Cornea

 

This guideline summarises the most common corneal problems that may require referral from Primary Care.

 

Red Flags¹

• Significant reduction in visual acuity
• Significant trauma, including penetrating trauma
• Severe eye pain
• Irregular, dilated or non-reactive pupil
• Large or deep abrasions
• Corneal opacity

*This list is not exhaustive

 

Corneal erosion/abrasion

Corneal abrasions are defects in the epithelial surface; most heal within 1-2 days¹. Typically present with sudden onset pain, discomfort or foreign body sensation of the eye.

Assessment

• Mechanism of injury and material involved should be determined where possible
• Check visual acuity where possible
• Identify foreign bodies – subtarsal (on the inner lid surface) foreign bodies should be located by everting the upper eyelid
• Identify corneal abrasions if possible – fluorescein should be used to stain the conjunctiva and cornea. An abrasion will fluoresce bright green with the cobalt-blue filter

 

Management

• Consider removing corneal foreign body if expertise and equipment available. Do not remove penetrating foreign body.
• Refer as below
• Consider Chloramphenicol ointment, after discussion with/referral to eye casualty, to prevent secondary infection.
• Pad may help symptoms but not speed up healing.
• Recurrent erosion – copious lubricants and lubricant ointment at night for 3 months

 

When to refer

Urgent Eye Casualty Referral

• Any red flag symptom or acute injury; including penetrating eye injury, chemical injury or foreign body.
• Persistent or worsening symptoms after 24 hours
• Superficial corneal injury due to contact lens use

 

Urgent Ophthalmology Referral (after red flags excluded)

• Recurrent erosion syndrome
• Rust rings that remain after removal of metallic foreign body. Consider discussion with Ophthalmology as appropriate.

 

Corneal Ulcer (microbial keratitis)

Contact lens wearers have an increased risk, as well as those with dry eyes, blepharitis, corneal injuries, inflammatory diseases and viral infections³.

Assessment:

• Stain the cornea with fluorescein dye and look for a yellow-green area of uptake with the cobalt blue filter
• Before staining if any discrete opacity of the cornea seen this should be considered microbial keratitis until proven otherwise – refer urgently to Eye Casualty as below

 

Management and Referral Instructions:

Bacterial

• Management:
  • Consider removing contact lens if wearing and safe to do so, and send to microbiology in silver top pot with saline
• Referral Instructions:
  • Refer urgently to Eye Casualty, especially if loss of vision, corneal opacity, thinning, or severe symptoms/red flags.
  • Ideally pt to be seen by them prior to commencing antibiotics but consider prescription for broad-spectrum antibiotic E.G Ofloxacin to commence if review with Eye Casualty >24hrs.

 

Dendritic (herpetic)

• Referral Instructions
  • Refer urgently to Eye Casualty

 

Keratoconus

Keratoconus is an eye condition where the cornea gradually becomes stretched, thinned, and takes on a cone-like shape. This irregular shape can distort vision.

• Referral Instructions
  • Refer routinely to Ophthalmology for corneal topography and formal diagnosis.  Once diagnosed, hospital eye service can support funding of contact lenses, fitted by community optometrists
  • Re-referral may be necessary if becomes intolerant of contact lens to consider surgery

 

Pinguecula/pterygium

Pinguecula is usually an asymptomatic raised lesion, white to yellow in colour, that can appear on the surface of the eye.

Pterygium is a growth of fleshy tissue that may start as a pinguecula. It can remain small or grow large enough to cover part of the cornea, affecting vision.

Click here for a simple picture showing the differences between Pingecula/Pterygium.

 

• Management
  • If inflamed, consider lubricating eye drops and topical NSAID
  • Advise limiting UV exposure, e.g. sunglasses/hat

 

• Referral Instructions
  • Refer as routine if significant growth across limbus and symptomatic

 

Advice and Guidance

Please send advice and guidance requests to Ophthalmology via eRS

 

Useful Information

Professional:

• Red eye | Health topics A to Z | CKS | NICE
• Eye, infections | Treatment summaries | BNF | NICE
• Corneal Abrasions, Foreign Bodies and Injuries | Doctor
• What Is a Pinguecula and a Pterygium (Surfer's Eye)? - American Academy of Ophthalmology

 

Patient

• Homepage - Keratoconus Group
• Corneal Injury and Foreign Bodies. Common cornea abrasions
• Pinguecula - College of Optometrists
• Recurrent corneal erosion syndrome
• Keratoconus - Moorfields Eye Hospital

 

References

• Corneal superficial injury | Health topics A to Z | CKS | NICE
• Pinguecula - College of Optometrists
• Corneal ulcers in general practice - PMC

 

Page review information

Date reviewed:        20 January 2026

Next review due:     20 January 2028

Sifter name:            Dr Kate Northridge

Contributor:            Mr Nazih Toumia, Consultant Ophthalmologist Royal Cornwall Hospital Trust