How can I differentiate between dry eye syndrome and other ocular surface disorders during a routine examination?

Differentiating between dry eye syndrome (DES) and other ocular surface disorders during a routine examination in general practice primarily involves identifying clinical features and symptoms that warrant specialist referral for definitive diagnosis NICE CKS. There is no single test adequate to formally diagnose dry eye disease or assess for underlying conditions, and specialist assessment typically requires equipment and expertise not available in primary care NICE CKS.

During a routine examination, an Admin should be aware of the following indicators that may suggest DES or other ocular surface disorders, prompting a referral:

• Clinical Features of Suspected Dry Eye Disease: While definitive diagnosis requires specialist tests, persistent or severe symptoms that do not respond to primary care management after 4–12 weeks should prompt referral NICE CKS. Eye signs that may be observed by a specialist include punctate epithelial erosions in exposed areas of the cornea and bulbar conjunctiva, increased mucus strands, filaments, and other tear film debris, and reduced corneal sensitivity NICE CKS.


• Red Flag Symptoms or Signs: Any red flag symptoms or signs that may indicate a serious or sight-threatening cause for symptoms, or a suspected serious complication, necessitate an urgent ophthalmology same-day assessment NICE CKS.


• Suspected Serious Underlying Causes: If a serious underlying cause is suspected, such as Stevens-Johnson syndrome or ocular cicatricial pemphigoid, an urgent referral to ophthalmology is required NICE CKS.


• Uncertain Diagnosis: An uncertain diagnosis, particularly if a child has unexplained symptoms or suspected corneal changes, warrants referral to ophthalmology or an appropriate specialist NICE CKS.


• Suspected Underlying Systemic Conditions: If an underlying systemic condition, such as Sjögren’s syndrome, is suspected, referral to ophthalmology or an appropriate specialist is indicated NICE CKS. For Sjögren's syndrome, diagnostics are advancing to include biomarkers and biomolecules beyond clinical symptoms, which are assessed by specialists Wu et al. 2024.


• Abnormal Lid Anatomy or Function: Abnormal lid anatomy or function also warrants referral, as surgical correction may be needed NICE CKS.

Specialist assessment for differentiation may include a slit lamp examination of the conjunctiva, tear film, cornea, eyelashes, and meibomian glands NICE CKS. Additional specialist investigations can include the Schirmer test, assessment of tear break-up time, tear osmolarity testing, ocular surface dye staining, and tests of lacrimal gland function NICE CKS. These comprehensive tests are crucial for distinguishing DES from other conditions and identifying underlying causes Wolffsohn 2017Akpek 2019College of Optometrists 2022 NICE CKS.