Optimising subjective grading of corneal staining in Sjögren's syndrome dry eye disease

James S. Wolffsohn, Alberto Recchioni, Olivia A. Hunt, Sònia Travé Huarte, Giuseppe Giannaccare, Marco Pellegrini, Marc Labetoulle

Research output: Contribution to journalArticlepeer-review


Aim: To assess whether smaller increment and regionalised subjective grading improves the repeatability of corneal fluorescein staining assessment, and to determine the neurological approach adopted for subjective grading by practitioners. Methods: Experienced eye-care practitioners (n = 28, aged 45 ± 12 years), graded 20 full corneal staining images of patients with mild to severe Sjögren's syndrome with the Oxford grading scheme (both in 0.5 and 1.0 increments, globally and in 5 regions), expanded National Eye Institute (NEI) and SICCA Ocular Staining Score (OSS) grading scales in randomised order. This was repeated after 7–10 days. The digital images were also analysed objectively to determine staining dots, area, intensity and location (using ImageJ) for comparison. Results: The Oxford grading scheme was similar with whole and half unit grading (2.77vs2.81,p = 0.145), but the variability was reduced (0.14vs0.12,p < 0.001). Regional grade was lower (p < 0.001) and more variable (p < 0.001) than global image grading (1.86 ± 0.44 for whole increment grading and 1.90 ± 0.39 for half unit increments). The correlation with global grading was high for both whole (r = 0.928,p < 0.001) and half increment (r = 0.934,p < 0.001) grading. Average grading across participants was associated with particle number and vertical position, with 74.4–80.4% of the linear variance accounted for by the digital image analysis. Conclusions: Using half unit increments with the Oxford grading scheme improve its sensitivity and repeatability in recording corneal staining. Regional grading doesn't give a comparable score and increased variability. The key neurally extracted features in assigning a subjective staining grade by clinicians were identified as the number of discrete staining locations (particles) and how close to the vertical centre was their spread, across all three scales.

Original languageEnglish
Pages (from-to)166-172
Number of pages7
JournalThe ocular surface
Early online date14 Mar 2024
Publication statusPublished - Apr 2024

Bibliographical note

Copyright © 2024 Published by Elsevier Inc. This is an open access article distributed under the terms of the Creative Commons Attribution License CC BY [https://creativecommons.org/licenses/by/4.0/], which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


  • Corneal staining
  • Dry eye disease
  • Objective grading
  • Sjögren's syndrome
  • Subjective grading


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