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Eyes

Dry eye disease

Last revised in January 2023

Dry eye syndrome is a chronic condition characterised by inflammation of the ocular surface and reduction in quality and/or quantity of tears.

Dry eye disease: Summary

  • Dry eye disease (or 'dry eye syndrome' or 'keratoconjunctivitis sicca') is a multifactorial disease of the ocular surface characterized by a loss of homeostasis of the tear film with reduced tear production or tear film instability, associated with ocular discomfort and/or visual symptoms. There are two main types that often overlap and co-exist:
    • Evaporative dry eye (more common) — increased tear film evaporation, most often due to a deficient lipid layer in the tear film.
    • Aqueous deficient dry eye — reduced aqueous secretion from lacrimal glands causing a reduced tear volume.
  • There are multiple possible causes of dry eye including Meibomian gland dysfunction, blepharitis, age-related changes, lid aperture disorders, primary or secondary Sjögren’s syndrome, rosacea, reduced blink interval, environmental factors, and iatrogenic causes including contact lens use, longterm topical eye preparation use, systemic medications, and post eye surgery or radiation.
  • Dry eye disease is usually a chronic condition with fluctuating severity and variable duration, depending on the underlying cause.
  • Complications include impact on daily activities including driving, reading, and sleep; anxiety and depression; corneal scarring, ulceration, infection, and perforation; or severe visual loss (rare).
  • A diagnosis of dry eye should be suspected if there are:
    • Symptoms of eye irritation, itching, or discomfort; eye dryness; transient blurring of vision; and watery eyes.
    • Signs such as mild conjunctival redness or mucous discharge.
  • Assessment of a person with suspected dry eye disease should include:
    • Asking about symptom onset, severity, duration, and fluctuation; impact on quality of life; any red flags; possible underlying causes or exacerbating factors; ocular history; current medication; and previous treatments.
    • Examination for visual acuity; red flag signs; typical signs of dry eye; abnormal lid anatomy or function; eyelid inflammation or deposits; and cranial nerves and skin for signs of other underlying conditions.
  • Management of a person with dry eye disease should include:
    • Advising on sources of information and support.
    • Advising on lifestyle measures for symptom relief, such as warm compresses, lid hygiene, and lid massage for blepharitis or Meibomian gland dysfunction; modification of contact lens use and environmental factors such as avoiding prolonged digital device use or exposure to air conditioning/drafts.
    • Reducing or stopping contributory drug treatment if possible.
    • Optimizing management of any associated ocular or systemic conditions.
    • Advising on the use of tear substitutes and arranging review if needed.
  • Specialist referral of a person with dry eye disease should be arranged if:
    • There are red flag symptoms or signs suggesting a serious or sight-threatening cause for dry eye (same-day ophthalmology assessment).
    • A serious underlying cause or complication is suspected (urgent ophthalmology referral).
    • There is an uncertain diagnosis.
    • There is a suspected underlying systemic condition such as Sjögren’s syndrome.
    • There is abnormal lid anatomy or function.
    • There are persistent or severe symptoms which do not respond to primary care management after 4–12 weeks.

Have I got the right topic?

From age 10 years onwards.

This CKS topic covers the diagnosis and management of dry eye disease in primary care.

This CKS topic does not cover the detailed management of underlying causes of dry eye disease or conditions associated with dry eye.

There are separate CKS topics on Blepharitis, Conjunctivitis - allergic, Conjunctivitis - infective, Meibomian cyst (chalazion), and Red eye.

The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary healthcare.

How up-to-date is this topic?

Changes

January 2023 — reviewed. A literature search was conducted in December 2022 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomised controlled trials published since the last revision of the topic. The topic title has been changed from 'Dry eye syndrome' to 'Dry eye disease' in line with current terminology in the literature. The definition of dry eye disease has been updated in line with the international Tear Film and Ocular Surface Society (TFOS) Dry Eye Workshop (DEWS) publication TFOS DEWS II Definition and classification report (Craig 2017). No major changes to clinical recommendations have been made.

Previous changes

August 2017 — reviewed. A literature search was conducted in June 2017 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomised controlled trials (RCTs) published since the last revision of the topic. No major changes to clinical recommendations have been made.

January 2014 — minor update. Following an enquiry from a manufacturer, the prescribing information node has been deleted. The table which had examples of tear replacement and ocular lubricant products has been replaced with a link to the British National Formulary (BNF), and the information on how to prescribe tear replacement and ocular lubricant products has been incorporated into the drug treatment node in the Management scenario.

September 2012 — reviewed. A literature search was conducted in September 2012 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of the topic. No changes to clinical recommendations have been made.

June 2012 — minor update. Typographical error corrected.

March 2011 — technical update. The management section of this topic has been simplified to improve clarity and navigation. There have been no changes to the clinical content or meaning of the recommendations.

September 2010 — minor update. Hydromoor® (hypromellose 0.3% preservative-free single dose eye drops) have been included.

March 2010 — minor update. Lubri-Tears® eye ointment has been discontinued. Prescription removed. 

December 2007 to March 2008 — converted from CKS guidance to CKS topic structure. The evidence-base has been reviewed in detail, and recommendations are more clearly justified and transparently linked to the supporting evidence. Although there is a new section on assessment, there are no major changes to the recommendations.

