Ophthalmology diagnosis and triage flowcharts (Guidelines)

TAM (Treatments and Medicines) NHS Highland
NHS Highland

Audience

  • Highland HSCP 

Obvious ophthalmological emergencies

  • Penetrating injuries
  • Chemical burns
  • Orbital cellulitis
  • Endophthalmitis
  • Sudden profound visual loss
  • Acute angle closure glaucoma
  • Corneal ulcer

See: Ophthalmology emergency guidelines

Double vision

Double vision (diplopia)
Two separate or one blurred image?
True Diplopia
Blurred vision
Diplopia still present with each eye covered separately?
See visual loss algorithm (Figure 3.2)
Yes
No
Monocular diplopia
Binocular diplopia
Still present when patient looks through a pinhole?
How are the 2 images seperated?
Yes
No
Horizontally
Vertically
Cortical abnormality
Media opacity, usually cataract
Ask the patient to look to the side that makes the diplopia worse
Aniscoria or ptosis present
Aniscoria or ptosis absent
CN III palsy
Possible aneurysm - refer physicians urgently
Eyes converge
Eyes diverge
Signs of thyroid orbitopathy present
Signs of thyroid orbitopathy absent
CNVI palsy
Internuclear ophthalmo-plegia
Restrictive myopathy usually tight inferior rectus
CN IV

 

KEY:
  Refer urgently: see Protocols overnight
  Email letter same day*
  Refer community optometrist
  Non urgent letter

 

*Book NTC Ophthalmology appointment following day if seen overnight.

 

Pupil size

Pupil sizes different (anisocoria)
Estimate degree of anisocoria in light and dark
Greatest in bright conditions
No significant difference
Greatest in the dark
Failure of the large pupil to constrict
Essential anisocoria
Failure of the small pupil to dilate
Ptosis and/or abnormal eye movements?
Subtle ptosis and/or dilation lag present?
Yes
No
Yes
No
CNIII palsy
Possible aneurysm
Refer physicians urgently
Adie's pupil
Horner's syndrome
If neck pain possible dissecting carotid aneurysm
Refer physicians urgently
Iritis: synechia indicate a previous bout of intraocular inflammation

 

KEY:
  Refer urgently: see Protocols overnight
  Email letter same day*
  Refer community optometrist
  Non urgent letter

 

*Book NTC Ophthalmology appointment following day if seen overnight.

 

Red eye

Red eye(s)
Unilateral or bilateral?
Unilateral
Bilateral
Lashes touching the eye
Ocular symptom
Yes
No
Predominately itchy
Predominately gritty or burning
Entropion or Trichiasis
Normal eyelid closure?
Allergic conjunctivitis
Discharge present?
Yes
No
Yes
No
Fluorescein dye application
CN VII palsy
Infective conjunctivitis
Dry eyes
Corneal staining
No corneal staining
Cornea appearance
Are pupil sizes different?
Focal hazy
Clear
Pupil larger and unresponsive on red eye side
Pupil same size or smaller on red eye side
Corneal ulcer
Corneal abrasion
Acute angle-closure glaucoma
Is photophobia present?
Yes
No
Iritis
Is the eye painful?
Yes
No
Scleritis
Episcleritis
KEY:
  Refer urgently: see Protocols overnight
  Email letter same day*
  Refer community optometrist
  Non urgent letter

 

*Book NTC Ophthalmology appointment following day if seen overnight.

 

Visual loss

Visual loss
Monocular visual loss - anterior visual pathway lesion
Binocular visual loss - posterior visual pathway lesion
Visual acuity
Pattern of field loss
Visual acuity reduced
Normal visual acuity but visual field defect
Homonymous defect
Bitemporal defect
Pinhole visual acuity
Peripheral retina
Post-chiasmal
Chiasmal
Visual acuity reduced
Visual acuity normal
Probable CVA: refer physicians urgently
Swinging flashlight test
Refractive error
Relative afferent pupillary defect (RAPD) present
RAPD absent
Fundoscopy
Fundoscopy
Abnormal retinal appearance
Normal retinal appearance
Clear retinal view
Hazy retinal view
Retina
Optic nerve
Macula
Media opacity

 

KEY:
  Refer urgently: see Protocols overnight
  Email letter same day*
  Refer community optometrist
  Non urgent letter

 

*Book NTC Ophthalmology appointment following day if seen overnight.

Watery eyes

Watery eyes (epiphoria)

Any of the following present:

  • Foreign body sensation
  • Redness
  • Corneal staining with fluorescein?
Yes
No
Reflex lacrimation
Lacrimal outflow abnormality
See red eye algorithm
Are lids in a normal position?
Yes
No
Is the blink and / or eye closure normal?
Ectropion
Yes
No
Punctal stenosis
CN VII palsy
Canalicular stenosis
Nasolacrimal duct stenosis

 

KEY:
  Refer urgently: see Protocols overnight
  Email letter same day*
  Refer community optometrist
  Non urgent letter

 

*Book NTC Ophthalmology appointment following day if seen overnight.

 

Editorial Information

Last reviewed: 01/02/2026

Next review date: 01/02/2029

Author(s): Ophthalmology Review Group .

Version: 4.1

Approved By: TAM subgroup of the ADTC

Reviewer name(s): Dr T Leslie, Consultant Ophthalmologist .

Document Id: TAM185