Management of dry eye

General good practice advice

Initial checks

• It is good practice to check visual acuity for patients presenting with an eye condition
• Check the visual acuity in each eye separately for distance; if the patient wears distance glasses, these should be worn for the test
• Record best corrected visual acuity—that is, wearing glasses or contact lenses where used
• If vision is reduced, recheck with the patient looking through a pinhole viewer, which improves the vision if there is any uncorrected need for glasses/lenses
• Significant reduction in the visual acuity is a good indicator for referral
• Review patient history, noting allergies, medical and ocular history, including amblyopia
• Always establish and record symptoms and onset (sudden/gradual/all/part/pain)
• Refer red eye with vision loss or other signs of concern to an ophthalmologist for evaluation

Eye examination

• Wash hands
• Observe lid margins, conjunctiva, and cornea with white light
• Instil one drop of fluorescein 0.25%:
  • observe for corneal staining (preferably using a blue light source)
• Diagnosis confirmed; treat accordingly; if concerned, seek advice from an ophthalmologist

Care pathway for dry eyes

• Dry eye syndrome is a condition where the eyes do not make enough tears, or the tears evaporate too quickly. This can lead to the eyes drying out and becoming inflamed. It is a common condition and becomes more common with age, especially in women. up to a third of people aged 65 or older may have dry eye syndrome. It is more common in those with connective tissue disorders, in blepharitis, and for contact lens wearers

Symptoms

• Dry, gritty, discomfort or tired eyes, which get worse throughout the day
• Mildly sensitive to light (not significant photophobia)
• Slight blurred vision, which improves on blinking
• Both eyes are usually affected (may be asymmetrical symptoms)

Signs

• Redness of the eyes
• Spotty (‘punctate’) fluorescein staining
• May be associated blepharitis (crusting of lashes, foamy tear film)

Eye examination

• Observe lids, conjunctiva, and cornea with white light
• Instil one drop of proxymethacaine 0.5% with fluorescein 0.25%:
  • observe for corneal staining preferably using a blue light
  • consider Schirmer tear test (wetting of tear test strip in five minutes, <5–7 mm abnormal)

Treatment

• Tear substitutes: mild to moderate cases of dry eye syndrome can usually be successfully treated using over-the-counter artificial tear drops; if a patient has severe symptoms and needs to use eye drops more than six times a day, or if they wear contact lenses, advise them to use preservative-free eye drops
• Eye ointment can also be used to help lubricate eyes, but it can often cause blurred vision, so it is probably best used only at night
• More severe cases may require specialist medication or lacrimal punctal plugs

Referral information

• Main switchboard tel: 020 7253 3411
• Booking centre tel: 020 7566 2357
• Choose and Book fax: 020 7566 2847
• Non Choose and Book fax: 020 7566 2351
• Cancer two-week referral fax: 020 7566 2073