February 2006 — minor update. Black triangle removed from carmellose sodium eye drops.

September 2004 — reviewed. Validated in November 2004 and issued in February 2005.

June 2001 — reviewed. Validated in November 2001 and issued in April 2002.

August 1998 — written, replacing the guidance called Dry eyes.

Update

New evidence

Evidence-based guidelines

No new evidence-based guidelines since 1 December 2022.

HTAs (Health Technology Assessments)

No new HTAs since 1 December 2022.

Economic appraisals

No new economic appraisals relevant to England since 1 December 2022.

Systematic reviews and meta-analyses

No new systematic reviews or meta-analysis which reach the CKS threshold for inclusion since 1 December 2022.

Primary evidence

No new randomized control trials in the major publications since 1 December 2022.

New policies

No new national policies or guidelines since 1 December 2022.

New safety alerts

No new safety alerts since 1 December 2022.

Changes in product availability

  • New product Cequa (ciclosporin) 0.9 mg/ml Eye drops. Product licensed for the treatment of moderate-to-severe dry eye disease (keratoconjunctivitis sicca) in adult patients who have not responded adequately to artificial tears. See more here.
  • New product Vevizye is licensed for the treatment of moderate to severe dry eye disease (keratoconjunctivitis sicca) in adult patients, which has not improved despite treatment with tear substitutes. See more here.

Goals and outcome measures

Goals

To support primary healthcare professionals to:

  • Identify dry eye disease and differentiate it from other causes of eye irritation, if possible.
  • Give advice on self-care techniques.
  • Advise on or prescribe tear substitutes if clinically indicated, for symptom relief.
  • Arrange specialist referral if appropriate, the urgency depending on clinical judgement.

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

No QOF indicators were found during the review of this topic.

QIPP - Options for local implementation

No QIPP indicators were found during the review of this topic.

NICE quality standards

No NICE quality standards were found during the review of this topic.

Background information

What is it?

  • Dry eye disease (or 'dry eye syndrome' or 'keratoconjunctivitis sicca') is a multifactorial disease of the ocular surface characterized by a loss of homeostasis of the tear film with reduced tear production or tear film instability, associated with ocular discomfort and/or visual symptoms [Craig, 2017] [Akpek, 2019] [College of Optometrists, 2022].
    • All regions of the ocular surface epithelia produce constituents of the tear film, including the corneal and conjunctival epithelia (produce mucins for the aqueous component); the lacrimal and accessory lacrimal glands on the upper eyelid (secrete water, proteins, immunoglobulins, vitamins, and nutrients for ocular surface health); and the meibomian glands in the upper and lower eyelids (produce the tear lipid layer to prevent tear evaporation) [RCOphth, 2017].
    • The tear film functions to provide lubrication, physical protection, immunological defence, and nutrition to the ocular surface [RCOphth, 2017].
  • There are two main types of dry eye disease that often overlap and co-exist [Craig, 2017] [Akpek, 2019] [College of Optometrists, 2022]:
    • Evaporative dry eye (more common) — increased tear film evaporation, most often due to a deficient lipid layer in the tear film caused by Meibomian gland dysfunction. See the CKS topic on Meibomian cyst (chalazion) for more information.
    • Aqueous deficient dry eye — reduced aqueous secretion from lacrimal glands causing a reduced tear volume.

What causes it?

Dry eye disease may have multiple contributory factors including tear film instability and hyperosmolarity, ocular surface inflammation and damage, and neurosensory abnormalities [Craig, 2017] [College of Optometrists, 2022]. Possible underlying causes of dysfunction or disease of the ocular surface and tear-secreting glands include:

How common is it?

Prevalence estimates vary depending on the definition of dry eye disease used, the study population, and the diagnostic methods used in epidemiological studies [Akpek, 2019].

  • The Tear Film and Ocular Surface Society (TFOS) Dry Eye Workshop (DEWS) publication reviewed 24 large international cohort studies and found [Stapleton, 2017]:
    • Prevalence of dry eye disease on the basis of symptoms with or without signs ranged from 5–50%.
    • Prevalence of dry eye disease based primarily on signs was higher, with estimates up to 75%.
    • In general, women showed a higher prevalence with increasing age than men; although, there was variability between studies.
    • Prevalence was higher in Asian than Caucasian populations.
  • A US population-based cohort study of adults (n = 3,722; mean age 65 years) found [Moss, 2000]:
    • The overall prevalence of self-reported dry eye was 14.4%.
    • Prevalence increased with age, varying from 8.4% in participants younger than 60 years to 19% in those aged more than 80 years.
    • The age-adjusted prevalence was 11.4% in men and 16.7% in women.
  • A US cross-sectional prevalence survey of two studies in men (n = 25,444) found [Schaumberg, 2009]:
    • The prevalence increased with age, with 3.9% of men aged 50–54 years affected, compared with 7.67% of men aged 80 years and older.
    • The age-standardized prevalence was 4.34%.
  • A US cross-sectional prevalence survey of women participating in the Women's Health Study (n = 39,876) found [Schaumberg, 2003]:
    • The prevalence increased with age, from 5.7% in women less than 50 years to 9.8% in women aged 75 years or older.
    • The age-adjusted prevalence was 7.8%.
  • A smaller population-based cross-sectional study (n = 3,824 women aged 20–87 years) using TwinsUK cohort data found [Vehof, 2014]:
    • 9.6% of participants had a diagnosis of dry eye disease and were using tear substitutes.
    • 20.8% of participants had experienced dry eye symptoms in the previous 3 months.
    • A possible association with chronic pain syndromes including chronic widespread pain, pelvic pain, and irritable bowel syndrome.

