How should I approach the management of a patient with suspected keratitis who presents with significant pain and photophobia?

For a patient presenting with suspected keratitis, significant pain, and photophobia, the primary approach should be urgent referral for specialist assessment ³. All cases of suspected ocular herpes simplex infection, which can manifest with such severe symptoms, require same-day assessment and specialist management by eye casualty or an emergency eye service ³. It is important not to initiate drug treatment while awaiting this specialist ophthalmology assessment ³.

To manage the patient's symptoms, advise the use of simple oral analgesia to alleviate discomfort ². Ocular lubricants can also be used for symptom relief ². For photophobia, patients may find some relief by keeping the eye shut, wearing sunglasses, or staying in low light ².

Certain treatments are not recommended in this context. Prescription of cycloplegics, such as cyclopentolate, is not recommended as they do not improve healing or pain management and can worsen glare ². Repeated administration of topical anaesthetics is absolutely contraindicated for any corneal injury, as this has been shown to delay corneal wound healing, mask worsening symptoms, and can be toxic to the corneal epithelium ². Topical analgesics (NSAIDs) are also not recommended ². Routine use of eye patches is not supported by evidence ².