Treatment Guidelines

National Guidance

It is estimated that up to 8 million people suffer from dry eyes in the UK and that up to 1 in 3 patients aged 65 years or older suffer from dry eye symptoms3.Dry eye syndrome, or dry eye disease, is a common condition that occurs when the eyes don’t make enough tears, or the tears evaporate too quickly. This leads to the eyes drying out and becoming red, swollen and irritated. Dry eye syndrome is also known as keratoconjunctivitis sicca.Nationally recognised guidelines from both Moorfields, NICE and PrescQIPP include the use of ocular lubricants as part or the treatment pathway for patients with dry eye syndrome.

Moorfields Eye Hospital1

Moorfields Eye Hospital NHS Foundation Trust is the leading provider of eye health services in the UK and a world-class centre of excellence for ophthalmic research and education.  Moorfields has developed clinical recommendations for identification and treatment of dry eye conditions both within primary and secondary care settings4 (treatment extract below).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 dropsEye ointment can also be used to help lubricate eyes, but it can often cause blurred vision, so it is probably best used only at nightMore severe cases may require specialist medication or lacrimal punctal plugsMoorfields prescribing guidelines for Ocular Lubricants1 lists Carmellose and preservative free Sodium Hyaluronate as treatment options for patients presenting with mild to severe dry eyes.

Extract from Moorfields Prescribing Guidelines for Ocular Lubricants

MILD dry eyesMODERATE dry eyesSEVERE dry eyes
Hypromellose 0.3% (Preserved)Sodium Hyaluronate 0.1% (unpreserved)Sodium Hyaluronate 0.1% (unpreserved)
Carmellose 0.5% (Preserved/unpreserved)Carmellose 1.0% (unpreserved)Sodium Hyaluronate 0.2% (unpreserved)
Carbomer 980 0.2% (Preserved/unpreserved)Carbomer 980 0.2% (Preserved/unpreserved)Liquid Paraffin Ointment
Preservative-free products should be prescribed for the following patient groups:
  • True preservative allergy
  • Soft contact lenses wearers
  • Evidence of epithelial toxicity with preservatives
  • Long term treatment or frequency

NICE Clinical Knowledge Summaries2

CKS advocate the use of eye lubricants as part of the treatment pathway for management of patients presenting with dry eye (treatment extract below)
  • Recommend use of tear supplements (sometimes called artificial tears or lubricant eye drops) if lifestyle measures do not relieve symptoms.
  • A large range of tear replacement and ocular lubricant products are available on prescription or over the counter. For a complete list of products available in the UK, see the British National Formulary (BNF).
  • Drops are best for daytime use with ointments or gels reserved for use before bed as these are most likely to cause temporary blurring of vision. Less viscous formulations are less likely to cause stinging and burning.
  • Hypromellose is the most frequently used preparation, but may need to be instilled every hour until symptoms improve, then frequency can be reduced.
  • Consider preservative free formulations if; the person is intolerant of preservative in tear supplements; has moderate to severe dry eye disease requiring drops more than 4 times per day; is using multiple preserved topical medications; or uses soft or hybrid contact lens

PrescQIPP3

Highlights treatment options for dry eyes and the use of preservative free products (extract below).
  • Second line – After a six to eight-week trial of first line agents, lubricants containing hydroxypropyl guar, carmellose sodium or sodium hyaluronate may be tried if necessary. Many products are available for both first and second line treatments and formularies should support prescribers to select appropriate cost-effective options.
  • Those on multiple preserved topical medications are at greater risk of preservative related problems.
  • Indications for the prescription of preservative-free eye drops
  • True preservative allergy
  • Evidence of epithelial toxicity from preservatives
  • Severe dry eye syndrome with ocular surface disease and impairment of lacrimal gland secretion
  • Chronic eye disease who are on multiple preserved topical medications
  • A prolonged daily frequency of administration of greater than 6 times a day
  • Soft or hybrid contact lens wearers

NHSE4

In 2018, NHSE issued guidance to CCGs advocating a reduction in prescribing for conditions that are suitable for self care5 known as “Conditions for which over the counter items should not routinely be prescribed in primary care: Guidance for CCG’s.” Within the guidance are recommendations for the prescribing of products used to treat dry eyes which includes the following recommendations:
  • Patients should be encouraged to manage both dry eyes and sore eyes by implementing some self-care measures such as good eyelid hygiene and avoidance of environmental factors alongside treatment
  • Mild to moderate cases of dry eye syndrome or sore tired eyes can usually be treated using lubricant eye treatments that consist of a range of drops, gels and ointments that can be easily purchased over the counter
CCG’s will be expected to reduce prescribing costs for dry eyes and the other conditions listed within the guidance and their performance will be monitored.
The VIZ Rx ocular lubricant range presents clinicians with a cost-effective range of products containing carmellose and sodium hyaluronate in a range of strengths and combinations for the treatment of mild, moderate and severe dry eyes. The preservative free formulations are in line with national guidelines and can be used in all patient groups, including those wearing soft contact lenses, with preservative allergy or epithelial toxicity; and those on long term or multiple treatments. The range is both cost effective and available OTC as Vizulize in line with NHSE guidance on promotion of self-care. 

  1. Moorfields “Common eye condition management – Dry Eyes”. Available from: https://www.moorfields.nhs.uk/content/dry-eyes <Accessed 7th January 2019>
  2. NICE Clinical Knowledge Summaries – Dry Eyes. Available from: https://cks.nice.org.uk/dry-eye-syndome#!scenario <Accessed 7th January 2019>
  3. Eye Preparations. Prescribing Bulletin 202. PrescQIPP: March 2018
  4. NHSE “Conditions for which over the counter items should not routinely be prescribed in primary care: Guidance for CCG’s”. Available from: https://www.england.nhs.uk/wp-content/uploads/2018/03/otc-guidance-for-ccgs.pdf <Accessed 7th January 2019>