Anterior eye health recording: current methods and best practice

September 1, 2015

Dr Wolffsohn presents the results of a survey completed by eye care practitioners worldwide regarding their current practices on anterior eye health recording. Recommendations on best practice are also presented, based on these study findings.

Take-home message: Dr Wolffsohn presents the results of a survey completed by eye care practitioners worldwide regarding their current practices on anterior eye health recording. Recommendations on best practice are also presented, based on these study findings.


By Dr James S. Wolffsohn

Accurate and repeatable recording of anterior eye health is an essential part of both clinical and research practice. It is required to aid the differentiation of normal physiological variation from pathological changes, to monitor disease and is of particular importance where successive appointments could be conducted by more than one clinician. Standardised and comprehensive record keeping has additional importance in legal cases, where the focus is generally on clinical records.

We recently carried out a study in which 809 eye care practitioners from across the world completed an online survey regarding their current clinical practice for anterior eye health recording. The results are intended to inform guidelines on best practice.

Written descriptions and sketching

Written descriptions of the same condition can vary widely1 and eye care practitioners differ in their artistic ability and prowess to sketch. In order to standardise anterior eye health recording between clinicians and to speed the recording process, subjective grading scales were popularised in the 1990s. However, sketching can be useful in visually indicating proportions and locations and therefore has been recommended as a better way of clinically recording the complexity of multiple locations, shapes and sizes of ocular surface staining2 if photography is not available, although staining depth may need noting with wordings.3


Grading scales

Grading scales allow the anterior ocular appearance to be referenced to standard ‘anchor’ images chosen to cover the range of clinical presentations of a particular feature or tissue of the anterior eye. These can be drawn, such as the Efron and VisionCare Institute (Johnson and Johnson) scales, photographic such as the Brien Holden Vision Institute (formerly the CCLRU) scales, or drawn features over healthy eye photographs such as the Jenvis (Alcon) scale (Figure 1).3 Pictorial (Efron) and photographic (CCLRU/Brien Holden Vision Institute) are currently equally popular and, having been around for about two decades,4,5 are used more often than the more recent Vision Care Institute (Johnson and Johnson) and Jenis (Alcon) scales.3

The scales usually contain between 4 and 5 images, with clinicians encouraged to interpolate to 1 decimal place to increase improve sensitivity.3 Grading scale grades are not interchangeable,6,7 have scales starting at grade 0 or 1 and use a wide range of highest grade. Hence practitioners should record the grading scale used (although this is rarely done)1 and ideally standardise this within a department. Using more than one scale is likely to reduce consistency.3 While attempts have been made to link the allocated grade to clinical decision making (e.g., 0 is normal and 3-4 needs urgent action), this overlooks physiological variation across a population, variations in clinical judgement and negates the fact that management strategies relating to different features are required at different levels within the spectrum of ‘severity’.

Despite the evidence as to the limitations of grading only to the nearest grading scale unit,8,9 only one in seven of eye care practitioners recently surveyed have adopted grading to one decimal place.3 While clinicians may not feel confident in the accuracy of their grade to one decimal place, a slight difference in option between two practitioners will result in a smaller discrepancy than if they fell either side of the boundary between units than grading to the nearest unit.

Surprisingly, about one fifth of practitioners always graded multiple different regions of the same feature in routine clinical practice and a further third reported doing this ‘sometimes’, even when the feature was not considered abnormal, despite the time required to achieve this.3 It became apparent from our study that the range of time available to record anterior eye health varies greatly, although respondents also reported that anterior eye health is taken seriously enough to devote on average about double the amount of time if needed in specific cases.3


Despite the move to using grading scales, (84.5% of eye-care practitioners reported using them in a recent survey),3 their sensitivity and reliability is still limited,10,11 as we are all subject to natural biases such as to grading features to the nearest whole number even when supposedly grading to decimal place resolution. Spending more time considering the grading of each feature generally reduces the variation between individuals, but a couple of seconds has been shown to be sufficient for most pathological features.12 However, even the linearity of grading scales (the change in severity between severity units) has been shown to be quite variable.13


With the rapid development of smart phone camera technology, reasonable quality images of the anterior eye can be captured with the addition of a macro-lens or slit lamp eye-piece adaptor, even if a practitioner does not have access to a digital slit lamp biomicroscope. The resolution of the image sensor does not have to be high to detect even the smallest features of interest in the anterior eye and moderate levels of image compression can be applied to reduce the file size with no ill-effects.14 A camera with low light sensitivity is needed to image without uncomfortable levels of light for the patient and particularly when imaging fluorescein fluorescence.15

As well as traditional photography, techniques such as Scheimpflug, Optical Coherence Tomography and corneal topography can be useful for recording aspects of anterior eye health.16 Newer imaging instruments can provide objective assessment of additional aspects such as corneal biomechanics (such as the Corvis) and the tear film stability and meibomian glands (such as the Keratograph and Cobra).


Objective grading

To improve on subjective grading, several studies have investigated computer-based objective grading of ocular surfaces (Figure 2). The thought process involved in subjective grading, even of features such as bulbar hyperaemia, are complex with some debate over whether colour information is actually important in grading hyperaemia, or whether the perceived area of blood vessel coverage alone is sufficient.10,17,18 However, image analysis techniques can predict the average grade of a group of experienced clinicians,2 but are many times more sensitive and reliable than subjective grading.19 Only one commercially available instrument currently attempts to objectively grade bulbar hyperaemia (Keratograph 5), but this feature has not been researched.

