Assessment and management of dry eye disease in the UK: standardising reality-based best practice
UK dry eye expert group · 2026 · Europe
Source and licence
- Authors
- Bita Manzouri, Sajjad Ahmad, Sophie Harper et al.
- Title
- Assessment and management of dry eye disease in the UK: standardising reality-based best practice
- Journal
- Eye, 2026
- Licence
- CC BY 4.0
- Changes
- Verbatim excerpts; formatting adapted
Full text retrieved 2026-10-27 from Europe PMC · PMC13195173
Licence statement of the original publication
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This page reproduces excerpts of the original publication; the original is authoritative. It has not been reviewed by a physician, does not state a recommendation of Medelix and does not replace medical advice. The guideline may have been updated since.
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Recommendations
Verbatim, with grade of recommendation or strength of consensus where given.
Initial assessment
- In order to diagnose DED, it is essential to capture information on both symptoms and signs*Consensus score: 3.87; Strength of agreement: Very strong
- It is important to ask an open question about the patient’s symptoms, but to follow up on, as a minimum, pain, grittiness (or foreign body sensation), blurred vision, photophobia and rednessConsensus score: 3.73; Strength of agreement: Very strong
- Symptomatic assessment, in every setting, should include timing and triggers of symptoms as well as their duration, nature, and impact on quality of lifeConsensus score: 3.73; Strength of agreement: Very strong
- In an ideal world, symptom questionnaires can offer an objective baseline for ongoing management, but barriers in terms of both time and practical considerations limit the feasibility of their useConsensus score: 2.93; Strength of agreement: Strong
- The presence of dry mouth (and/or dry nostrils) may be suggestive of Sjogren’s Syndrome and should be captured if presentConsensus score: 3.73; Strength of agreement: Very strong
- As a minimum, the following signs should be assessed* on initial patient presentation: tear break-up time, fluorescein staining (including for PEEs), conjunctival injection/hyperaemia and eyelid assessment (including MGD)Consensus score: 4.00; Strength of agreement: Very strong
- Corneal sensation testing should be performed as standard* if a patient reaches secondary care in order to rule out corneal neuropathyConsensus score: 3.47; Strength of agreement: Very strong
- Where a Schirmer’s test (unanaesthetised) can be competently performed, this can provide useful additional information but is not required for a basic assessmentConsensus score: 2.67; Strength of agreement: Moderate
- When assessing a patient with suspected DED, it is essential to ask about ocular co-pathology and medications, along with any past ocular procedures and prior or current measures taken to address their DED symptomsConsensus score: 3.87; Strength of agreement: Very strong
Grading the severity of DED
- The presence of DED can be inferred from a combination of fluorescein staining and short ( ≤ 10 s) tear break-up time (TBUT)Consensus score: 3.20; Strength of agreement: Very strong
- Severe DED can be indicated (in either eye) by an Oxford staining score of 4 or greater, along with a TBUT of 3 or fewer seconds and a substantial negative impact on the patient’s quality of life; filamentary changes can also be indicative of severe diseaseConsensus score: 4.00; Strength of agreement: Very strong
- Moderate DED can be indicated (in either eye) by an Oxford staining score of 2–3, along with TBUT of 4–6 s and a moderate impact on the patient’s quality of lifeConsensus score: 3.73; Strength of agreement: Very strong
- Mild DED can be indicated (in either eye) by an Oxford staining score of 0–1, along with a TBUT of 7–10 s and a mild impact on the patient’s quality of lifeConsensus score: 3.60; Strength of agreement: Very strong
- If a patient lacks staining but is experiencing pain (neuropathic pain) in either eye†, they should be referred to an appropriate specialistConsensus score: 3.33; Strength of agreement: Very strong
Initial treatment of DED in the community
- Initial treatment in the community setting should comprise lid hygiene and lifestyle measures, along with unpreserved lubricants*Consensus score: 3.87; Strength of agreement: Very strong
- Patients with mild DED and no other concerns should be managed by a community optometristConsensus score: 3.71; Strength of agreement: Very strong
- A range of lubricants are available for treatment of DED, but any lubricant used must be preservative-freeConsensus score: 2.40; Strength of agreement: Strong
- A once-daily administration of lubricants is unlikely to be sufficient: patients should be advised to apply them at least 3–4 times daily*Consensus score: 3.33; Strength of agreement: Very strong
- If symptoms are not controlled despite frequent use of lubricant drops, escalation of treatment should be consideredConsensus score: 3.60; Strength of agreement: Very strong
Initial treatment of DED in secondary care (general ophthalmology)
- As a minimum, assessments on presentation in secondary care* should include fluorescein staining, TBUT, vision, lid function and blink reflex, tear meniscus height and meibomian gland assessmentConsensus score: 3.47; Strength of agreement: Very strong
- A simple assessment of corneal sensation (presence or absence)* should also be performed in secondary careConsensus score: 3.73; Strength of agreement: Very strong
- The tests outlined above (minimum assessments on presentation in secondary care) should be repeated even if results from prior testing are available, in case of changesConsensus score: 3.87; Strength of agreement: Very strong
- The following treatments can be considered for prescription by a general ophthalmologist: short-course topical corticosteroids, ciclosporin A, oral doxycycline, acetylcysteine 5%Consensus score: 3.87; Strength of agreement: Very strong
