG. Resolves over one to two weeks.

Infectivity: highly contagious. Patients should avoid shared towels, pillows, and face cloths; wash hands before and after touching the eye; and avoid sharing eye-drop bottles. Separate pillowcases during the symptomatic period.

No school or childcare exclusion is required per Australian Government communicable disease guidelines, though symptomatic individuals should practise strict hand hygiene.

Epidemic keratoconjunctivitis (EKC) — caused by specific adenoviral serotypes (particularly adenovirus 8 and 19) — can produce subepithelial corneal infiltrates that cause persistent glare, photophobia, and visual blurring for weeks to months after the acute phase resolves. Refer ophthalmology if corneal involvement affects vision.

Bacterial conjunctivitis

Bacterial conjunctivitis is characterised by purulent yellow or green discharge, eyelids stuck together on waking, and typically unilateral onset. Common causative organisms in the community include Staphylococcus aureus, Streptococcus pneumoniae, and Haemophilus influenzae.

Management: the majority of cases self-resolve within seven days. Per eTG and AMH:

• Chloramphenicol 0.5% eye drops — one to two drops every two hours while awake on day one, then four times daily for five days
• Chloramphenicol 1% eye ointment — at night (particularly useful in young children or when drops are difficult to instil)
• Alternative: framycetin sulfate 0.5% with gramicidin drops, four times daily

In line with NICE CKS antibiotic stewardship guidance applicable in Australian practice, antibiotic treatment may be deferred in mild presentations with clear safety-net advice to return if symptoms worsen or persist beyond seven days.

No school exclusion is required unless purulent discharge is present and local policy mandates it. Hand hygiene is the key infection control measure.

Allergic conjunctivitis

Allergic conjunctivitis is characterised by intense itch as the dominant symptom, bilateral involvement, watery or stringy mucoid discharge, conjunctival oedema (chemosis), and eyelid swelling. There is typically a history of atopy, seasonal pollen exposure, pet dander, or dust mite sensitivity.

Management per eTG:

• Avoidance of identified allergens where practicable
• Cool compresses and preservative-free saline rinses
• Topical antihistamine or mast-cell stabiliser drops — olopatadine 0.1% twice daily is preferred (combined H1 antagonist and mast-cell stabiliser, rapid onset, Schedule 3 OTC); alternatives include ketotifen twice daily or sodium cromoglycate four times daily
• Oral antihistamines (fexofenadine, loratadine, cetirizine) for systemic atopic symptoms; allergic rhinitis frequently co-exists and can be managed concurrently
• Severe vernal or atopic keratoconjunctivitis — refer ophthalmology for topical ciclosporin or supervised steroid

STI-related conjunctivitis

Gonococcal conjunctivitis — hyperacute onset (within 24 hours), copious purulent discharge, marked chemosis and lid oedema. Sight-threatening — corneal perforation can occur without prompt treatment. Requires emergency department referral, intramuscular ceftriaxone 1 g, saline ocular irrigation, and full STI workup per ASHM Australasian STI Management Guidelines. Add oral doxycycline 100 mg twice daily for seven days to cover possible co-infection with chlamydia.

Chlamydial conjunctivitis — subacute or chronic mucopurulent discharge, large tarsal follicles on lid eversion, often without significant pain. STI workup including genital and pharyngeal swabs is essential. Treat with azithromycin 1 g orally as a single dose (or doxycycline 100 mg twice daily for seven days) per ASHM. Partner notification is required.

Trachoma — caused by specific Chlamydia trachomatis serovars — remains endemic in certain remote Aboriginal communities in Australia. Management follows the Australian Government trachoma programme SAFE strategy (Surgery, Antibiotics, Facial cleanliness, Environmental improvement) as a public health intervention. GPs practising in affected communities should be familiar with the programme protocols and reporting requirements.

