The Definition and Classification of Dry Eye Disease: Report of the Definition and Classification Subcommittee of the International Dry Eye Workshop (2007)

The aim of the DEWS Definition and Classification Subcommittee was to provide a contemporary definition of dry eye disease, supported within a comprehensive classification framework. A new definition of dry eye was developed to reflect current understanding of the disease, and the committee recommended a three-part classification system. The first part is etiopathogenic and illustrates the multiple causes of dry eye. The second is mechanistic and shows how each cause of dry eye may act through a common pathway. It is stressed that any form of dry eye can interact with and exacerbate other forms of dry eye, as part of a vicious circle. Finally, a scheme is presented, based on the severity of the dry eye disease, which is expected to provide a rational basis for therapy. These guidelines are not intended to override the clinical assessment and judgment of an expert clinician in individual cases, but they should prove helpful in the conduct of clinical practice and research.

Reliability and validity of the Ocular Surface Disease Index

OBJECTIVE

To evaluate the validity and reliability of the Ocular Surface Disease Index (OSDI) questionnaire.

METHODS

Participants (109 patients with dry eye and 30 normal controls) completed the OSDI, the National Eye Institute Visual Functioning Questionnaire (NEI VFQ-25), the McMonnies Dry Eye Questionnaire, the Short Form-12 (SF-12) Health Status Questionnaire, and an ophthalmic examination including Schirmer tests, tear breakup time, and fluorescein and lissamine green staining.

RESULTS

Factor analysis identified 3 subscales of the OSDI: vision-related function, ocular symptoms, and environmental triggers. Reliability (measured by Cronbach alpha) ranged from good to excellent for the overall instrument and each subscale, and test-retest reliability was good to excellent. The OSDI was valid, effectively discriminating between normal, mild to moderate, and severe dry eye disease as defined by both physician's assessment and a composite disease severity score. The OSDI also correlated significantly with the McMonnies questionnaire, the National Eye Institute Visual Functioning Questionnaire, the physical component summary score of the Short Form-12, patient perception of symptoms, and artificial tear usage.

CONCLUSIONS

The OSDI is a valid and reliable instrument for measuring the severity of dry eye disease, and it possesses the necessary psychometric properties to be used as an end point in clinical trials.

Methodologies to diagnose and monitor dry eye disease: report of the Diagnostic Methodology Subcommittee of the International Dry Eye WorkShop (2007)

The role of the Diagnostic Methodology Subcommittee of the Dry Eye Workshop was 1) to identify tests used to screen, diagnose and monitor dry eye disease, 2) to establish criteria for test performance, and 3) to consider the utility of tests in a variety of clinical settings. The committee created a database of tests used to diagnose and monitor dry eye, each compiled by an expert in the field (rapporteur) and presented within a standard template. Development of the templates involved an iterative process between the Chairman of the subcommittee, the rapporteurs, and, at times, an additional group of expert reviewers. This process is ongoing. Each rapporteur was instructed on how to the complete a template, using a proforma template and an example of a completed template. Rapporteurs used the literature and other available sources as the basis for constructing their assigned template. The chairman of the subcommittee modifed the template to produce a standardized version and reviewed it with the rapporteur. The completed database will be searchable by an alphabetical list of test names, as well as by functional groupings, for instance, tests of aqueous dynamics, lipid functions, etc. The templates can be accessed on the website of the Tear Film and Ocular Surface Society (www.tearfilm.org). This report provides a general overview of the criteria applied in the development of tests for screening and diagnosis.

Tear cytokine profiles in dysfunctional tear syndrome

PURPOSE

To compare tear cytokine and chemokine concentrations in asymptomatic control and Dysfunctional Tear syndrome (DTS) patients and determine the correlations between tear inflammatory mediators and clinical severity.

DESIGN

Prospective observational cohort study.

METHODS

Concentrations of epidermal growth factor (EGF), interleukin (IL)-1 alpha (1alpha), 1 beta (1beta), 6, 10, 12, and 13, interferon gamma (IFN-gamma), tumor necrosis factor alpha (TNF-alpha), and chemokines: IL-8 (CXC); macrophage inflammatory protein-1 alpha (MIP-1alpha) (CCL3); and regulated upon activation, normal T-cell expressed and secreted (RANTES CCL5) were measured by a multiplex immunobead assay in an asymptomatic control group and DTS patients with and without meibomian gland disease (MGD). Spearman correlations between tear cytokines and severity of irritation symptoms and ocular surface signs were calculated.