Record cards

Paper record cards (which take up more space and are harder to search) are still preferred to electronic records (which can be less versatile for recording information in the form desired by the eye care practitioner) in clinical practice (Figure 3).3 However, intriguingly, one-sixth of a recent sample are using both (paper record cards 85.9% vs 31.5% for electronic patient record storage).3 This is most likely to be explained by practitioners working at multiple practices. Record cards which were blank or contained anterior health proforma headings such as cornea, conjunctiva, lids and lashes, lens, media, sclera, iris and adnexia, appear equally popular in clinical practice.3


Longer time dedicated to grading generally reduces the variation between practitioners, but a couple of seconds has been found to be sufficient for most pathological features,12 allowing anterior eye recording to be completed in a matter of minutes, particular with focused and prudent use of grading scales, sketching and photography. A global survey of eye care practitioners current practice habits combined with a review of the academic literature recommended:


  • Use a grading scale specifying which one you use1 and always grade to one decimal place to enhance sensitivity.8,9

  • Record what you see live (instead of trying to memorise the grading scale images) rather than based on how you intend to manage a condition.

  • In routine clinical practice (with reference to a visible grading scale) grade at every visit:
  • bulbar and limbal hyperaemia

  • limbal neovascularisation

  • conjunctival papillary redness and roughness (in white light to assess colouration with fluorescein instilled to aid visualisation of papillae/follicles);20

  • blepharitis;

  • meibomian gland dysfunction;

  • staining (both corneal and conjunctival); the type of staining dye used should always be recorded and when staining is present, a sketch denoting the position, shape and depth of the affected area should be included. It should be noted when using fluorescein that the spectral radiance peak of cobalt blue illumination used in most slit-lamp biomicroscopes is typically between 452 and 484nm, much below the optimum excitation wavelength of 495nm and likewise yellow filters without a sharp band pass at 500nm will reduce the imaging of excited fluorescein molecules.21

  • Both in routine practice and for acute management of patient, record by grading, sketching or photographing (as appropriate) other anterior eye features only if they are remarkable, but indicate that the key tissue which have been examined such as lids and lashes, conjunctiva/sclera, cornea, iris and crystalline lens (a proforma paper or electronic record card may aid this) as nothing recorded is considered to indicate nothing was done.


  • N. Efron et al., Clin. Exp. Optom. 2011;94:82-86.

  • R.C. Peterson and J.S. Wolffsohn. Optom. Vis. Sci. 2009;86:273-278.

  • J.S. Wolffsohn et al. and the British Universities Committee of Contact Lens Educators (BUCCLE). Cont. Lens Anterior Eye. 2015;38:266-271

  • N. Efron. Ophthalmic Physiol. Optics. 1998;18:182-186.

  • R. Terry et al., Optom. Vis. Sci. 1995;12:16.

  • N. Efron et al., Ophthalmic Physiol. Opt. 2001;21:17-29.

  • J.S. Wolffsohn. Br. J. Ophthalmol. 2004;88:1434-1438.

  • J.D. Twelker and I.L. Bailey. Invest. Ophthalmol. Vis. Sci. 2000;41:s927.

  • I.L. Bailey et al., Invest. Ophthalmol. Vis. Sci. 1991;32:422-432.

  • P. Fieguth and T. Simpson. Invest. Ophthalmol. Vis. Sci. 2002;43:340-347.

  • R.C. Peterson and J.S. Wolffsohn. Br. J. Ophthalmol. 2007;91:1464-1466.

  • N. Efron and S. McCubbin. Optom. Vis. Sci. 2007;84:1082-1086.

  • J.S Wolffsohn and C. Purslow. Contact Lens Ant. Eye. 2003;26:108-109.

  • R.C. Peterson and J.S. Wolffsohn. Br. J. Ophthalmol. 2005;89:828-830.

  • J.S. Wolffsohn. Anterior eye imaging. In: Ocular Imaging: Essential Eye Series. Butterworth-Heinemann, Oxford. 2008.

  • J.S. Wolffsohn an L.N. Davies. Exp. Rev. Ophthalmol. 2007;2:755-768.

  • E.B. Papas. Invest. Ophthalmol. Vis. Sci. 2000;41:687-691.

  • J.S Wolffsohn and C. Purslow. Contact Lens Ant. Eye. 2003;26:27-35.

  • R.C. Peterson and J.S. Wolffsohn. Br. J. Ophthalmol. 2007;91:1464-1466.  

  • N. Kier et al., Optom. Practice. 2010;11:123-134.

  • R.C. Peterson et al., Am. J. Ophthalmol. 2006;142:572-575.


Dr James S Wolffsohn


Dr Wolffsohn works as xxxx at the Ophthalmic Research Group, Life and Health Sciences, Aston University, Birmingham, UK.

This article is based upon research published in J.S. Wolffsohn, S.A. Naroo, C. Christie, J. Morris, R. Conway, C. Maldonado-Codina and the British Universities Committee of Contact Lens Educators (BUCCLE). Anterior eye health recording. Contact Lens & Anterior Eye. 2005;38:266-271.

The author declares no conflicts of interest relating to the content of this article.