C. Less common but important red eye conditions

Condition	Distinguishing features	Management
Subconjunctival haemorrhage	Painless, blood visible under conjunctiva, no vision change, no discharge	Reassure; resolves over one to two weeks; check blood pressure if recurrent; exclude open globe injury if traumatic
Stye (hordeolum)	Tender focal eyelid swelling at lash follicle	Warm compress three to four times daily; topical chloramphenicol; rarely requires incision
Chalazion	Painless firm lid lump, chronic meibomian gland blockage	Warm compress for four weeks; refer ophthalmology if persistent, for incision and curettage
Blepharitis	Lid margin inflammation, crusting, chronic dry eye component	Lid hygiene: warm compress and cleansing twice daily; preservative-free lubricants; low-dose doxycycline for rosacea-associated
Episcleritis	Sectoral redness, mild discomfort, no vision change, blanches with phenylephrine	Self-limiting; topical lubricant ± NSAID drops; autoimmune workup if recurrent or bilateral
Pterygium	Wedge of vascularised conjunctival tissue advancing from limbus onto cornea	Reassure; lubricants for dryness; refer ophthalmology if encroaching on the visual axis
Corneal foreign body / abrasion	History of exposure, pain, foreign-body sensation, fluorescein reveals defect or embedded material	Remove foreign body (cotton tip or 25G needle bevel-side); chloramphenicol drops for five days; review at 24–48 hours; no patching
Chemical injury	Exposure history, severe pain	Immediate copious irrigation for ≥30 minutes before transport; Morgan lens if available; pH testing; ED urgently
Dry eye	Bilateral grittiness, burning, fluctuating vision, worsens in air-conditioning	Preservative-free lubricant drops; see relevant dry eye resources
Pinguecula	Yellowish conjunctival nodule, UV-related	Reassure; lubricant if irritated; no treatment unless inflamed (pingueculitis)

Do not patch corneal abrasions — RANZCO and Cochrane evidence confirm no benefit from patching; it may slow healing and increase infection risk. Modern management is antibiotic prophylaxis and review.

Do not prescribe topical corticosteroid drops without ophthalmology involvement — topical steroids are harmful in herpetic keratitis, where they cause dendritic ulcers to expand rapidly and can lead to corneal perforation and permanent visual loss.

Do not dispense topical anaesthetic drops for home use — oxybuprocaine and amethocaine are for single in-clinic use only. Repeated application causes corneal epithelial toxicity and masks disease progression.

D. Australian operations — prescribing and referral pathways

Prescribing in Australian general practice

Per AMH and PBS Online:

• Chloramphenicol 0.5% drops and 1% ointment — Schedule 3 (pharmacist-only OTC); no prescription required in Australian pharmacies
• Olopatadine 0.1% drops — Schedule 3 (OTC); preferred for allergic conjunctivitis
• Ketotifen drops and sodium cromoglycate 2% drops — Schedule 3 (OTC); alternatives for allergic conjunctivitis
• Oral antihistamines — Schedule 2 or 3; widely available OTC
• Topical corticosteroid drops — prescription-only; require ophthalmology supervision; not appropriate for use in general practice without specialist input
• Aciclovir 3% ophthalmic ointment — requires ophthalmology or authorised prescriber; not initiate in general practice without specialist direction
• Valaciclovir (oral) — PBS-listed; appropriate to initiate in general practice for herpes zoster ophthalmicus (Hutchinson’s sign or periocular VZV) while arranging urgent ophthalmology referral
• Ceftriaxone — intramuscular; administered in emergency department for gonococcal conjunctivitis; not a general practice prescription in this context

MBS

Standard GP consultation items via MBS Online cover red eye assessment. The Aboriginal and Torres Strait Islander Health Assessment (item 715) includes ocular review and should incorporate a trachoma risk assessment in communities with endemic disease.