RESULTS

Tear concentrations of IL-6, IL-8 and TNF-alpha were significantly higher in DTS with and without MGD and EGF was significantly reduced in the DTS without MGD group compared with the control group. MIP-1alpha was greater in entire DTS and DTS without MGD groups than the control group and RANTES was greater in DTS with MGD than the control and DTS without MGD groups. IL-12 was significantly higher in the DTS with MGD than the DTS without MGD subgroup. Significant correlations were observed between IL-6 and irritation symptoms and between a number of cytokines and chemokines and clinical parameters.

CONCLUSIONS

As predicted, patients with DTS have higher levels of inflammatory mediators in their tears that show correlation with clinical disease parameters. Furthermore, different tear cytokine/chemokine profiles were observed in DTS patients with and without MGD groups.

Dysfunctional Tear Syndrome

PURPOSE

To develop current treatment recommendations for dry eye disease from consensus of expert advice.

METHODS

Of 25 preselected international specialists on dry eye, 17 agreed to participate in a modified, 2-round Delphi panel approach. Based on available literature and standards of care, a survey was presented to each panelist. A two-thirds majority was used for consensus building from responses obtained. Treatment algorithms were created. Treatment recommendations for different types and severity levels of dry eye disease were the main outcome.

RESULTS

A new term for dry eye disease was proposed: dysfunctional tear syndrome (DTS). Treatment recommendations were based primarily on patient symptoms and signs. Available diagnostic tests were considered of secondary importance in guiding therapy. Development of algorithms was based on the presence or absence of lid margin disease and disturbances of tear distribution and clearance. Disease severity was considered the most important factor for treatment decision-making and was categorized into 4 levels. Severity was assessed on the basis of tear substitute requirements, symptoms of ocular discomfort, and visual disturbance. Clinical signs present in lids, tear film, conjunctiva, and cornea were also used for categorization of severity. Consensus was reached on treatment algorithms for DTS with and without concurrent lid disease.

CONCLUSION

Panelist opinion relied on symptoms and signs (not tests) for selection of treatment strategies. Therapy is chosen to match disease severity and presence versus absence of lid margin disease or tear distribution and clearance disturbances.

Correlation of tear lipid layer interference patterns with the diagnosis and severity of dry eye

PURPOSE

To observe and classify tear film lipid layer interference patterns in normal volunteers and dry eye patients and to investigate the relation between the lipid layer interference patterns in the dry eyes and the results of other dry eye examinations.

METHODS

Precorneal tear lipid layer interference patterns were observed at the central cornea in 25 eyes of 13 normal controls and 85 eyes of 48 dry eye patients. Observed patterns were classified in masked fashion by five physicians into five grades: grade 1, somewhat gray color, uniform distribution; grade 2, somewhat gray color, nonuniform distribution; grade 3, a few colors, nonuniform distribution; grade 4, many colors, nonuniform distribution; and grade 5, corneal surface partially exposed. Other methods of dry eye examination were also performed, including the cotton thread test, the Schirmer I test and modified Schirmer I test, measurement of tear film breakup time, scoring of corneal fluorescein staining density (grades 0 to 3) and area (grades 0 to 3), and rose bengal staining (grades 0 to 9).

RESULTS

In 92 (84%) of 110 eyes, four or more of the five physicians agreed in their grade classifications. Among the 92 eyes, normal control eyes were classified into grades 1 and 2 (10 and 12 eyes, respectively) and dry eyes were classified into grades 2, 3, 4, and 5 (22, 26, 10, and 12 eyes, respectively). There was a significant correlation between the grading and the results of other dry eye examination modalities, including fluorescein staining, rose bengal staining, and tear film breakup time.

CONCLUSIONS

Tear lipid layer interference patterns are highly correlated with dry eye severity.

Tear meniscus measurement in the diagnosis of dry eye

PURPOSE

Assessment of the tear film meniscus is a quantitative, minimally invasive, direct measurement of tear film quantity. The aim of this study was to assess the efficacy of tear meniscus parameter measurement in the diagnosis of dry eye.

