The 35 Golden Eye Rules

THE 35 GOLDEN EYE RULES
1.
Always test and record vision
The patient should wear any distance spectacles during eye chart
A 1mm pin hole will improve acuity in refractive errors.
testing.
2.
Never pad a discharging eye
3.
Any blurred vision requires prompt investigation
disease.
4.
5.
6.
7.
Allow it to drain.
Distinguish whether it is sudden or gradual, painful or painless.

Distorted vision (metamorphsia) may indicate treatable macular
Refer squint (strabismus) when it is detected because:
Children do not grow out of squints.
Intraocular pathology must be excluded.
Amblyopia requires early treatment.
Irritable eyes are often dry
Dry eyes: use tear supplements.
Blepharitis: check lid hygiene, remove crusting.
Chronic allergy: avoid steroids.
Ask patients with a red eye about, photophobia, reduced vision, frank
ocular pain. They may indicate a significant ocular problem such as:
Corneal foreign body
Corneal ulcer / keratitis
Intraocular inflammation (uveitis)
Acute glaucoma
Refer patients with eyelid ulcers
An eyelid ulcer may be a basal cell carcinoma.
8.
Conjunctivitis is almost always bilateral, (sooner or later)
Bacterial conjunctivitis responds rapidly to treatment.
Pre-auricular lymphadenopathy may indicate viral conjunctivitis.
If conjunctivitis is recurrent it may be due to a blocked nasolacrimal
duct.
9.
10.
A corneal abrasion should heal in 24 hours if the cause is removed
Use antibiotic ointment and a doubled pad.
Review the patient daily until the lesion is healed.
Patients with UV flash burns may need sedation.
Exclude a dendritic ulcer.
Never use steroids if herpes simplex is suspected

With herpes simplex remember:
11.
It may be relatively painless
There is often a history of recurrence and scarring
Use antivirals only
Refer the patient
Retinal detachment requires referral
12.
13.
Warning signs of retinal detachment include floaters, flashes and field

defects.
More mistakes in medicine are made by not looking than not knowing
Eye examination requires illumination and magnification.
Local anaesthetic drops in single use containers assist examination of

painful lesions.
Never use anaesthetic drops for continued pain relief.
Fluorescein staining highlights epithelial abrasions or ulcers.
Prevent corneal exposure
14.
Protect the cornea during anaesthesia or loss of consciousness

remove any contact lenses and tape the eyelids closed.
Lubricants or lid surgery are indicated in exophthalmos or facial palsy.
Steroids are dangerous

Complications of steroids include:
15.
16.
Corneal perforation with herpes simplex.
Glaucoma (open angle)
Cataract formation
Infection (fungal)
If there is a corneal abrasion, look for a foreign body
Evert and closely inspect the upper eyelid for a subtarsal foreign body
and remove it with a moistened cotton bud.
Look for ingrowing eyelashes.
Leave some foreign bodies alone
17.
18.
19.
Never attempt to remove foreign bodies that are deep central corneal,
intra-ocular or intra-orbital. Refer patients with these foreign bodies.
Consider an intra-ocular foreign body
Suspect one if there is a history of hammering or high-speed injury.
The entry wound may seem trivial.
If it is suspected, send the patient for an X-ray and refer.
Sudden loss of vision is an emergency
In the elderly, suspect temporal arteritis. With optic nerve ischaemia,

the patient will have an afferent pupil defect start high-dose oral
steroids and confirm the diagnosis by recording the elevated ESR.
Other causes of sudden loss of vision include retinal artery or vein

occlusion and macular haemorrhage
A penetrating eye injury is an emergency
Use a sterile pad with no eye drops or ointment.
20.
21.
22.
23.
Make sure the patient has nil by mouth.
If treatment is delayed, give systemic antibiotics/tetanus toxoid.
Gentle transport is essential: use analgesia, anti-emetics and sedation.
With facial and lid injuries, first exclude eye injury
Eyelid lacerations require accurate apposition of the lid margin.
Do not excise eyelid skin.
Using the ophthalmoscope
Pupil dilatation aids diagnosis.
Use tropicamide 0.5% to dilate the pupil.
The only contraindication to dilation is head injury.
The risk of precipitating acute glaucoma when dilating a pupil is low.
Irrigate chemical burns
Immediately irrigate copiously with water for 15 minutes.
Instill a local anaesthetic to evert and swab the eyelids.
Refer the patient for emergency eye care.
Optic discs are easily seen

Consider:
24.
Papilloedema if there are blurred margins and the patient has good
vision.
Optic neuritis if there are reduced vision, pain on eye movements and
an afferent pupil defect, with or without visible disk abnormality. This
is a disease of young patients.
Ischemic optic neuropathy: Painless loss of vision, disk swelling,

afferent papillary defect.
Behind the black eye there may be a blunt eye injury
If there is diplopia, suspect a blowout fracture of the orbital floor. An

X-ray or CT scan is needed.
25.
Hyphaema may indicate a severe injury. To avoid a rebleed, prescribe

rest and tell the patient to avoid aspirin. Refer the patient
Transient blindness can be serious

Causes include:
26.
27.
28.
29.
Carotid artery disease - occasionally retinal emboli are visible.
Migraine aura (often without headache).
Blindness in diabetes mellitus is largely preventable
Perform ophthalmoscopy through dilated pupil at time of diagnosis