What is the prognosis?

Dry eye disease is usually a chronic condition with fluctuating severity and variable duration depending on the underlying cause and treatment [Akpek, 2019].

  • Dry eye disease is usually not curable but symptoms can generally be improved with treatment and modification of underlying causes, where possible. Symptoms may worsen due to increasing age, inappropriate treatment, poor treatment adherence, and underlying systemic disease.

What are the complications?

Possible complications of dry eye disease include:

Diagnosis of dry eye disease

When should I suspect a diagnosis of dry eye disease?

Symptoms and signs of dry eye disease are usually bilateral and vary between people. Clinical features do not necessarily correlate with disease severity.

  • Eye irritation, itching, or discomfort which may be burning, stinging, or a ‘gritty’ foreign body sensation.
  • Eye dryness (not always present).
  • Transient blurring of vision; watery eyes (due to reflex tearing).
  • Redness of the eyelids or conjunctiva.
  • Photosensitivity.
  • Mucous discharge.
  • Eye fatigue.
  • Contact lens intolerance.

Basis for recommendation

The information on diagnosis is based on the UK College of Optometrists clinical management guideline Dry eye (keratoconjunctivitis sicca, KCS) [College of Optometrists, 2022], the American Academy of Ophthalmology (AAO) clinical guideline Dry eye syndrome. Preferred Practice Pattern [Akpek, 2019], and expert opinion in review articles on dry eye disease [Tong, 2012b; DTB, 2016; Milner, 2017].

How should I assess a person with suspected dry eye disease?

If a diagnosis of dry eye disease is suspected:

  • Ask about:
    • Any symptoms, their onset, severity, duration, fluctuation over time (typically worsen by the end of the day), and impact on quality of life.
    • Any red flags which may indicate a serious underlying cause for symptoms.
      • These include sudden-onset pain or visual loss, persistent or severe visual loss, diplopia, unilateral symptoms, or systemic symptoms such as weight loss or fever. See the CKS topic on Red eye for more information.
    • Any exacerbating factors such as environmental conditions, allergy, or low blink rate.
    • Previous ocular history including possible causes, such as topical eye preparations, contact lens use, ocular surgery, or other eye conditions.
    • Past medical history and symptoms of a possible associated condition or underlying cause.
    • Smoking history, alcohol intake, and exposure to smoke and fumes including occupational history.
    • Previous treatments including tear substitutes, and any drug treatments that may cause or worsen symptoms.
  • Perform an eye, cranial nerve, and general examination. Be aware this may be normal.
    • Assess visual acuity — this should not be severely impaired in most people.
    • Examine for red flag signs which may indicate a serious underlying or alternative cause for symptoms. See the section on Differential diagnosis for more information.
    • Assess for incomplete or infrequent blink.
    • Examine the cornea and conjunctiva for typical signs such as mild conjunctival redness.
    • Examine the eyelids for signs of incomplete closure or malposition, such as proptosis, lid retraction, ectropion, or entropion. Evert and inspect the eyelid margins for signs of inflammation (suggesting blepharitis) and abnormal deposits or secretions (suggesting Meibomian gland dysfunction). See the CKS topics on Blepharitis and Meibomian cyst (chalazion) for more information.
    • Assess for other signs suggesting a possible associated condition or cause, including skin conditions and trigeminal and facial cranial nerve function.

Basis for recommendation

The recommendations on assessment are based on the international Tear Film and Ocular Surface Society (TFOS) Dry Eye Workshop (DEWS) publications TFOS DEWS II Diagnostic methodology report [Wolffsohn, 2017] and TFOS DEWS II Management and therapy report [Jones, 2017], the UK College of Optometrists clinical management guideline Dry eye (keratoconjunctivitis sicca, KCS) [College of Optometrists, 2022], the American Academy of Ophthalmology (AAO) clinical guideline Dry eye syndrome. Preferred Practice Pattern [Akpek, 2019], and expert opinion in review articles on dry eye [Tong, 2012a; Milner, 2017] and on tear substitutes [Tong, 2012b].

Clinical features on history-taking

  • The information that symptoms of dry eye may be worse by the end of the day is based on the AAO clinical guideline [Akpek, 2019].
  • The information about possible red flags is based on the TFOS DEWS II publication on diagnosis, which notes that sudden-onset pain or visual loss needs urgent assessment for possible eye trauma, infection, or ulceration [Wolffsohn, 2017]. This approach is supported by expert opinion in a review article which notes additional red flags such as diplopia and systemic symptoms which need further investigation [Tong, 2012a].

