Approach

Clinical findings do not always correlate with symptoms: some patients are troubled by symptoms but have minimal defects on examination, whereas others are relatively free of symptoms but have significant defects. No single sign, symptom, or test result can establish the diagnosis of dry eye disease (DED).[2] Diagnosis relies on a combination of detailed history taking, clear documentation, ophthalmologist-led examination, and specific diagnostic tests.[1][3] This should include evidence of systemic signs with referral to appropriate specialties if necessary.

History

The basic history should establish and describe:[1][2][3]

  • Symptoms and signs (e.g., irritation, excessive tearing; burning, stinging, mild itching, dry, foreign body sensations; photophobia, blurry vision; contact lens intolerance, redness, mucous discharge, increased blinking, eye fatigue; symptoms that worsen throughout the day)

  • Exacerbating conditions (e.g., decreased humidity, fans, reading, digital device use)

  • Symptom duration.

A more detailed history should establish risk factors that can aid with diagnosis and management:[2][3][4][5][6][11][16][19][20][21]

  • Older age, female sex, and Asian ethnicity

  • Medication history (e.g., oral contraceptives, hormone replacement therapy, antihistamines, beta-blockers, anticholinergics, diuretics, psychotropic drugs, retinoids, topical ophthalmologic medicines)

  • Presence of systemic conditions (e.g., Sjögren syndrome, rheumatoid arthritis, systemic lupus erythematosus, systemic sclerosis/scleroderma, Stevens-Johnson syndrome, mixed connective tissue disorder, sarcoidosis, diabetes mellitus, Parkinson's disease, HIV, hepatitis C, vitamin A deficiency)

  • History of haematopoietic stem cell transplantation with or without graft-versus-host disease developing

  • Ocular history (including specific risk factors, such as contact lens usage, previous lid surgeries, previous laser eye surgeries, blepharitis/meibomianitis, trauma, and allergic conjunctivitis).

Questionnaires have been designed to enhance standardisation and reproducible quantification of DED. The most commonly employed questionnaire is the Ocular Surface Disease Index (OSDI), which assesses dry eye-related symptoms (e.g., grittiness, pain, visual disturbance, etc.), exacerbating factors, and impact on daily functioning.[3] Other options are the National Eye Institute NEI-VFQ25 and Standard Patient Evaluation of Eye Dryness Questionnaire (SPEED).[2]

Physical examination

Patients presenting with symptoms suggestive of dry eye undergo macroscopic examination and slit-lamp biomicroscopy to:[2]

  • Document signs of dry eye

  • Assess the quality, quantity, and stability of the tear film

  • Determine other causes of ocular irritation.

Macroscopic examination includes the following:[2]

  • Evaluation of the tear film and ocular surface

  • Lid position and eyelashes, including the presence or absence of lagophthalmos and proptosis

  • Other conditions that warrant further investigation, such as allergic keratoconjunctivitis, Demodex mites at the eyelash bases, and anterior and/or posterior blepharitis and meibomianitis at the lid margins.

Slit-lamp biomicroscopy (e.g., using fluorescein, rose bengal, or lissamine green) is particularly useful when evaluating the following elements:

  • Staining in relation to the severity of dryness on slit-lamp examination, using established grading systems where appropriate

  • Tear film abnormalities, including mucous strands, debris, and froth; tear film meniscus height (assessing aqueous volume); and tear film break-up time, with or without fluorescein drops (assessing tear film stability)

  • Puncta, including patency, presence, and position of plugs

  • Conjunctival changes, including the inferior fornix and tarsal conjunctiva (e.g., mucous threads, scarring, erythema, papillary reaction, follicle enlargement, keratinisation, subepithelial fibrosis, foreshortening, symblepharon) and the bulbar conjunctiva (e.g., punctate staining; hyperaemia; conjunctivochalasis; localised drying; keratinisation, chemosis, chalasis, follicles)

  • Corneal changes, including localised interpalpebral drying, punctate epithelial erosions assessed with fluorescein dye, punctate staining, filaments, defects, basement membrane irregularities, mucous plaques, keratinisation, pannus formation, thinning, infiltrates, ulceration, scarring, neovascularisation, past corneal or refractive surgery.

Findings reported during physical examination will vary with the underlying condition and disease severity. [Figure caption and citation for the preceding image starts]: Allergic (vernal) keratoconjunctivitisPrivate collection of Dr Jonathan Smith and Dr Philip Severn; used with permission [Citation ends].com.bmj.content.model.Caption@8c23582

[Figure caption and citation for the preceding image starts]: BlepharitisPrivate collection of Dr Jonathan Smith and Dr Philip Severn; used with permission [Citation ends].com.bmj.content.model.Caption@5d3c671[Figure caption and citation for the preceding image starts]: Dry eye (stained with rose bengal)Private collection of Dr Jonathan Smith and Dr Philip Severn; used with permission [Citation ends].com.bmj.content.model.Caption@a6d9820

Examination for dry eye is particularly important before cataract and refractive surgery because its presence can adversely affect outcomes.

DED may be identified during routine comprehensive eye evaluations.[24]

Other tests

Schirmer's test assesses aqueous tear production and involves leaving Schirmer's paper strips in closed eyes for 5 minutes.[1] When performed without anaesthesia, Schirmer's test measures the total secretion (i.e., reflex and basic). When the test is performed with anaesthesia, it measures basic secretion.

Tear film osmometry measures tear film osmolarity. It is not widely available and is used in academic settings more often than in clinical practice.[3] Other emerging tests include metalloproteinase-9 (MMP-9) detection, corneal topography, ocular surface interferometry, infrared thermography (assessing tear evaporation rate), in-vivo confocal microscopy, and ocular surface immune markers.[25][26][27][28][29][30][31][32][33][34]

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