- 💎 Cyst of Moll — blocked apocrine gland; dome-shaped, transilluminates (clear fluid)
- 💎 Cyst of Zeis — blocked sebaceous gland; yellow oily content, does NOT transilluminate
- 💎 Chalazion — granulomatous; painless nodule from blocked Meibomian duct
- 💎 Molluscum contagiosum — Poxviridae; refer to ophthalmologist to prevent follicular conjunctivitis
- 🚨 Red flags for malignancy: lid margin distortion, madarosis/poliosis, recurrent chalazion, ulceration, proptosis
Benign Eyelid Lesions
Cyst of Moll (top-left), Cyst of Zeis (top-right), Chalazion (bottom-left), Molluscum contagiosum (bottom-right)
Swollen Red Eyelid — Preseptal vs Orbital Cellulitis
- 💎 Preseptal cellulitis: infection ANTERIOR to orbital septum — normal vision, pupils, and movements
- 💎 Can be managed with oral antibiotics in reliable patients
- 🚨 Orbital cellulitis: infection POSTERIOR to septum — MEDICAL EMERGENCY
- 🚨 Features: pain on eye movement, proptosis, diplopia, reduced VA
- 🚨 Immediate hospital referral for IV antibiotics and CT orbit
Diagnostic flowchart for swollen red eyelid evaluation and management
Watery Eyes (Epiphora)
- 💎 Three mechanisms: reflex overproduction (most common), lacrimal pump failure, nasolacrimal obstruction
- 💎 Dry eye → reflex tearing — paradoxical watery eye; treat the underlying dry eye
- 💎 Ectropion / facial palsy → pump failure; surgical lid correction often required
- 💎 Dacryocystitis — pain/swelling medial canthus; oral antibiotics → refer for DCR
- 🚨 Congenital glaucoma — watery eye + photophobia + enlarged cornea in infants = EMERGENCY
Lacrimal drainage anatomy and causes of epiphora with management flowchart
Diplopia — Cranial Nerve Palsies
- 💎 First step: monocular (ocular cause) vs binocular (neurological/muscular)
- 💎 CN VI palsy — horizontal diplopia worse at distance and on lateral gaze
- 💎 CN IV palsy — vertical diplopia; worse on downgaze; head tilt compensation
- 💎 CN III palsy — ptosis, large exotropia; pupil involvement indicates aneurysm
- 🚨 Painful CN III palsy + dilated pupil = posterior communicating artery aneurysm — NEUROSURGICAL EMERGENCY
- 🚨 Headache + jaw claudication + CN palsy in elderly → Giant Cell Arteritis
Eye positions in different gaze directions for CN III, IV, and VI palsies
Refractive Errors
- 💎 Myopia (short-sighted) — focus anterior to retina; concave lens; typically school-age onset
- 💎 Hyperopia (long-sighted) — focus posterior to retina; convex lens; risk of amblyopia if uncorrected
- 💎 Astigmatism — rugby-ball shaped cornea; blurred at all distances
- 💎 Presbyopia — universal age-related near vision loss from age ~40
- 💎 Referral: VA < 6/9 in children, < 6/12 in adults, or 2-line difference between eyes
Diagram of emmetropia, myopia, hyperopia, and astigmatism with corrective lens effects
Age-Related Macular Degeneration (ARMD)
- 💎 Dry AMD: drusen + geographic atrophy → gradual central vision loss
- 💎 AREDS2 supplements (Vit C/E, lutein/zeaxanthin, zinc, copper) slow progression in intermediate-advanced dry AMD
- 💎 2024 Update: AREDS2 also slows geographic atrophy (late dry AMD) by ~55% over 3 years
- 🚨 Wet AMD: choroidal neovascularisation → sudden metamorphopsia → URGENT referral (within 1 week)
- 🚨 Treatment: intravitreal anti-VEGF (ranibizumab, aflibercept, faricimab)
- 💎 Home Amsler grid monitoring to detect early conversion from dry to wet
Extensive macular drusen in dry AMD
Wet AMD vs Dry AMD
- 💎 Dry AMD: gradual central blurring, drusen on fundoscopy, geographic atrophy
- 💎 Wet AMD: acute/subacute central loss, metamorphopsia, subretinal fluid/haemorrhage
- 💎 Refer Advanced dry AMD within 1 month; Suspected wet AMD within 1 WEEK
- 💎 Intermediate AMD: annual screening; consider AMD care pathway
- 🚨 Any new metamorphopsia or sudden change in Amsler grid → urgent same-week referral
Disciform scar with subretinal haemorrhage in advanced wet AMD
Diabetic Retinopathy — Fundoscopy