Referral pathways

Emergency department — call 000 or go immediately:

• Acute angle-closure glaucoma
• Hyperacute gonococcal conjunctivitis
• Chemical injury (after starting irrigation)
• Orbital cellulitis
• Suspected open globe (penetrating injury)
• Endophthalmitis (post-operative or post-traumatic)

Same-day ophthalmology:

• Anterior uveitis
• Scleritis
• Herpetic keratitis (dendritic ulcer on fluorescein)
• Herpes zoster ophthalmicus (Hutchinson’s sign or periocular lesions)
• Contact-lens wearer with red eye

Routine ophthalmology:

• Persistent EKC corneal infiltrates affecting vision
• Pterygium encroaching on the visual axis
• Persistent chalazion after four weeks of warm compress
• Severe or refractory allergic keratoconjunctivitis

STI clinic or sexual health service:

• Confirmed or suspected adult gonococcal or chlamydial conjunctivitis (plus partner notification per ASHM)

E. Special populations

Contact-lens wearers — any red eye in a contact-lens wearer is treated as potentially infectious keratitis until proven otherwise by ophthalmology. Advise immediate cessation of lens wear. Do not prescribe standard topical chloramphenicol as sole management — Pseudomonas aeruginosa keratitis and Acanthamoeba keratitis both require specialist-directed treatment.

Neonates — ophthalmia neonatorum requires urgent ophthalmology and paediatric infectious diseases input. Timing of onset guides the likely aetiology: chemical or sterile (first 24 hours, now uncommon following change from silver nitrate prophylaxis); gonococcal (24–48 hours, profuse purulent — emergency); chlamydial (5–14 days, mucopurulent — oral erythromycin required, not topical alone, to prevent chlamydial pneumonia); HSV (10–14 days, with possible vesicles — intravenous aciclovir). All neonatal conjunctivitis requires specialist management.

Children — antibiotic prescription for paediatric conjunctivitis can be deferred in mild cases. Evidence supports hand hygiene plus reassurance as the primary strategy for most viral presentations. For clearly bacterial purulent discharge, topical chloramphenicol is appropriate. Children and their families should be advised about hygiene to limit household transmission.

Older adults — subconjunctival haemorrhage is more common with age; check blood pressure if recurrent. Dry eye is prevalent and may present as a chronic red eye. Be cautious with topical anaesthetic administration in clinic in older patients who may have reduced tolerance or adherence.

First Nations Australians in remote communities — trachoma remains a public health challenge in specific regions. GPs practising in these areas should be familiar with the trachoma screening and SAFE programme pathways available through Australian Government resources.

When to escalate

Refer urgently to ophthalmology or ED:

• Acute angle-closure glaucoma — immediate ED
• Herpetic keratitis (dendritic ulcer on fluorescein) — same-day ophthalmology + valaciclovir
• Anterior uveitis — same-day ophthalmology
• Scleritis — same-day ophthalmology
• Orbital cellulitis — ED admission
• Hyperacute gonococcal conjunctivitis — ED + ceftriaxone
• Chemical injury — irrigate first, then ED
• Contact-lens wearer with red eye — ophthalmology (same-day if pain or vision change)

Refer routinely to ophthalmology:

• Persistent EKC corneal infiltrates causing visual symptoms
• Pterygium encroaching on the visual axis
• Persistent chalazion unresponsive to four weeks of warm compress
• Severe or refractory vernal or atopic keratoconjunctivitis

What this article is and is not

This is general health information drawn from current Australian clinical guidelines — RANZCO, Therapeutic Guidelines, AMH, ASHM — and is intended to support, not replace, clinical judgement. It is not personal medical advice and does not create a doctor–patient relationship. Decisions about diagnosis, treatment, and referral are made with your own GP or treating clinician. If you experience sudden vision loss, severe eye pain, or chemical exposure, seek emergency care immediately.

For Australian consumer information: HealthDirect — Conjunctivitis, Better Health Channel — Eye infections.

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Sources cited

1. Royal Australian and New Zealand College of Ophthalmologists (RANZCO)
2. Therapeutic Guidelines (eTG) — Eye and antimicrobial
3. Australian Medicines Handbook
4. ASHM Australasian STI Management Guidelines
5. NICE CKS — Conjunctivitis
6. Australian Government — School exclusion / communicable diseases
7. HealthDirect — Conjunctivitis
8. Better Health Channel — Eye infections
9. MBS Online
10. PBS Online