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      The challenge of dry eye diagnosis

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          Abstract

          The currently available methods for the diagnosis of dry eye are still far from being perfect for a variety of reasons. This review attempts to highlight the advantages and disadvantages of both traditional tests (such as Schirmer’s test, break-up time and ocular surface staining) and innovative noninvasive procedures, including tear meniscus height measurement, corneal topography, functional visual acuity, tear interferometry, tear evaporimetry and tear osmolarity assessment.

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          Most cited references 155

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          The lack of association between signs and symptoms in patients with dry eye disease.

          The purpose of this report was to examine the relation between clinical tests and dry eye symptoms in patients with dry eye disease. Seventy-five patients with dry eye disease (ICD-9 code 375.15) were included in these analyses. There was no specific entry criterion for enrollment in addition to a previous dry eye diagnosis in this clinic-based sample. Patients represented varying types and severity of dry eye disease and were previously diagnosed by clinic attending doctors in this university clinic setting. The study examination included a symptom interview that assessed dryness, grittiness, soreness, redness, and ocular fatigue. The interview was followed by a clinical dry eye examination conducted in the following sequence: meibomian gland assessment, tear meniscus height, tear breakup time test, fluorescein staining, the phenol red thread test, Schirmer test, and rose bengal staining. Partial Spearman correlation coefficients, the Wilcoxon rank sum test, chi 2 test, and multivariate logistic regression were used to evaluate the relationship between dry eye tests and symptoms. Symptoms were generally not associated with clinical signs in patients with dry eye disease. There were no significant correlations between signs and symptoms after adjustment for age and artificial tear use. The rank of each clinical test result did not statistically differ when stratified by the presence of patient symptoms in Wilcoxon rank sum analyses. Likewise, the frequency of patient symptoms did not differ statistically when stratified by a positive clinical test result in chi 2 analyses. In multivariate logistic regression analyses, no clinical test significantly predicted frequently reported symptoms after adjustment for age and artificial tear use. These results suggest a poor relation between dry eye tests and symptoms, which represents a quandary in dry eye clinical research and practice.
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            Tear film osmolarity: determination of a referent for dry eye diagnosis.

            To determine new referents, or cutoff levels for tear film hyperosmolarity in the diagnosis of keratoconjunctivitis sicca (KCS) and to assess their effectiveness in independent patient groups. A meta-analysis was performed on published data for tear osmolarity in samples of normal eyes and various subtypes of dry eye, and pooled estimates of the mean and standard deviations for normal and (all) dry eye subjects were determined. Diagnostic referents were derived from the intercept between the distributions of osmolarity in the two samples and from receiver operator characteristic (ROC) curves. This referent was tested for effectiveness of diagnosis in independent groups with normal and dry eyes. An osmolarity referent of 315.6 mOsmol/L was derived from the intercept of the distribution curves, and 316 mOsmol/L from the ROC curve. When applied to independent groups of normal and dry eye subjects a value of 316 mOsmol/L was found to yield sensitivity of 59%, specificity of 94%, and an overall predictive accuracy of 89% for the diagnosis of dry eye syndrome. Tear hyperosmolarity, defined by a referent of 316 mOsmol/L, was superior in overall accuracy to any other single test for dry eye diagnosis (Lactoplate, Schirmer test, and Rose Bengal staining), even when the other test measures were applied to a diagnosis within the sample groups from which they were derived. For overall accuracy in the diagnosis of dry eye, the osmolarity test was found to be comparable with the results of combined (in parallel or series) tests.
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              Impaired functional visual acuity of dry eye patients.

              To report dry eye patients' functional visual acuity, which was measured after sustained eye opening for 10-20 seconds, as a simulation of visual function of daily acts of gazing, which is defined as looking at an object with involuntary blink suppression. Interventional clinical nonrandomized comparative trial. We measured ordinary best-corrected visual acuity and functional visual acuity in non-Sjögren's syndrome (non-SS, N = 10) and Sjögren's syndrome (SS, N = 12) patients and in normal controls (N = 8), prospectively. Surface regularity index (SRI) of corneal topography was also measured under routine circumstances and after sustained eye opening. Blink rates while gazing were measured during reading in another 28 dry eye patients and during driving in another 8 normal controls. Functional visual acuity did not change (1.27-1.16) in normal controls, but decreased significantly from 1.18-0.336 in non-SS patients (P = .0007) and from 1.15-0.228 (P < .00001) in SS patients. SRI after sustained eye opening increased in non-SS (P = .032) and SS patients (P = .0007), but not in the normal controls. Blink rates during reading (P < .001) and driving (P = .012) were significantly decreased from baseline blink rates. This study shows that the visual function of dry eye patients becomes abnormal with ocular surface irregularity when the eye is kept open for 10-20 seconds. Our data indicate impaired visual function in dry eye patients while gazing. Functional visual acuity may be important in daily activities.
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                Author and article information

                Journal
                Clin Ophthalmol
                Clinical Ophthalmology
                Clinical ophthalmology (Auckland, N.Z.)
                Dove Medical Press
                1177-5467
                1177-5483
                March 2008
                : 2
                : 1
                : 31-55
                Affiliations
                [1 ] Centro Salus, Bologna, Italy;
                [2 ] Department of Ophthalmology, Siriraj Hospital, Mahidol University, Thailand;
                [3 ] Department of Ophthalmology and Visual Sciences, University of Illinois, Chicago, IL, USA;
                [4 ] Department of Ophthalmology, Ludwig–Maximilians University, Munich, Germany;
                [5 ] Department of Ophthalmology, University of Mississippi, Jackson, MS, USA;
                [6 ] Department of Ophthalmology, School of Dental Medicine, Tsurumi University, Yokohama City, Kanagawa, Japan
                Author notes
                Correspondence: Giacomo Savini Centro Salus, Via Saffi4H, 40131 Bologna, Italy Tel +39 051 555311 Fax +39 051 524486 Email giacomo.savini@ 123456alice.it
                Article
                co-2-31
                2698717
                19668387
                © 2008 Dove Medical Press Limited. All rights reserved
                Categories
                Review

                Ophthalmology & Optometry

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