Dry Eye (Keratoconjunctivitis Sicca, KCS)
The CMGs are guidelines on the diagnosis and management of a range of common and rare, but important, eye conditions that present with varying frequency in primary and first contact care.
The CMGs are guidelines on the diagnosis and management of a range of common and rare, but important, eye conditions that present with varying frequency in primary and first contact care.
The 2017 International Dry Eye Workshop (DEWS II) has provided the following definition: Dry eye is a multifactorial disease of the ocular surface characterised by
a loss of homeostasis of the tear film, and accompanied by ocular symptoms, in which tear film instability and hyperosmolarity, ocular surface inflammation and
damage, and neurosensory abnormalities play aetiological roles.
Aetiology: Dry Eye Disease (DED) is divided into aqueous-deficient dry eye and evaporative dry eye, and the two forms can occur together. The lists that follow
are simplified from TFOS DEWS II:
1. Aqueous-deficient Dry Eye (ADDE)
2. Evaporative Dry Eye (EDE)
Tear deficiency can also be related to tear film dysfunction:
Wide variation in prevalence worldwide (6.5% to 52.4%); higher prevalence in women in all studies
Wide variation in prevalence by symptom compared to clinical diagnosis
Prevalence rises with age, between 2.0% and 10.5% per decade
Factors that aggravate symptoms:
Anterior blepharitis
Allergic and infective conjunctivitis
Eyelid abnormality or dysfunction leading to exposure (exposure keratopathy)
Nocturnal lagophthalmos (failure to close eyes at night)
Practitioners should recognise their limitations and where necessary seek further advice or refer the patient elsewhere
GRADE* Level of evidence and strength of recommendation always relates to the statement(s) immediately above
Patient education regarding the condition
Modification of local environment
(GRADE*: Level of evidence=low, Strength of recommendation=strong)
Advise diet rich in omega-3 essential fatty acids
(GRADE*: Level of evidence=low, Strength of recommendation=strong)
Oral essential fatty acid supplements (omega-3 and omega-6): a recent high-quality RCT found that patients who were randomly assigned to receive supplements containing 3000mg of omega-3 fatty acids for 12 months did not have significantly better outcomes than those who were assigned to receive placebo
(GRADE*: Level of evidence=moderate, Strength of recommendation=weak)
Tear conservation
(GRADE*: Level of evidence=moderate, Strength of recommendation=strong)
Lid hygiene for meibomian dysfunction (hot compresses, lid hygiene) (see Clinical Management Guideline on Blepharitis)
(GRADE*: Level of evidence=moderate, Strength of recommendation=strong)
Protection with therapeutic contact lenses
(GRADE*: Level of evidence=low, Strength of recommendation=weak)
Tear supplements (preferably unpreserved) for use during the day ± unmedicated ointment for use at bedtime
(Recent systematic review found no evidence to support the superiority of any particular tear supplement)
Liposomal sprays in evaporative dry eye
(GRADE*: Level of evidence=moderate, Strength of recommendation=strong)
NB Patients on long-term medication may develop sensitivity reactions which may be to active ingredients or to preservative systems (see Clinical Management
Guideline on Conjunctivitis Medicamentosa). They should be switched to unpreserved preparations
Topical steroids (such as fluorometholone or loteprednol) may be considered for short-term use in some cases. The usual precautionary surveillance is required
(GRADE*: Level of evidence=moderate, Strength of recommendation=weak)
B2: alleviation or palliation; normally no referral
(If idiopathic and not associated with systemic disease)
B1: initial management followed by routine referral if adequate trial of topical treatment or punctal plugs fails, or for secondary complications (vascularisation, corneal scaring, melt, or infection). If lid anatomy or function is abnormal, refer. If the condition is not idiopathic, for example if Sjögren’s syndrome or an unidentified underlying disease are suspected, refer.