METHODS

Tear meniscus radius of curvature, height, width and cross-sectional area (TMC, TMH, TMW, XSA) were determined by photographing an optic section of the inferior tear meniscus (colored with a min volume of fluorescein) at 12 x magnification, and then scanning developed images into a computer analysis program. Fifteen dry eye subjects and 15 age-matched controls were assessed. Dry eye subjects satisfied the criteria of a rose bengal staining score >/= 1, and a mean phenol red thread 15s wetted length </= 10 mm.

RESULTS

TMC, TMH and XSA were all reduced in magnitude in the dry eye group compared to the control group (mean +/- SD; TMC: 0.314 +/- 0.160 mm vs. 0.545 +/- 0.259 mm, TMH: 0.244 +/- 0.089 mm vs. 0.461 +/- 00.173 mm, XSA: 0.0082 +/- 0.0048 mm2 vs. 0.0176 +/- 0.0103 mm2, ANOVA, p < 0.05). Both TMC and TMH showed good diagnostic accuracy (166.7% and 160% respectively), with a dry eye referent value of </=0.35 mm for each parameter. TMC and TMH also showed strong correlations with the cotton thread test, non-invasive breakup time, and ocular surface staining scores (p < 0.01). TMH was the most powerful predictor of tear film insufficiency.

CONCLUSIONS

This study has shown tear meniscus assessment to be a useful alternative to existing tests for dry eye.

Tear film stability and tear surface tension

Surface tension has been measured by the method of Ferguson and Kennedy on small (0.3-0.4 microliter) samples of tears from 65 normal and 35 dry eyes. Non-invasive break-up time (NIBUT) was also measured on the same patients as an indication of tear film stability. The mean (+/- SD) surface tension value was 43.6 +/- 2.7 mN/m for normals, and 49.6 +/- 2.2 mN/m for dry eyes. All NIBUT values for dry eyes were below 20 sec (8.9 +/- 5.1 sec, mean +/- SD, n = 35) while 53% of normal values were 30 sec or over. A negative correlation was found between surface tension and NIBUT for both dry eyes and normals. Comparison of surface tension results for tears and a variety of standard solutions indicated that mucus makes the greatest contribution, even at low concentrations, but the effect of proteins can be large, especially in inflammatory states where serum proteins leak from conjunctival vessels. The measurement of surface tension is simple and direct, and in conjunction with the NIBUT value can help in classification of tear quality in questionably dry eye cases.

Impression cytology on conjunctiva and cornea in dry eye patients establishes a correlation between squamous metaplasia and dry eye clinical severity

PURPOSE

To obtain deeper knowledge of the cellular transition in squamous metaplasia, and to look for a correlation between the clinical grade of severity of dry eye and the grade of squamous metaplasia of the corneal and conjunctival epithelium, studied by impression cytology.

METHODS

A total of 143 patients with dry eye disorders of different grades of clinical severity and 33 control subjects of matched age and sex were studied. Symptoms, clinical tests (including Schirmer test, slit-lamp examination, break-up time, rose Bengal staining, vanishing lacunar sulci, and neovascularization), and tear osmolarity were used to establish the diagnosis of dry eye. The subjects were classified into six clinical grades, grade 0 indicating normal and grades 1 to 5 progressively more severe dry eye. Impression cytology specimens were taken from the central cornea and different areas of the conjunctiva of one eye from all patients. A morphologic and morphometric study of the photographs obtained by light microscopy showed cell size, nuclear size, nuclear-cytoplasmic ratio (N:C) in nonsecretory epithelial cells, and density of goblet cells.

RESULTS

Morphometric and morphologic studies of the ocular surface cells indicated significant differences, mainly in cell sizes, nuclear alterations, and the N:C ratio, in nonsecretory epithelial cells of the conjunctiva and cornea, and in goblet cell densities from the conjunctiva, between the clinically normal eyes and those with the five grades of clinical severity of dry eye, with different degrees of squamous metaplasia.

CONCLUSIONS

A morphologic and morphometric analysis of the ocular surface from patients with dry eye obtained by impression cytology led us to draft a new grading system containing one normal level and five levels of squamous metaplasia. This new grading system is based on a significant decrease in the number of goblet cells with less periodic acid-Schiff-hematoxylin-positive staining, an increase in nonsecretory cell size, more marked cell separation, a lower N:C ratio, and an increase in nuclear alterations. The clinical severity of the dry eye correlates with these alterations.

Prevalence of dry eye subtypes in clinical optometry practice

BACKGROUND

Dry eye conditions are now recognized as having multiple causes. A subtype-based dry eye diagnostic protocol was developed to determine the prevalence of dry eye and dry eye subtypes, and the effects of age and gender, in subjects presenting to clinical optometry practice.