Clinical features on examination

  • The information that eye, cranial nerve, and general examination may be normal is based on expert opinion in a review article [Tong, 2012a].
  • The information that visual acuity should not be severely impaired in most people is based on the AAO clinical guideline [Akpek, 2019] and expert opinion in review articles [Tong, 2012a; Milner, 2017].
  • The information about typical signs of mild conjunctival redness is based on the AAO clinical guideline [Akpek, 2019] and expert opinion in a review article [Tong, 2012a].

What else might it be?

Other conditions which may present similarly to dry eye disease include other causes for a red and/or painful eye, such as:

  • Possible serious or sight-threatening causes including corneal ulcer, acute glaucoma, keratitis, iritis, or uveitis. See the CKS topics on Corneal superficial injury, Glaucoma, Red eye, and Uveitis for more information.
  • Anterior blepharitis. See the CKS topic on Blepharitis for more information.
  • Allergic conjunctivitis, infective conjunctivitis, or giant papillary conjunctivitis (associated with trauma to the upper tarsal plate, may be secondary to contact lens wear or foreign body). See the CKS topics on Conjunctivitis - allergic and Conjunctivitis - infective for more information.
  • Trachoma — corneal inflammation and scarring of the conjunctiva, caused by Chlamydia trachomatis. See the CKS topic on Chlamydia - uncomplicated genital for more information.
  • Exposure keratopathy due to eyelid abnormality or dysfunction.
  • Nocturnal lagophthalmos (failure to close the eyes at night) — preventing formation of a stable inter-blink tear film.

Basis for recommendation

The information on the differential diagnosis of dry eye disease is largely based on the international Tear Film and Ocular Surface Society (TFOS) Dry Eye Workshop (DEWS) publications TFOS DEWS II Definition and classification report [Craig, 2017] and TFOS DEWS II Diagnostic methodology report [Wolffsohn, 2017], the UK College of Optometrists clinical management guideline Dry eye (keratoconjunctivitis sicca, KCS) [College of Optometrists, 2022], the American Academy of Ophthalmology (AAO) clinical guideline Dry eye syndrome. Preferred Practice Pattern [Akpek, 2019], and expert opinion in review articles on dry eye [Tong, 2012a; Milner, 2017].

  • The information about serious or sight-threatening causes of red eye is extrapolated from the TFOS DEWS publication on diagnosis [Wolffsohn, 2017], expert opinion in a review article [Milner, 2017], and is also pragmatic, based on what CKS considers to be good clinical practice.
  • The information about anterior blepharitis is based on the TFOS DEWS publication on diagnosis [Wolffsohn, 2017] and the College of Optometrists clinical management guideline [College of Optometrists, 2022].
  • The information about different forms of conjunctivitis is based on the TFOS DEWS publication on diagnosis [Wolffsohn, 2017], the College of Optometrists clinical management guideline [College of Optometrists, 2022], and the AAO clinical guideline, which notes that exogenous irritants and allergens may not cause dry eye but may aggravate symptoms [Akpek, 2019].
  • The information about trachoma is based on the TFOS DEWS publication [Wolffsohn, 2017].
  • The information about exposure keratopathy is based on the College of Optometrists clinical management guideline [College of Optometrists, 2022].
  • The information about nocturnal lagophthalmos is based on the TFOS DEWS publication on classification [Craig, 2017] and the College of Optometrists clinical management guideline [College of Optometrists, 2022].

Management

Scenario: Management of dry eye disease

From age 10 years onwards.

When should I refer a person with suspected dry eye disease?

If a person has clinical features of suspected dry eye disease:

  • Arrange an urgent ophthalmology same-day assessment if the person has:
  •  Arrange urgent referral to ophthalmology if:
    • A serious underlying cause is suspected, such as Stevens-Johnson syndrome or ocular cicatricial pemphigoid.
  • Arrange referral to ophthalmology or an appropriate specialist, the urgency depending on clinical judgement, if the person:
    • Has an uncertain diagnosis, especially if a child has unexplained symptoms or suspected corneal changes.
    • Has a suspected underlying systemic condition such as Sjögren’s syndrome.
    • Has abnormal lid anatomy or function.
    • Has persistent or severe symptoms that do not respond to primary care management after 4–12 weeks, depending on clinical judgement. See the section on Management for more information.

Basis for recommendation

The recommendations on referral are based on the National Institute for Health and Care Excellence (NICE) technology appraisal guidance Ciclosporin for treating dry eye disease that has not improved despite treatment with artificial tears [NICE, 2015], the international Tear Film and Ocular Surface Society (TFOS) Dry Eye Workshop (DEWS) publications TFOS DEWS II Diagnostic methodology report [Wolffsohn, 2017] and TFOS DEWS II Management and therapy report [Jones, 2017], the UK College of Optometrists clinical management guideline Dry eye (keratoconjunctivitis sicca, KCS) [College of Optometrists, 2022], the Royal College of Ophthalmologists clinical guideline Serum eye drops for the treatment of severe ocular surface disease [RCOphth, 2017], the American Academy of Ophthalmology (AAO) clinical guideline Dry eye syndrome. Preferred Practice Pattern [Akpek, 2019], and expert opinion in review articles on dry eye [Tong, 2012a; DTB, 2016; Milner, 2017].

