The combined pressures of the European Working Time Directive, 4 h waiting time target, and growing rates of unplanned hospital attendances have forced a major consolidation of eye casualty departments across the country, with the remaining units seeing a rapid increase in demand. We examine the effect of these changes on the provision of emergency eye care in Central London, and see what wider lessons can be learned. We surveyed the managers responsible for each of London's 8 out-of-hours eye casualty services, analysed data on attendance numbers, and conducted detailed interviews with lead clinicians. At London's two largest units, Moorfields Eye Hospital and the Western Eye Hospital, annual attendance numbers have been rising at 7.9% per year (to 76 034 patients in 2010/11) and 9.6% per year (to 31 128 patients in 2010/11), respectively. Using Moorfields as a case study, we discuss methods to increase capacity and efficiency in response to this demand, and also examine some of the unintended consequences of service consolidation including patients travelling long distances to geographically inappropriate units, and confusion over responsibility for out-of-hours inpatient cover. We describe a novel 'referral pathway' developed to minimise unnecessary travelling and delay for patients, and propose a forum for the strategic planning of London's eye casualty services in the future.