Table 1 Key consensus statements and scores.
From: Assessment and management of dry eye disease in the UK: standardising reality-based best practice
Statement | Consensus score | Percentage who strongly agree | Percentage who strongly agree or slightly agree | Strength of agreement | |
|---|---|---|---|---|---|
Initial assessment | |||||
1 | In order to diagnose DED, it is essential to capture information on both symptoms and signs* | 3.87 | 93.3 | 100.0 | Very strong |
2 | 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 redness | 3.73 | 86.7 | 100.0 | Very strong |
3 | Symptomatic assessment, in every setting, should include timing and triggers of symptoms as well as their duration, nature, and impact on quality of life | 3.73 | 86.7 | 100.0 | Very strong |
4 | 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 use | 2.93 | 60.0 | 93.3 | Strong |
5 | The presence of dry mouth (and/or dry nostrils) may be suggestive of Sjogren’s Syndrome and should be captured if present | 3.73 | 86.7 | 100.0 | Very strong |
6 | 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) | 4.00 | 100.0 | 100.0 | Very strong |
8 | Corneal sensation testing should be performed as standard* if a patient reaches secondary care in order to rule out corneal neuropathy | 3.47 | 73.3 | 100.0 | Very strong |
9 | Where a Schirmer’s test (unanaesthetised) can be competently performed, this can provide useful additional information but is not required for a basic assessment | 2.67 | 46.7 | 93.3 | Moderate |
10 | 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 symptoms | 3.87 | 93.3 | 100.0 | Very strong |
Grading the severity of DED | |||||
16 | The presence of DED can be inferred from a combination of fluorescein staining and short ( ≤ 10 s) tear break-up time (TBUT) | 3.20 | 60.0 | 100.0 | Very strong |
17 | 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 disease | 4.00 | 100.0 | 100.0 | Very strong |
18 | 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 life | 3.73 | 86.7 | 100.0 | Very strong |
19 | 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 life | 3.60 | 80.0 | 100.0 | Very strong |
20 | If a patient lacks staining but is experiencing pain (neuropathic pain) in either eye†, they should be referred to an appropriate specialist | 3.33 | 80.0 | 93.3 | Very strong |
Initial treatment of DED in the community | |||||
21 | Initial treatment in the community setting should comprise lid hygiene and lifestyle measures, along with unpreserved lubricants* | 3.87 | 93.3 | 100.0 | Very strong |
22 | Patients with mild DED and no other concerns should be managed by a community optometrist | 3.71 | 85.7 | 100.0 | Very strong |
25 | A range of lubricants are available for treatment of DED, but any lubricant used must be preservative-free | 2.40 | 53.3 | 86.7 | Strong |
26 | A once-daily administration of lubricants is unlikely to be sufficient: patients should be advised to apply them at least 3–4 times daily* | 3.33 | 66.7 | 100.0 | Very strong |
28 | If symptoms are not controlled despite frequent use of lubricant drops, escalation of treatment should be considered | 3.60 | 80.0 | 100.0 | Very strong |
Initial treatment of DED in secondary care (general ophthalmology) | |||||
32 | 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 assessment | 3.47 | 86.7 | 93.3 | Very strong |
33 | A simple assessment of corneal sensation (presence or absence)* should also be performed in secondary care | 3.73 | 86.7 | 100.0 | Very strong |
34 | 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 changes | 3.87 | 93.3 | 100.0 | Very strong |
35 | The following treatments can be considered for prescription by a general ophthalmologist: short-course topical corticosteroids, ciclosporin A, oral doxycycline, acetylcysteine 5% | 3.87 | 93.3 | 100.0 | Very strong |
36 | The following treatments should be prescribed only by a corneal specialist: scleral lenses, insulin, secretagogues, autologous serum eyedrops, oral pilocarpine, off-licence agents | 3.47 | 86.7 | 93.3 | Very strong |
38 | If a patient responds positively to steroids, indicating that inflammation is present, treatment with ciclosporin A should be initiated to minimise steroid-related side-effects | 3.47 | 73.3 | 100.0 | Very strong |
40 | Punctal plugs can be considered once inflammation is controlled but should not be initiated beforehand | 3.60 | 80.0 | 100.0 | Very strong |
Referral | |||||
41 | 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 pathways | 3.87 | 93.3 | 100.0 | Very strong |
42 | 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 specialist | 4.00 | 100.0 | 100.0 | Very strong |
44 | 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 timeframe | 2.27 | 53.3 | 80.0 | Strong |
45 | Patients with severe DED that is refractory to treatment should be referred to a corneal specialist in a routine timeframe | 2.93 | 73.3 | 86.7 | Strong |
46 | 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 months | 3.73 | 86.7 | 100.0 | Very strong |
47 | 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 sensation | 2.53 | 60.0 | 86.7 | Strong |
48 | 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 deterioration | 2.27 | 46.7 | 86.7 | Moderate |
Ongoing management and follow-up | |||||
49 | 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 resolved | 3.87 | 93.3 | 100.0 | Very strong |
50 | 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 inflammation | 3.73 | 86.7 | 100.0 | Very strong |
55 | Treatment for DED is generally of a long-term nature, requiring repeat prescriptions: it is important that GPs are aware of this need | 3.87 | 93.3 | 100.0 | Very strong |
Discharge | |||||
56 | 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-manage | 3.87 | 93.3 | 100.0 | Very strong |
59 | The patient’s GP and/or community optometrist should be copied into a letter explaining previous and ongoing management of the disease | 3.87 | 93.3 | 100.0 | Very strong |
60 | 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 capacity | 3.6 | 80.0 | 100.0 | Very strong |