Arranging same-day ophthalmology assessment
  • The recommendation about red flag symptoms or signs is based on the AAO clinical guideline [Akpek, 2019], expert opinion in a review article [Tong, 2012a], and is also pragmatic, based on what CKS considers to be good clinical practice.
  • The recommendation about a suspected serious complication is extrapolated from the AAO clinical guideline [Akpek, 2019], expert opinion in a review article [DTB, 2016], and is also pragmatic, based on what CKS considers to be good clinical practice.
Arranging urgent ophthalmology assessment
  • The recommendation about a serious underlying cause is based on the College of Optometrists clinical management guideline, which recommends arranging an ophthalmology referral to be seen within one week [College of Optometrists, 2022].
Arranging ophthalmology or other specialist assessment
  • The recommendation if there is an uncertain diagnosis, particularly in children, is extrapolated from the AAO clinical guideline, which notes that ocular rosacea may be difficult to diagnose in children as skin features are less common, and children may present with corneal involvement and potentially sight-threatening visual impairment. It also notes the importance of assessing for underlying systematic or alternative causes for symptoms in children [Akpek, 2019].
  • The recommendation if there is a suspected underlying systemic condition is based on the College of Optometrists clinical management guideline [College of Optometrists, 2022] and the AAO clinical guideline [Akpek, 2019].
  • The recommendation if there is abnormal lid anatomy or function is based on the College of Optometrists clinical management guideline. Surgical tarsorrhaphy or other lid surgery may be needed to correct eyelid malposition and provide symptom relief [College of Optometrists, 2022].
  • The recommendation if symptoms do not respond to primary care management after 4–12 weeks is based on limited evidence in the literature. The TFOS DEWS publication on management recommends waiting 4–12 weeks to see if a particular treatment works [Jones, 2017], and the TFOS DEWS publication on diagnosis recommends arranging specialist eye examination if symptoms do not improve with treatment after one month [Wolffsohn, 2017]. CKS notes that the College of Optometrists clinical management guideline and the AAO clinical guideline do not specify a time period within which specialist referral should be arranged. The time frame should include clinical judgement of disease severity and the impact on the person. 
    • There is no single test which is adequate to establish a formal diagnosis of dry eye disease and to assess for underlying conditions, and specialist assessment may include slit lamp examination of the conjunctiva, tear film, cornea, eyelashes, and meibomian glands. Additional specialist investigations may include Schirmer test, assessment of tear break-up time, tear osmolarity testing, ocular surface dye staining, and tests of lacrimal gland function, which may be helpful in the diagnosis of Sjögren's syndrome [Wolffsohn, 2017; Akpek, 2019; College of Optometrists, 2022]. CKS notes that the equipment and expertise for these tests usually requires referral to an optometrist or ophthalmologist.
    • Eye signs may include punctate epithelial erosions in the exposed areas of the cornea and bulbar conjunctiva; increased mucus strands, filaments, and other tear film debris; and reduced corneal sensitivity [College of Optometrists, 2022].
    • Specialist treatment following referral varies depending on the underlying cause, but may include short-term topical steroids for their anti-inflammatory effect and topical ciclosporin A (CsA) if there is severe keratitis in adults that has not improved despite treatment with tear substitutes, which has an immodulatory and anti-inflammatory effect on the cornea and lacrimal glands [NICE, 2015; Jones, 2017; Akpek, 2019; College of Optometrists, 2022]. Other specialist treatments include protection with therapeutic contact lenses, advice about moisture chamber eyewear, temporary punctal plugs or surgical occlusion of puncta with thermal or laser cautery, or serum eye drops [Jones, 2017; Milner, 2017; RCOphth, 2017; Akpek, 2019; College of Optometrists, 2022].

How should I manage a person with suspected dry eye disease?

If a person with dry eye disease does not need urgent specialist referral and can be managed in primary care:

