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Itchy or irritating eyes or eyelids

GPs Dr Keith Hopcroft and Dr Vincent Forte look at a common presentation and offer guidance on likely causes and red flags

This is a nuisance symptom that 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.

Differential diagnosis


• Allergic conjunctivitis (usually hay fever)

• Infective conjunctivitis

• Dry eyes

• Blepharitis

• Blocked tear duct


• 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


• Pubic lice – can affect eyelashes

• Floppy eyelid syndrome – chronic conjunctivitis with lax eyelids in obese, middle-aged men

• Sebaceous gland carcinoma

• Thyroid eye disease



• Swab: may be necessary in persistent discharge; essential in neonates who have had sticky eyes since birth.

• Schirmer's test: to assess for dry eye – may be performed by the optician.


• TFT, thyroid autoantibodies, MRI orbits – if thyroid eye disease is suspected.

• 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 over-the-counter 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 sticky eyes from birth.

• The rare sebaceous gland carcinoma causes blepharitis-type symptoms, but with localised inflammation and localised loss of lashes.


Dr Keith Hopcroft is a GP in Basildon, Essex

Dr Vincent Forte is a GP in Gorleston, Norfolk

This is an extract from the fourth edition of Symptom Sorter. Pulse readers can buy Symptom Sorter at the special price of £19.99 plus P&P (usual price £24.99 plus P&P). To claim the discount, please order direct from Radcliffe Publishing at entering discount code DX62 at the checkout, or order by telephone on 10235 528820 quoting the same code. Offer ends 17 December 2010

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