- 💎 Screen T2DM at diagnosis; T1DM within 5 years of diagnosis
- 💎 NPDR: microaneurysms → dot/blot haemorrhages → cotton wool spots → hard exudates
- 💎 PDR: neovascularisation at disc (NVD) or elsewhere (NVE) → vitreous haemorrhage
- 💎 Diabetic macular oedema — leading cause of vision loss in working-age adults; OCT diagnosis
- 🚨 PDR or M1 maculopathy → urgent ophthalmology referral
- 🚨 Good VA does NOT exclude sight-threatening retinopathy
Microaneurysms — earliest fundoscopic sign of non-proliferative diabetic retinopathy
Proliferative Diabetic Retinopathy
- 💎 NVD (neovascularisation at disc) or NVE (elsewhere) = proliferative DR
- 💎 Risk of vitreous haemorrhage and tractional retinal detachment
- 💎 Treatment: pan-retinal photocoagulation (PRP) laser or intravitreal anti-VEGF
- 🚨 Urgent ophthalmology referral — do not delay
- 💎 Optimise glycaemic control, BP, and lipids to slow progression
Neovascularisation at the disc (NVD) — hallmark of proliferative diabetic retinopathy
The Eye in Systemic Disease
- 💎 Thyroid Eye Disease: lid retraction, lid lag, proptosis, diplopia, compressive optic neuropathy
- 💎 Uveitis (anterior): HLA-B27 spondyloarthropathies (AS), Behçet's, JIA
- 💎 Hypertensive retinopathy: AV nipping, flame haemorrhages, cotton wool spots, papilloedema
- 💎 Kayser-Fleischer rings → Wilson's disease
- 💎 CMV retinitis — 'pizza pie' appearance in advanced immunocompromise
- 🚨 Scleritis — severe boring pain + scleral oedema → often associated autoimmune disease
AV nipping at vessel crossing — hypertensive retinopathy
Glaucoma — Optic Disc Cupping
- 💎 Primary Open-Angle Glaucoma (POAG) — chronic, insidious, often asymptomatic until late
- 💎 Risk factors: family history, elevated IOP, older age, myopia, African ethnicity
- 💎 Fundoscopy: increased cup-to-disc ratio (>0.6), asymmetry between eyes, disc notching
- 💎 Visual field defects: arcuate scotoma, nasal step
- 🚨 Refer if C/D > 0.6, asymmetry ≥ 0.2, or suspicious disc regardless of IOP
- 💎 Annual screening recommended for at-risk patients >40 years
Progressive cup-to-disc ratio enlargement from normal (0.2) to advanced glaucoma (0.99)
Other Fundoscopy Findings
- 💎 CRAO: cherry-red spot + pale retina + attenuated vessels → sudden painless visual loss
- 💎 CRVO: disc swelling + tortuous dilated veins + flame haemorrhages in all 4 quadrants
- 💎 Papilloedema: blurred disc margins + peripapillary haemorrhages → raised ICP until proven otherwise
- 💎 Retinal detachment: pale elevated retinal folds → flashing lights + floaters + curtain visual loss
- 🚨 All of the above = SAME-DAY emergency ophthalmology referral
- 💎 Retinitis pigmentosa: bone-spicule pigmentation + vessel attenuation + night blindness
Cherry-red spot at the macula with pale retina — central retinal artery occlusion (CRAO)
Key Summary
Key Point
🚨 Orbital cellulitis (pain on movement, proptosis, reduced VA) = immediate hospital referral
Key Point
🚨 Painful CN III palsy + dilated pupil = aneurysm until proven otherwise — neurosurgical emergency
Key Point
🚨 New metamorphopsia / sudden central vision change = wet AMD — refer within 1 WEEK
Key Point
💎 Dry eye: artificial tears QDS; doxycycline for rosacea-MGD; refer if persistent
Key Point
💎 DR screening: T2DM at diagnosis; T1DM within 5 years — good VA does NOT exclude PDR
Key Point
💎 Myopia control: 0.05% atropine superior efficacy (LAMP 2024); 0.01% if SE minimisation preferred
Key References
- Sun MT et al. Eyelid lesions in general practice. Aust J Gen Pract. 2019;48(8):509-514.
- Carlisle RT, Digiovanni J. Differential diagnosis of the swollen red eyelid. Am Fam Physician. 2015;92(2):106-12.
- Yam JC et al. LAMP 5-year trial — 0.05% atropine for myopia. Ophthalmology. 2024 Mar.
- Keenan TDL et al. AREDS2 slows geographic atrophy. Ophthalmology. 2024 Jul.
- SIDRP — SERI-NHGEI AMD Referral Criteria Guidelines (local Singapore guidelines).
- Cochrane GM et al. Management of refractive errors. BMJ. 2010;340:c1171.