  • Advise on sources of information and support, such as:
    • The joint Royal College of Ophthalmologists and Royal National Institute of Blind People (RNIB) publication Understanding dry eye.
    • The NHS information Dry eyes.
  • Advise on lifestyle measures for symptom relief, such as:
    • Warm compresses, lid hygiene, and lid massage, especially if blepharitis or Meibomian gland dysfunction are present. See the CKS topics on Blepharitis and Meibomian cyst (chalazion) for more information.
    • Modification of contact lens wear.
      • Advise to wear contact lenses for shorter periods, and remove lenses if dry eye symptoms occur.
      • Advise that changing lens type or solution may help, and to seek advice from an optometrist if needed.
    • Moisture chamber eyewear (such as wrap-around glasses or specialist goggles).
    • Modification of environmental factors.
      • Increase relative humidity and avoid prolonged periods of digital device use or exposure to air conditioning or drafts, if possible.
      • Lower computer screens to below eye level (decreasing lid aperture), and increase blink frequency with digital device use and reading.
      • Avoid alcohol and exposure to cigarette and other smoke.
  • Advise that symptoms of dry eye may worsen following keratorefractive surgery (particularly LASIK laser-assisted in situ keratomileusis), and symptoms should be controlled before surgery is considered.
  • If a person is using drug treatment that may cause or contribute to symptoms, consider a dose reduction, different route of administration, or switching to alternative treatment(s) if clinically appropriate.
  • Ensure optimal management of any associated ocular or systemic condition(s) that may cause symptoms, where possible.
  • Advise on the use of tear substitutes ('artificial tears') if lifestyle measures are insufficient for symptom relief.
    • Advise on the chronic nature of dry eye disease and the fact that longterm treatment is usually needed.
    • Advise that a large range of tear substitutes are available over-the-counter in different formulations, such as eye drops, gels, ointments, and sprays.
      • Advise that low-viscosity drops are usually recommended for daytime use due to the reduced risk of adverse effects such as blurred vision, eyelid debris, and eye stinging. Increased viscosity ointments or gels may be needed for overnight use.
      • Options include hypromellose, which provides temporary relief but needs frequent application, and carbomers (more viscous preparations). For a complete list of products available in the UK, see the electronic Medicines Compendium (eMC) or the British National Formulary (BNF).
    • Advise the use of preservative-free topical formulations, where possible, particularly if the person:
      • Is intolerant of preservative in tear supplements (risk of conjunctivitis medicamentosa).
      • Has moderate-to-severe dry eye disease requiring topical preparations more than 4 times per day.
      • Is using multiple topical eye preparations.
      • Uses soft or hybrid contact lenses.
  • Arrange follow-up within 4–6 weeks of starting treatment with tear substitutes.
    • If symptoms are not relieved with an initial topical preparation, consider switching to an alternative; for example, one containing sodium hyaluronate, or a lipid-based preparation or lipsomal spray, particularly if Meibomian gland dysfunction is present. See the CKS topic on Meibomian cyst (chalazion) for more information.
      • Seek specialist advice if there is any uncertainty as to which topical preparation to recommend or prescribe.
    • If symptoms do not respond to primary care treatment after 4–12 weeks, arrange specialist referral, depending on clinical judgement. See the section on Referral for more information.

Basis for recommendation

The recommendations on the management of dry eye disease in primary care are based on the international Tear Film and Ocular Surface Society (TFOS) Dry Eye Workshop (DEWS) publication TFOS DEWS II Management and therapy report [Jones, 2017], the UK College of Optometrists clinical management guideline Dry eye (keratoconjunctivitis sicca, KCS) [College of Optometrists, 2022], the American Academy of Ophthalmology (AAO) clinical guideline Dry eye syndrome. Preferred Practice Pattern [Akpek, 2019], the Royal College of Ophthalmologists clinical guideline Serum eye drops for the treatment of severe ocular surface disease [RCOphth, 2017], the NHS England (NHSE) publication Conditions for which over the counter items should not routinely be prescribed in primary care: guidance for CCGs [NHS England, 2018], a Cochrane systematic review Over the counter (OTC) artificial tear drops for dry eye syndrome [Pucker, 2016], a European consensus review article on tear substitutes [Barabino, 2020], and expert opinion in review articles on dry eye disease [Messmer, 2015; DTB, 2016; Milner, 2017] and tear substitutes [Tong, 2012b].

