This article provides a UK-focused consensus on the assessment, management and referral of DED, with the aim of providing comprehensive, aligned and localised guidance for UK community and hospital-based optometrists and ophthalmologists. The panel was able to reach a moderate-to-strong consensus on almost all statements, with those relating to IP optometrists forming a notable exception. IP optometrists are able to prescribe licensed therapies, including pharmacological management, for ocular conditions including DED [15, 32]. They should work within their area of expertise and with support and supervision as appropriate [33]; not all IP optometrists may be confident and competent to prescribe topical corticosteroids or steroid-sparing anti-inflammatory agents like CsA, but a UK study found that when appropriately trained, their diagnosis and management decision-making in an acute hospital setting is equivalent to that of consultant ophthalmologists [19]. Within HES across the UK, a scope-of-practice survey found that IP optometrists prescribe medications required by patients following an in-clinic optometry assessment more frequently than general practitioners (GPs) [34]. Optometrists are also playing an increasingly central role as the first point of contact for eye care provision across the UK [15], but there is variation between and within the nations (England, Northern Ireland, Scotland and Wales) [15, 35,36,37]. Previous studies have shown that, with IP optometrists integrated into primary care pathways, very few patients require hospital referral [37]. There is the potential for IP optometrists to play a more significant and consistent role in the treatment of moderate-to-severe DED across all nations of the UK.
Statements concerning initial assessment generally achieved strong consensus, but a few only reached moderate levels of agreement. Symptom questionnaires are widely used in clinical studies of DED [2, 22] and can provide an objective symptomatic baseline to assess the progress of the patient on treatment; indeed, the OSDI-6 is specifically recommended in the recently published DEWS III [2]. However, in the daily clinical setting in the NHS, time in particular is a significant barrier and these questionnaires are not widely used [15]. In discussions, questions were also raised about how symptom questionnaire results would be communicated further along the patient pathway, given the lack of a universally integrated approach to electronic patient records [38]. Until these issues can be addressed, it is unlikely that symptom questionnaires will become a standard part of clinical assessment for dry eye disease in the UK.
The panel could only reach moderate consensus on the role of the Schirmer’s test. While it can provide useful information—particularly where ADDED is suspected – its reliability as a measure of DED is debated, particularly for mild forms of the disease [39, 40]. Additionally, Schirmer’s strips are not universally available in community practice and the test takes a long time (5 min [39]), making it impractical to position as an essential test in the context of busy NHS eye clinics. There are numerous additional signs and assessments that are not covered in the statements within this article, including osmolality and meibography; some of these require specialist equipment and others are controversial. For reference, an overview of the strengths and weaknesses of these techniques is included in Supplementary Table 4. In general, the panel felt it was important to focus on what would form an acceptable minimum standard that could be achieved in all settings, which is reflected by the small number of recommended assessments. The recently published DEWS III guidance strongly recommends the use of conjunctival staining with lissamine green [2], a test that is not readily available in the UK—particularly in community settings. As this test is therefore not practical within NHS practice, it was not included as an essential assessment by the panel. Additionally, corneal sensation testing is an important assessment that should take place at some point to rule out serious neurological damage, but the panel recognises it is not possible to conduct objectively in most settings.
There was a lack of strong consensus that female patients should be asked about hormonal medications, such as birth control or HRT. This is surprising, given sex hormones and in particular HRT and anti-androgens are thought to be risk factors for DED [8, 23, 24], and female sex is in itself a risk factor [8, 24] (see Fig. 2 and Supplementary Box 1). A stronger consensus may have been reached if the statement referred specifically to female patients over the age of 40 or around the age of menopause.
When assessing patients who have connective tissue disorders, only 40% of respondents strongly agreed that they would consider such patients for hospital referral if they experienced symptoms of DED; this may have achieved stronger consensus if the focus of the statement had been on the systemic symptoms, rather than DED itself. The link between DED and connective tissue disorders such as rheumatoid arthritis is well established and has been suggested to result from immune cell infiltration and associated inflammation in ocular tissues [8, 23, 41], as well as potentially from medications for rheumatological disorders [23].
Patients undergoing treatment in the community whose DED cannot be controlled with multiple applications of artificial tears, or whose DED has a significant evaporative component, may be advised to try more advanced lubricants: those containing more than one active ingredient, such as lipids [42] or trehalose. These classes of artificial tears may help to stabilise the tear film, as well as lubricating the ocular surface [43]. The relatively low proportion of the panel (53%) who strongly agreed on the necessity of preservative-free artificial tears was surprising, given the general preference in the treating community for preservative-free options [8, 15, 42]. Some reviews have recently suggested there is a lack of strong evidence for this preference [27, 29], which may have influenced the outcome here, as well as the availability of new, less toxic preservatives [8].
