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Grading Of Corneal and Conjunctival Staining in the Context of Other Dry Eye Tests

Bron, Anthony J. FCOphth, FMedSci; Evans, Victoria E. BOptom(Hons); Smith, Janine A. MD

Clinical Sciences

Purpose To describe the Oxford Scheme for grading ocular surface staining in dry eye and to discuss optimization of stain detection using various dyes and filters. Also, to propose a sequence of testing for dry eye diagnosis.

Methods The grading of corneal and conjunctival staining is described, using the Oxford Scheme, including biomicroscopy, optical filters, illumination conditions, and the characteristics of and instillation techniques used for, selected clinical dyes.

Results A series of panels, labeled A–E, in order of increasing severity, reproducing the staining patterns encountered in dry eye, are used as a guide to grade the degree of staining seen in the patient. The amount of staining seen in each panel, represented by punctate dots, increases by 0.5 of the log of the number of dots between panels B to E. The use of the vital dyes fluorescein, lissamine green, and rose Bengal is described; fluorescein and lissamine green, used in conjunction with appropriate absorption filters, are recommended for use in clinical trials. The placement of staining in relation to the sequence of other diagnostic tests is discussed.

Conclusions The monitoring and assessment of corneal and conjunctival staining can be greatly enhanced by the use of a grading scale, controlled instillation of dyes, and standard evaluation techniques. This is of particular benefit in clinical trials, where ocular surface staining is commonly employed as an outcome measure

From the Nuffield Laboratory of Ophthalmology (Drs Bron and Evans), University of Oxford, Oxford, UK; and the Division of Epidemiology and Clinical Research (Dr Smith), National Eye Institute, National Institutes of Health, Bethesda, MD.

Received for publication January 28, 2003; accepted June 17, 2003.

Reprints: Anthony J. Bron, Nuffield Laboratory of Ophthalmology, University of Oxford, Walton Street, Oxford OX2 6AW, England (e-mail:

© 2003 Lippincott Williams & Wilkins, Inc.