A3: if SJS or OCP are suspected, refer urgently (within one week) to ophthalmologist
*GRADE*: Grading of Recommendations Assessment, Development and Evaluation (www.gradeworkinggroup.org)
Sources of evidence
Courtin R, Pereira B, Naughton G, Chamoux A, Chiambaretta F, Lanhers C, Dutheil F. Prevalence of dry eye disease in visual display terminal workers: a systematic review and meta-analysis. BMJ Open. 2016;6(1):e009675
Craig JP, Nichols KK, Akpek EK, Caffery B, Dua HS, Joo C-K, Liu Z, Nelson JD, Nichols JJ, Tsubota K, Stapleton F. TFOS DEWS II Definition and Classification Report. Ocul Surf. 2017;15:276-83
Dry Eye Assessment and Management Study Research Group. n-3 Fatty Acid Supplementation for the Treatment of Dry Eye Disease. N Engl J Med. 2018 Apr 13. doi: 0.1056/NEJMoa1709691. [Epub ahead of print]
Ervin A-M, Wojciechowski R, Schein O. Punctal occlusion for dry eye syndrome. Cochrane Database Syst Rev. 2010;9:CD006775.
Jones L, Downie LE, Korb D, Benitez-del-Castillo JM, Dana R, Deng, SX, Dong PN, Geerling G, Yudi Hida R, Liu Y, Yul Seo K, Tauber J, Wakamatsu TH, Xu J, Wolffsohn JS, Craig JP. TFOS DEWS II Management and Therapy Report. Ocul Surf. 2017;15:575-628
Liu A, Ji J. Omega-3 essential fatty acids therapy for dry eye syndrome: a metaanalysis of randomized controlled studies. Med Sci Monit. 2014;20:1583-9
Marcet MM, Shtein RM, Bradley EA, Deng SX, Meyer DR, Bilyk JR, Yen MT, Lee WB, Mawn LA. Safety and Efficacy of Lacrimal Drainage System Plugs for Dry ye Syndrome: A Report by the American Academy of Ophthalmology. Ophthalmology. 2015;122(8):1681-7
Pucker AD, Ng SM, Nichols JJ. Over the counter (OTC) artificial tear drops for dry eye syndrome. Cochrane Database Syst Rev. 2016;2:CD009729
Wolffsohn JS, Arita R, Chalmers R, Djalilian A, Dogru M, Dumbleton K, Gupta PK, Karpecki P, Lazreg S, Pult H, Sullivan BD, Tomlinson A, Tong L, Villani E, Yoon
KC, Jones L, Craig JP. TFOS DEWS II Diagnostic Methodology Report. Ocul Surf.2017;15:539-74
Dry Eye Disease is also known by the medical term Keratoconjunctivitis Sicca, which means inflammation of the conjunctiva (the membrane overlying the white of the eye) and the cornea (the clear window of the eye) caused by dryness resulting from a deficiency or disorder of the tear film (the thin layer of tears covering the surface of the eye). It is a common condition affecting many people in the later decades of life. Most cases have no apparent cause but some are related to various inflammatory conditions, surgical treatment or as a side-effect of drug treatment. Some are caused by abnormalities of the eyelids or blinking, or by disorders of the meibomian (oil) glands of the eyelid margin.
Patients complain of irritation of the eyes, a feeling that there is something in the eye, a discharge from the eye, and sometimes blurred vision. They notice that their symptoms are worse in windy or dry conditions or when irritants such as smoke are in the air. When they are examined in the clinic they may be found to have reduced tear production or increased tear evaporation (sometimes due to lack of normal oil gland secretion). There may be damage to the surface of the eye produced by the increased saltiness of the tears.
Tears can be supplemented with various drops and ointments. It is also possible to conserve natural tears by blocking the openings of the tear ducts, either temporarily with tiny plugs or permanently by surgery. Where the problem relates to a disorder of the oil glands, treatment is directed to the eyelids.
Dry eye (Keratoconjunctivitis Sicca) (KCS)
Version 13
Date of search 22.08.17
Date of revision 19.04.18
Date of publication 09.05.18
Date for review 21.08.19
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