It is expected that assessments in secondary care will be more comprehensive than those carried out in the community setting, both as a result of available equipment and because patients presenting to secondary care are more likely to have complex or severe issues. For dry eye disease, assessment of lid function should include ensuring the blink reflex is complete, as well as investigating for the presence of lagophthalmos, entropion and ectropion. Statements around treatment in secondary care generally reached strong or very strong consensus, with the exception of topical azithromycin, which only a little over half of the panel agreed should be prescribed by a corneal specialist. In discussions, prescribing of azithromycin varied in dosing and frequency even within the core steering group.
Secondary care treatments not discussed in detail by the panel included meibomian orifice probing, intense pulsed light (IPL) and Lipiflow: these are not commonly available on the NHS. However, a brief overview of these treatments is included in Supplementary Box 2, to support discussions with patients who enquire about them following their own research.
Red flags that should trigger urgent or emergency referral were identified by the panel as severe corneal damage (such as corneal melting, thinning or perforation or confluent superficial punctate keratitis), corneal ulcer, infection or superinfection, atypical or neurotrophic signs. These align with severe complications identified in the NICE Clinical Knowledge Summaries [16] as requiring urgent referral: punctate epithelial erosions of the conjunctiva and cornea; corneal scarring, thinning, ulceration, or neovascularisation; corneal infection; corneal perforation (rare) and severe visual loss (rare). The Clinical Knowledge Summaries also highlight additional red-flag symptoms (sudden-onset pain or visual loss, persistent or severe visual loss, diplopia, unilateral symptoms, or systemic symptoms such as weight loss or fever) necessitating a same-day assessment [16].
The panel reached weak consensus that filamentary keratitis, a potential complication of DED that can cause pain and discomfort [44], should be cause for referral to secondary care in a routine timeframe (within several months). Some respondents preferred referral to a corneal specialist and the timeframe in the statement may also have contributed to the poor consensus: a ‘soon’ timeframe would perhaps have received more support, and this is shown in Table 2.
A patient who previously underwent successful treatment with short-course, mild topical steroids may experience a flare-up later on. Owing to the time needed for referral, and the sometimes-debilitating nature of symptoms even when an urgent referral is not required, a moderate consensus was reached that where non-potent steroids have been successful before, a new course could be initiated by a community prescriber in the meantime, applying only to low-potency topical corticosteroids (commonly including fluorometholone, prednisolone phosphate and hydrocortisone sodium phosphate [45]); this is a pragmatic recommendation to avoid further deterioration of the patient’s condition.
While very strong consensus was reached on most statements around follow-up and ongoing management, there was weak consensus that doxycycline should be held in reserve for rescue if symptoms flare up. Doxycycline, a member of the tetracycline family of antibiotics, has anti-inflammatory properties [46] and is commonly part of treatment for MGD [14, 47]. However, evidence around its use in DED is mixed [14, 47] and the optimal dosing of doxycycline, along with other tetracyclines, has not been well established [14]. The panel’s opinions on its routine use may also be influenced by concerns around potential gastrointestinal side effects, photosensitivity, and significant risks to the child in pregnant and breastfeeding mothers [48].
Strong consensus was reached that the frequency of follow-up is dependent on the level of disease control. Supplementary Table 3 outlines the frequency of follow-up recommended dependent on the patient’s status, from weekly for those with ongoing red-flag or urgent issues, to six-monthly for patients whose DED is responding to treatment with no or manageable side-effects. These latter patients should be considered for discharge to their local optometric practitioner.
In general, strong or very strong consensus was reached on all statements relating to discharge. Important points include education for patients to support ongoing self-management, communication with community practitioners on discharge from secondary care, ensuring continuity of treatment even once the patient is no longer involved with the hospital eye service, and the role of PIFU, where possible.
This study, as a qualitative consensus exercise, does have limitations, including the process adopted for selection of representation on the panel. Furthermore, geographical distribution was limited, with no representation from specialists based in Wales, and only one member of the steering panel is an IP optometrist. The conclusions of the panel members may not therefore be equally applicable to all devolved nations of the UK, which have differing healthcare systems. The process deviated from a Delphi approach by incorporating multiple rounds of verbal discussion, in order to help refine statements further; these discussions were by definition not anonymous, although rounds of voting were recorded anonymously.
In summary, this article offers a consensus view on management of DED specific to the UK. The key consensus recommendations may help to support nationwide consistent and effective assessment, diagnosis, management and referral, irrespective of clinical setting. For future directions, there is a plethora of devices and equipment now available for diagnosing, objectively documenting, and treating DED. A consensus on what might be the most appropriate additional modalities, both effective and affordable within the NHS setting, would be valuable. This could then form the basis for recommendations to NHS management to support making this technology available across the DED patient pathway.