Article Date: 9/1/2004

the dry eye file
The Dry Eye Workup
Thorough screening is crucial to detecting dry eye.
Milton M. Hom, O.D., F.A.A.O.

Dry eye workups are well documented. Many tests are devoted to the detection, diagnosis and monitoring of treatment, and every expert has his favorites and not-so favorites. For me, the most critical space within the clinical realm of dry eye is the screening. If you don't screen properly, the dry eye goes undetected.

My dry eye workup starts with the general eye examination. I ask every patient about dryness. If a patient experiences discomfort or if the dryness interferes with activities, then we carefully look at dry eyes. One of the first priorities is to establish a set of baseline findings. I like to monitor improvement or, in some cases, regression. I divide the workup into two categories:

1. symptoms

2. signs.


The gold standard for monitoring treatment has been the Ocular Surface Disease Index (OSDI). It's an easy and short (12 question) questionnaire to administer. My assistants score the OSDI at every patient visit.


Checking signs is a bit more involved. Here's what I look at:

Staining. Fluorescein staining is a must in my workup. Lissamine green staining and Rose Bengal are actually optional to my thinking. A recent study by Koh showed that fluorescein staining with a yellow filter was 75% better than Rose Bengal for mild to moderate staining. I've seen cases where fluorescein picked up staining areas that lissamine green missed.

Tear tests. Tear break-up time is a favorite. Schirmer is not. Cho and Yap looked at nine asymptomatic patients and tested their Schirmer II scores over a two-week period. Almost 70% of the patients measured less than 6 mm (close to severe dry eye). Four subjects measured 0 mm of wetting. For me, Schirmer II testing is just too unreliable and too time consuming.

Gland expression. Expressing the meibomian glands is important and not performed enough, in my opinion. Express the glands firmly and observe the quality and quantity of the oil to detect lid disease. If the meibum doesn't look motor-oil like and puddles at the orifice, then you have meibomian gland dysfunction (MGD). The patient can have MGD without any other associated blepharitis or rosacea.

Other tests

For a thorough workup, don't forget these tests:

Blink observation. Observing the way a patient blinks offers insight as to whether distribution problems exist. Incomplete or infrequent blinks usually indicate a need for lubrication. Many patients who have lagophthalmos will also display an incomplete blink.

Pollen and mold counts. Monitoring pollen counts has helped me determine whether allergies are playing a role in dryness. The National Allergy Bureau's Web site ( regularly reports on pollen and mold counts according to area. If the dryness is occurs during times of high pollen and mold counts, I add a topical allergy medication to the regimen.

The treatment plan

After performing the tests, I categorize the dry eyes into one of the following areas:

If it's lid margin disease, I prescribe lid hygiene and/or oral antibiotics. Mild distribution problems merit lubrication during the day and at night. If there's no lid margin disease and mild dryness is present, I use lubrication such as Allergan's Refresh Tears, Refresh Liquigel, Refresh Endura or Alcon's Systane as a starting point. For moderate dry eye and to increase tear production, I prescribe Allergan's Restasis.

References available on request



Optometric Management, Issue: September 2004