Advising on sources of information and support
  • This recommendation is based on the College of Optometrists clinical management guideline [College of Optometrists, 2022], the AAO clinical guideline [Akpek, 2019], and is also pragmatic, based on what CKS considers to be good clinical practice.
Advising on lifestyle measures
  • The recommendation about warm compresses, lid hygiene, and lid massage is based on the TFOS DEWS publication [Jones, 2017], the AAO clinical guideline [Akpek, 2019], moderate-quality evidence cited in the College of Optometrists clinical management guideline [College of Optometrists, 2022], and is supported by expert opinion in a review article [Milner, 2017].
  • The recommendation about modification of contact lenses is based on expert opinion in a review article [Tong, 2012b] and is pragmatic, based on what CKS considers to be good clinical practice.
  • The recommendation about moisture chamber eyewear is based on the fact this can reduce the impact of environmental conditions on the ocular surface, as recommended in the TFOS DEWS publication [Jones, 2017] and expert opinion in a review article [Milner, 2017].
  • The recommendation about modification of environmental factors is based on the TFOS DEWS publication [Jones, 2017], low-quality evidence in the College of Optometrists clinical management guideline [College of Optometrists, 2022], the AAO clinical guideline [Akpek, 2019], and expert opinion in a review article [Milner, 2017].
Advising on keratorefractive surgery
  • This recommendation is based on the AAO clinical guideline, which notes dry eye symptoms may worsen the outcomes of refractive, corneal, and cataract surgery. It states that LASIK (laser-assisted in situ keratomileusis) may be considered if pre-existing dry eye symptoms can be improved pre-operatively [Akpek, 2019].
Advising on drug treatment modification
  • This recommendation is based on the TFOS DEWS publication [Jones, 2017] and the AAO clinical guideline [Akpek, 2019].
Managing associated conditions
  • This recommendation is pragmatic, based on what CKS considers to be good clinical practice.
Advising on the use of tear substitutes
  • The information about the chronic nature of symptoms and longterm need for treatment is based on the AAO clinical guideline [Akpek, 2019].
  • The information about the range of tear substitute preparations available over-the-counter is largely based on the NHS England publication [NHS England, 2018] and a European consensus review [Barabino, 2020].
    • Tear supplements aim to replace and/or supplement the natural tear film. Different preparations vary in active ingredients, formulations, osmolarity, viscosity, and pH. They tend to be well tolerated with rare adverse effects, such as blurred vision, eye discomfort, and foreign body sensation [Jones, 2017].
    • Tear substitutes alleviate symptoms 'through reduction of friction and shear forces caused by blink-induced biomechanical trauma' [RCOphth, 2017]. There is limited trial evidence that they increase tear film stability and reduce ocular surface stress, reduce debris, and dilute a hyperosmolar tear film [Messmer, 2015; Milner, 2017].
    • The NHSE guidance states that people should self-manage mild-to-moderate dry eye symptoms using over-the-counter topical preparations [NHS England, 2018].
    • The information about when to use low-viscosity drops and increased viscosity ointments or gels to minimize the risk of adverse effects and increase adherence to treatment is based on the TFOS DEWS publication [Jones, 2017] and the College of Optometrists clinical management guideline [College of Optometrists, 2022].
    • The information about examples of topical eye preparations that are available is extrapolated from the Royal College of Ophthalmologists clinical guideline [RCOphth, 2017] and expert opinion in a review article [DTB, 2016]. A Cochrane systematic review of 43 randomized controlled trials (RCTs) of over-the-counter tear substitutes (n = 3,497) found low-quality evidence that the majority of preparations are of similar efficacy and generally safe, but it noted heterogeneity of study characteristics and design, and recommended further studies to confirm these conclusions [Pucker, 2016].
  • The recommendations about when to use preservative-free topical formulations are based on the TFOS DEWS publication [Jones, 2017], the College of Optometrists clinical management guideline [College of Optometrists, 2022], the Royal College of Ophthalmologists clinical guideline [RCOphth, 2017], and the AAO clinical guideline [Akpek, 2019]. The information about contact lens users is also based on the expert opinion of previous external reviewers of this CKS topic.
    • The TFOS publication notes that preservative-containing topical eye preparations may be associated with allergic, toxic, or inflammatory reactions, particularly if medication is used long-term. Ideally all topical eye preparations for dry eye would be supplied in unit-dose or preservative-free multi-dose containers, however factors such as cost and product availability may limit this in practice [Jones, 2017].
    • Expert opinion in a review article notes that preservative-containing preparations may be appropriate if a person has mild symptoms 'and an otherwise healthy ocular surface' as preservative is likely to be diluted in the tear film [DTB, 2016].
Arranging follow-up
  • The recommendation to consider switching to an alternative tear substitute such as a lipid-containing preparation if symptoms persist, is largely based on the TFOS DEWS publication [Jones, 2017] and the AAO clinical guideline [Akpek, 2019]. The College of Optometrists clinical management guideline also recommends use of liposomal sprays if evaporative dry eye is present, as these can help to restore the lipid layer of the tear film [College of Optometrists, 2022].
    • The recommendation to seek specialist advice if there is uncertainty about what to prescribe is pragmatic, based on what CKS considers to be good clinical practice.
  • The recommendation to arrange specialist referral if symptoms persist after 4–12 weeks is largely based on the TFOS DEWS publication [Jones, 2017].

Supporting evidence

This CKS topic is largely based on the National Institute for Health and Care Excellence (NICE) technology appraisal guidance Ciclosporin for treating dry eye disease that has not improved despite treatment with artificial tears [NICE, 2015], various international Tear Film and Ocular Surface Society (TFOS) Dry Eye Workshop (DEWS) publications, the UK College of Optometrists clinical management guideline Dry eye (keratoconjunctivitis sicca, KCS) [College of Optometrists, 2022], the American Academy of Ophthalmology (AAO) clinical guideline Dry eye syndrome. Preferred Practice Pattern [Akpek, 2019], and expert opinion in review articles. The rationale for individual recommendations is outlined in the relevant basis for recommendation sections of the topic.

How this topic was developed

This section briefly describes the processes used in developing and updating this topic. Further details on the full process can be found in the About Us section and on the Clarity Informatics website.

Search strategy

A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of dry eye syndrome.

Search dates

August 2017 - December 2022

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline.

  • exp Dry Eye Syndromes/, exp Keratoconjunctivitis Sicca/, dry eye syndrome.tw., (keratoconjunctivitis ADJ sicca).tw.

Sources of guidelines

Sources of systematic reviews and meta-analyses

  • The Cochrane Library:
    • Systematic reviews
    • Protocols
    • Database of Abstracts of Reviews of Effects
  • Medline (with systematic review filter)
  • EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

Sources of randomized controlled trials

  • The Cochrane Library:
    • Central Register of Controlled Trials
  • Medline (with randomized controlled trial filter)
  • EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

Sources of national policy

Patient experiences

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

  • Clinical accuracy.
  • Consistency with other providers of clinical knowledge for primary care.
  • Accuracy of implementation of national guidance (in particular NICE guidelines).
  • Usability.