(except in prepubertal children).
Repeat screening five years after diagnosis, then at least two-yearly.
Refer the patient if retinopathy is present.
Hypertensive retinopathy
Its presence may indicate longstanding or severe hypertension.
These patients are prone to retinal vein and artery occlusion.
Visual loss may be the presenting symptom of malignant hypertension
Headaches are rarely due to a refractive cause
Ocular causes - examine for acute glaucoma, iritis, scleritis
Extra-ocular causes - examine for papilloedema, visual field defects,

temporal artery tenderness.
Visual field defects are ocular (horizontal) or central (vertical)

Consider:
30.
Vertical - homonymous hemianopia, bitemporal field defects.
Horizontal - branch artery occlusion, open-angle glaucoma, retinal

detachment.
Pupil examination differential diagnoses:
Pupil is irregular - iritis, injury, surgery.
Pupil is dilated - Ocular trauma, third nerve palsy, adrenergic drugs.
31.
32.
Pupil is constricted - Horners syndrome, narcotics, glaucoma drops

(pilocarpine), iritis
There is an afferent pupil defect - retinal artery occlusion or optic

nerve lesion.
Cataract surgery is the most common eye operation
It is advised when symptoms are interfering with the patients lifestyle.
It is minimally invasive with local anaesthesia and day surgery.
Cataract does not recur. YAG laser capsulotomy may be required at a

later date.
Chronic open-angle glaucoma requires screening

There are no early signs or symptoms.
33.
It is familial.
Elevated intra-ocular pressure causes optic disc cupping and visual

field loss.
Treatment compliance is a problem.
Recommend routine screening for all adults older than 40. Ocular
examination for presbyopic glasses provides a good opportunity for
screening.
Acute angle closure glaucoma is rare
It is rare in people younger than 60.
vomiting.
Symptoms include pain, haloes and blurred vision, nausea and
Signs include a shallow anterior chamber, a red eye, hazy cornea and a
fixed mid dilated oval pupil.
Treatment: start pilocarpine drops and diamox, then refer urgently.
34.
Admit the following to hospital at once:
Hyphaema.
Hypopyon.
Penetrating eye injuries.
Severe chemical burns.
Acute glaucoma.
If you dont know, ask.

35.
Beware of herpes zoster ophthalmicus if the nose is involved
If the external nasal branch is involved the eye is likely to be involved.
Early systemic treatment is required.
Assessment by an ophthalmologist is essential.
References
Based on the original Golden Eye Rules by Dr John L. Colvin and reviewed by Dr.
Ehud Zamir, Director of Medical Eye Education, Royal Victorian Eye & Ear Hospital
1 November 2004

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THE 35 GOLDEN EYE RULES

Always test and record vision

A 1mm pin hole will improve acuity in refractive errors.

Never pad a discharging eye

Any blurred vision requires prompt investigation

Distinguish whether it is sudden or gradual, painful or painless.

Refer squint (strabismus) when it is detected because:

Children do not grow out of squints.

Intraocular pathology must be excluded.

Amblyopia requires early treatment.

Irritable eyes are often dry

Dry eyes: use tear supplements.

Blepharitis: check lid hygiene, remove crusting.

Chronic allergy: avoid steroids.

Corneal foreign body

Corneal ulcer / keratitis

Intraocular inflammation (uveitis)

Refer patients with eyelid ulcers

An eyelid ulcer may be a basal cell carcinoma.

Conjunctivitis is almost always bilateral, (sooner or later)

Bacterial conjunctivitis responds rapidly to treatment.

Pre-auricular lymphadenopathy may indicate viral conjunctivitis.

If conjunctivitis is recurrent it may be due to a blocked nasolacrimal

A corneal abrasion should heal in 24 hours if the cause is removed

Use antibiotic ointment and a doubled pad.

Review the patient daily until the lesion is healed.

Patients with UV flash burns may need sedation.

Exclude a dendritic ulcer.

Never use steroids if herpes simplex is suspected

It may be relatively painless

There is often a history of recurrence and scarring

Use antivirals only

Refer the patient

Retinal detachment requires referral

Warning signs of retinal detachment include floaters, flashes and field

Eye examination requires illumination and magnification.

Local anaesthetic drops in single use containers assist examination of

Never use anaesthetic drops for continued pain relief.

Fluorescein staining highlights epithelial abrasions or ulcers.

Prevent corneal exposure

Protect the cornea during anaesthesia or loss of consciousness

Lubricants or lid surgery are indicated in exophthalmos or facial palsy.

Steroids are dangerous

Corneal perforation with herpes simplex.

Glaucoma (open angle)

If there is a corneal abrasion, look for a foreign body

Look for ingrowing eyelashes.

Leave some foreign bodies alone

Consider an intra-ocular foreign body

Suspect one if there is a history of hammering or high-speed injury.

The entry wound may seem trivial.

If it is suspected, send the patient for an X-ray and refer.

Sudden loss of vision is an emergency

In the elderly, suspect temporal arteritis. With optic nerve ischaemia,

Other causes of sudden loss of vision include retinal artery or vein

A penetrating eye injury is an emergency

Use a sterile pad with no eye drops or ointment.

Make sure the patient has nil by mouth.

If treatment is delayed, give systemic antibiotics/tetanus toxoid.

Gentle transport is essential: use analgesia, anti-emetics and sedation.

With facial and lid injuries, first exclude eye injury

Eyelid lacerations require accurate apposition of the lid margin.