Dry Eye Severity Grader
Evidence-based severity grading from Grade 0 (Healthy) to Grade 4 (Very Severe) with instant management recommendations and referral triggers — based on TFOS DEWS II 2017 and Asia Dry Eye Society Guidelines.
Last updated: March 2026
1. Symptom Score
0–12 Healthy · 13–22 Mild · 23–32 Moderate · 33–42 Severe · ≥43 Very Severe
2. Tear Break-Up Time
≥10 s Healthy · 5–9 Mild · 3–4 Moderate · 1–2 Severe · <1 s Very Severe
Repeat ×3; record mean. NIBUT preferred (avoids reflex tearing).
3. Oxford Staining Grade
Allow 2–3 min after fluorescein instillation before grading.
MGD domain grade = most severe finding across all 5 parameters.
5. Schirmer I Test
≥10 mm Healthy · 6–9 Mild · 3–5 Moderate · 1–2 Severe · ≤1 mm Very Severe
Note: Schirmer has ~25% sensitivity; a positive result is clinically significant.
6. Tear Meniscus Height
Optional≥0.25 Healthy · 0.20–0.24 Mild · 0.15–0.19 Moderate · 0.10–0.14 Severe · <0.10 Very Severe
Enter at least one clinical finding above — overall DED grade and management plan will appear here instantly.
Printable Resource
Dry Eye Severity Assessment Tool (PDF)
Pre-formatted clinical worksheet — OSDI, DEQ-5, TBUT, Oxford staining, MGD, and Schirmer grading tables. Grade 0 to Grade 4. For use at the slit lamp.
Singapore Context
Singapore-Specific Clinical Considerations
MGD-dominant evaporative DED accounts for ~70% of DED in Singapore. Prevalence: 12–35% depending on diagnostic criteria (Tong et al., 2015).
Tropical Climate & Environmental Factors
| Environmental Factor | Impact on Dry Eye | Clinical Implication |
|---|---|---|
| High ambient humidity (70–90% RH) | Partially protective outdoors | Symptoms may fluctuate; assess in clinical context |
| Pervasive air-conditioning (22–24°C) | Marked indoor humidity reduction | Indoor environment is the major trigger in SG |
| High UV index (UVI 10–14 daily) | Ocular surface inflammation | Photoprotective lenses recommended |
| Urban particulate matter (PM2.5) | Conjunctival irritation | Peak PSI periods may worsen grade |
| Contact lens wear (>40% urban SG) | Reduced TBUT; lipid disruption | Assess CL wear hours; switch modality PRN |
| Screen time (avg >9 hr/day SG) | Reduced blink rate (~50%) | Blink training; 20-20-20 rule counselling |
Ethnic & Demographic Considerations
| Population Group | Considerations | Relevant Adjustment |
|---|---|---|
| Chinese (74%) | Higher myopia → more CL wearers; LASIK-associated DED common | Post-refractive DED protocol; Grade 1–2 common |
| Malay (13%) | Higher MGD prevalence; cosmetic eye practices | Lid hygiene emphasis; MGD Grade 2–3 |
| Indian (9%) | Higher Sjögren's susceptibility; systemic autoimmune overlap | Lower threshold for ANA/RF screening; Grade 3–4 |
| Elderly (>65 yr) | Androgen decline → gland atrophy; polypharmacy | Medication review; Grade 2–3 common |
| Paediatric (screen-related) | Rising prevalence; atypical presentation | DEQ-5 adapted; typically Grade 1–2 |
Locally Available Investigations
| Investigation | Device / Location | Threshold | Notes |
|---|---|---|---|
| Tear osmolarity | TearLab; i-Pen (selected clinics) | >308 mOsm/L | Inter-eye Δ >8 mOsm/L diagnostic |
| NIBUT / Meibography | Keratograph 5M; Sirius (major chains) | NIBUT <7.8 s | Preferred over fluorescein TBUT |
| LipiView / LipiScan | Selected ophthalmology centres | Gland dropout >50% | Refer if MGD Grade 3 |
| InflammaDry (MMP-9) | Available via distributor | ≥40 ng/mL = positive | Useful pre-CsA (Grade ≥2) |
| Anterior OCT (meniscus) | OCT units in most polyclinics | TMH <0.2 mm | Non-invasive volume estimate |
| Sjögren's antibodies (SS-A/B) | SNEC; NUH; TTSH labs | Via referral | If DEQ-5 ≥12 + systemic symptoms (Grade 3–4) |
Related Resources
Disclaimer
This tool is intended for use by registered optometrists in Singapore as a clinical aide. It does not replace professional clinical judgment, comprehensive ocular examination, or current Ministry of Health Singapore guidelines. All therapeutic interventions must be prescribed within the optometrist's scope of practice under the Optometrists and Opticians Act (Cap 213A). Drug prescribing requires collaboration with or referral to a licensed medical practitioner. Evidence base: TFOS DEWS II 2017 · Asia Dry Eye Society Guidelines · MOH Singapore Primary Care CPG: Dry Eye Disease 2022.