Principles of the consultation process

  • The process is inclusive and any individual may participate.
  • To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
  • Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
  • Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
  • External reviewers are not paid for commenting on the draft topics.
  • Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
  • All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
  • All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

  • Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
  • Stakeholders identified from the following groups are invited to review draft topics:
    • Experts in the topic area.
    • Professional organizations and societies (for example, Royal Colleges).
    • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
    • Guideline development groups where the topic is an implementation of a guideline.
    • The British National Formulary team.
    • The editorial team that develop MeReC Publications.
  • Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

  • Topic selection
  • Scoping of topic
  • Selection of clinical scenarios
  • First draft internal review
  • Second draft internal review
  • External review
  • Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

  • Animal studies
  • Original research is not written in English

Possible exclusions for reviewed literature:

  • Sample size too small or study underpowered
  • Bias evident or promotional literature
  • Population not relevant
  • Intervention/treatment not relevant
  • Outcomes not relevant
  • Outcomes have no clear evidence of clinical effectiveness
  • Setting not relevant
  • Not relevant to UK
  • Incorrect study type
  • Review article
  • Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

  • Feasibility
    • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
  • Organizational and Financial Impact Analysis
  • Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
    • Eligible population
    • Current interventions
    • Likely uptake of new intervention or recommendation
    • Cost of the current or new intervention mix
    • Impact on other costs
    • Condition-related costs
    • In-direct costs and service impacts
    • Time dependencies
  • Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

  • Personal financial interests
  • Personal family interest
  • Personal non-financial interest
  • Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.

References

  • Akpek, E.K., Amescua, G., Farid, M., et al. (2019) Dry eye syndrome. Preferred practice pattern. Ophthalmology 126(1), 286-334. [Abstract]
  • Barabino, S., Benitez-del-Castillo, J.M., Fuchsluger, T., et al. (2020) Dry eye disease treatment: the role of tear substitutes, their future, and an updated classification. European Review for Medical and Pharmacological Sciences 24(17), 8642-8652. [Abstract]
  • College of Optometrists (2022) Dry eye (keratoconjunctivitis sicca, KCS). College of Optometrists. http://www.college-optometrists.org [Free Full-text]
  • Craig, J.P., Nichols, K.K., Akpek, E.K., et al. (2017) TFOS DEWS II Definition and classification report. The Ocular Surface 15(3), 276-283. [Abstract]
  • DTB (2016) The management of dry eye. BMJ 54, 9-12. [Free Full-text]
  • Jones, L., Downie, L.E., Korb, D., et al. (2017) TFOS DEWS II Management and therapy report. The Ocular Surface 15(3), 575-628. [Abstract]
  • Messmer, E.M. (2015) The pathophysiology, diagnosis, and treatment of dry eye disease. Deutsches Arzteblatt International 112(5), 71-81. [Abstract] [Free Full-text]
  • Milner, M.S., Beckman, K.A., Luchs, J.I., et al. (2017) Dysfunctional tear syndrome: dry eye disease and associated tear film disorders - new strategies for diagnosis and treatment. Current Opinion in Ophthalmology 27(Suppl 1), 3-47. [Abstract] [Free Full-text]
  • Moss, S.E., Klein, R. and Klein, B.E. (2000) Prevalence of and risk factors for dry eye syndrome. Archives of Ophthalmology 118(9), 1264-1268. [Abstract]
  • NHS England (2018) Conditions for which over the counter items should not routinely be prescribed in primary care: guidance for CCGs. NHS England. http://www.england.nhs.uk [Free Full-text]
  • NICE (2015) Ciclosporin for treating dry eye disease that has not improved despite treatment with artificial tears. National Institute for Health and Care Excellence. http://www.nice.org.uk [Free Full-text]
  • Pucker, A.D., Ng, S.M. and Nichols, J.J. (2016) Over the counter (OTC) artificial tear drops for dry eye syndrome. The Cochrane database of systematic reviews 23(2), CD009729. [Abstract] [Free Full-text]
  • RCOphth (2017) Serum eye drops for the treatment of severe ocular surface disease. Royal College of Ophthalmologists. http://www.rcophth.ac.uk [Free Full-text]
  • Schaumberg, D.A., Sullivan, D.A., Buring, J.E. and Dana, M.R. (2003) Prevalence of dry eye syndrome among US women. American Journal of Ophthalmology 136(2), 318-326. [Abstract]
  • Schaumberg, D.A., Dana, R., Buring, J.E. and Sullivan, D.A. (2009) Prevalence of dry eye disease among US men: estimates from the Physicians' Health Studies. Archives of Ophthalmology 127(6), 763-768. [Abstract] [Free Full-text]
  • Stapleton, F., Alves, M., Bunya, V.Y., et al. (2017) TFOS DEWS II Epidemiology report. The Ocular Surface 15(3), 334-365. [Abstract]
  • Tong, L., Tan, J., Thumboo, J. and Seow, G. (2012a) Dry eye. BMJ 345(e7533). [Abstract] [Free Full-text]
  • Tong, L., Petznick, A., Lee, S. and Tan, J. (2012b) Choice of artificial tear formulation for patients with dry eye: where do we start? Cornea 31(Suppl 1), S32-S36. [Abstract]
  • Vehof, J., Kozareva, D., Hysi, P.G. and Hammond, C.J. (2014) Prevalence and risk factors of dry eye disease in a British female cohort. British Journal of Ophthalmology 98(12), 1712-1717. [Abstract]
  • Wolffsohn, J.S., Arita, R., Chalmers, R., et al. (2017) TFOS DEWS II Diagnostic methodology report. The Ocular Surface 15(3), 539-574. [Abstract]
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