- The following treatments should be prescribed only by a corneal specialist: scleral lenses, insulin, secretagogues, autologous serum eyedrops, oral pilocarpine, off-licence agentsConsensus score: 3.47; Strength of agreement: Very strong
- If a patient responds positively to steroids, indicating that inflammation is present, treatment with ciclosporin A should be initiated to minimise steroid-related side-effectsConsensus score: 3.47; Strength of agreement: Very strong
- Punctal plugs can be considered once inflammation is controlled but should not be initiated beforehandConsensus score: 3.60; Strength of agreement: Very strong
Referral
- Severe corneal damage (corneal melting, thinning or perforation or confluent SPK), a corneal ulcer or (super)infection should trigger an urgent referral to eye casualty, or a corneal specialist dependent on local pathwaysConsensus score: 3.87; Strength of agreement: Very strong
- Patients with atypical or neurotrophic signs (such as a persistent defect of the cornea or other features that would heighten anxiety about a patient) should be referred soon to a corneal specialistConsensus score: 4.00; Strength of agreement: Very strong
- Patients with an underlying systemic or autoimmune disease, unexplainable changes in vision, or recent-onset redness that cannot be resolved with over-the-counter medicines or antibiotics, should be referred to a general ophthalmologist or corneal specialist in a routine timeframeConsensus score: 2.27; Strength of agreement: Strong
- Patients with severe DED that is refractory to treatment should be referred to a corneal specialist in a routine timeframeConsensus score: 2.93; Strength of agreement: Strong
- Timeframes for referrals may vary according to local resources, but urgent referrals should ideally be within 24–48 h, soon referrals within one week to one month and routine referrals within several monthsConsensus score: 3.73; Strength of agreement: Very strong
- Referral letters from general ophthalmology to cornea should always include, as a minimum, information about: vision, current medications, prior surgeries, prior DED treatments, advice and outcomes, corneal fluorescein staining score, red-flag signs, any systemic diseases, tear meniscus height, meibomian gland function assessment (blepharitis, anterior, posterior), lid function, and corneal sensationConsensus score: 2.53; Strength of agreement: Strong
- If a patient who has previously been successfully treated with short-course, mild steroids experiences a flare-up, it is advisable for a community prescriber to initiate a new short course while waiting for a referral to avoid deteriorationConsensus score: 2.27; Strength of agreement: Moderate
Ongoing management and follow-up
- Frequency of follow-up is dependent on the level of disease control, as defined by the tolerability of the patient’s symptoms and degree to which signs are resolvedConsensus score: 3.87; Strength of agreement: Very strong
- DED is considered to be under control when symptoms are reduced by treatment to a level the patient considers tolerable and signs have improved from baseline, with no clinical evidence of inflammationConsensus score: 3.73; Strength of agreement: Very strong
- Treatment for DED is generally of a long-term nature, requiring repeat prescriptions: it is important that GPs are aware of this needConsensus score: 3.87; Strength of agreement: Very strong
Discharge
- A patient with DED can be discharged when symptoms are stable and well-controlled with no need for specialised treatments, and when they are both happy and able to self-manageConsensus score: 3.87; Strength of agreement: Very strong
- The patient’s GP and/or community optometrist should be copied into a letter explaining previous and ongoing management of the diseaseConsensus score: 3.87; Strength of agreement: Very strong
- Patient-initiated follow-up (PIFU) could be offered for a period of time from 12–36 months depending on the initial grade of severity of DED and on local capacityConsensus score: 3.6; Strength of agreement: Very strong
Abstract
Background: Assessment and management of dry eye disease (DED) in the UK is increasingly taking place outside of specialist ophthalmology settings. While comprehensive, evidence-based international guidance exists, much of it does not reflect the realities of practice in the UK. A panel of experts was brought together to identify areas of consensus on assessment, management, and appropriate referral of DED in the UK National Health Service (NHS).
Methods: A questionnaire was circulated to a panel consisting of 15 optometrists, ophthalmologists, and corneal specialists with experience and expertise in DED. Based on their responses, consensus statements were developed and underwent two rounds of voting, in which respondents indicated to what extent they agreed with each statement. A core steering panel of seven experts discussed the results and provided further context for the statements.
Results: Strong or very strong consensus was reached for 57/62 statements. Statements with very strong consensus included guidance on the minimum symptoms and signs to be assessed on initial presentation and simple guidance for grading the severity of the disease. Statements regarding initial treatment were divided by setting (primary and secondary care), and a strong or very strong consensus was reached on 17/20 statements relating to treatment options in these settings. Statements specific to referral included approximate target timelines, where possible, as well as guidance on key supporting information to help improve the efficiency of patient care.
Conclusions: This consensus provides a UK-focused resource to support consistent and effective care for patients with DED within the NHS.
Contents of the original publication
The section headings of the original.
- Introduction
- Materials and methods
- Expert panel
- Process
- Definition of consensus
- Results
- Initial assessment
- DED subtypes
- Grading severity
- Initial treatment in the community
- Initial treatment in secondary care
- Referral
- Ongoing management and follow-up
- Discharge
- Discussion
- Summary
- What was known before
- What this study adds
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