The healthy ocular surface is a complex, composite unit that is essential for patient comfort and visual function. A number of components need to work in an integrated manner to ensure that this is achieved, and a variety of causes can result in the final common symptom complex that can be termed the itching, burning eye. Many of these causes may be due to relatively common and simple issues related to lid disease, allergies, tear dysfunction, excessive computer use, exposure to polluted environment, and convergence problems. However, a smaller group may have potentially more serious pathology due to causes such as underlying immune dysfunction, or tumors; rarely, intraocular conditions and some neurological causes may present with ocular redness and grittiness. Failure or delay in the diagnosis of these latter entities can result in significant morbidity to the eye. This article will clarify issues related to the functioning of the ocular surface, provide a diagnostic algorithm for managing these patients, and discuss the current knowledge in the management of these conditions once they are diagnosed. It is targeted at the practicing ophthalmologist and should help him or her to manage this problem effectively.