METHODS

Dry eye diagnostic criteria were: presence of one or more McMonnies dry eye survey primary symptoms, fluorescein tear break time < 10 s and rose bengal ocular surface staining. Dry eye subtype differential diagnosis was made predominantly on the basis of biomicroscopic signs. Subtype categories were: lipid anomaly dry eye (LADE), aqueous tear deficiency (ATD), primary mucin anomalies, allergic/toxic dry eye (ADE), primary epitheliopathies and lid surfacing/blinking anomalies (LSADE).

RESULTS

Dry eye prevalence was 10.8% for n = 1584 subjects. Dry eye was significantly more prevalent in subjects 40 years or older (18.1%) compared with those < 40 years (7.3%) (p = 0.001). LADE was the most prevalent subtype (4.0%), followed by ADE at 3.1%, LSADE at 1.8%, and ATD at 1.7%. ATD was the only subtype with a significant gender prevalence difference, being more prevalent in women (p = 0.0023). The prevalence of LADE and ATD were significantly greater in those 40 years or older (p = 0.001 and p = 0.0023 respectively).

CONCLUSIONS

The results of this study support a subtype-based approach to dry eye diagnosis and management in clinical practice.

Dry eye diagnosis and management in 2004

PURPOSE OF REVIEW

To document the changes in treatment paradigm for the management of dry eye. Restasis is 0.05% cyclosporine A and is the first immunomodulatory agent approved for treatment of dry eye.

RECENT FINDINGS

Mounting evidence supports the inflammatory mechanism as explanation for the occurrence of dry eye disease. Immunomodulation has been shown to be effective in treating patients with moderate to severe dry eye disease caused by keratoconjunctivitis sicca. This addresses one of the two main forms of dry eye. There is a new report that immunomodulation using topical 0.05% cyclosporine A (Restasis) may also have a positive effect on meibomian gland dysfunction, the other main form of dry eye.

SUMMARY

Dry eye disease is defined as an abnormality of tear film resulting in changes in the ocular surface. These changes may be seen on ocular examination with the use of fluorescein and supravital staining techniques. Classification of dry eye disease shows two main types: aqueous deficiency and evaporative loss. There is hope that both of these types of dry eye will respond to immunomodulation therapy. Restasis shows promise as the first of these agents to be approved as therapy to treat moderate to severe dry eye disease.

Three different types of dry eye syndrome

We analyzed patients with dry eye syndrome with regard to autoimmune conditions. A total of 116 patients with dry eye syndrome were divided into three groups: simple dry eye (SDE), i.e., dry eye with no circulating autoantibodies; autoimmune positive dry eye (ADE), dry eye with circulating autoantibodies; and Sjogren's syndrome (SS), dry eye associated with Sjogren's syndrome. Schirmer test showed values of 3.0 +/- 2.2 mm in SDE, 3.1 +/- 2.0 mm in ADE, and 2.4 +/- 2.3 mm in SS reflecting the inadequacy of this test in differentiating among the groups. However, Schirmer test with nasal stimulation showed values of 19.1 +/- 12.4 mm in SDE and 16.4 +/- 10.9 mm in ADE, which were significantly higher than the 7.0 +/- 6.6 mm found in SS (p < 0.01). Moreover, ocular surface alterations evaluated by vital staining and brush cytology were significantly milder in SDE and ADE than in SS. SDE and ADE have less ocular surface abnormalities with good reflex tearing, whereas SS has less reflex tearing and more squamous metaplasia.

Hyperosmolarity of the tear film in dry eye syndrome

Hyperosmolarity of the tear film is recognized as an important pathogenetic factor in dry eye syndrome (DES). Hyperosmolarity testing has been hampered in the past by difficulties in tear collection and analytic procedures that required laboratory facilities. The Tearlab Osmolarity System is a new user-friendly tool that only needs tiny volumes for analysis and determines hyperosmolarity semi-automatically. We measured tear film osmolarity with the Tearlab in 200 healthy individuals and patients with DES. Dry eye diagnosis was established when > or =3 of the following criteria were fulfilled:(1) Ocular Surface Disease Index > 15; (2) staining of the cornea in the typical interpalpebral area; (3) staining of the conjunctiva in the typical interpalpebral area; (4) tear film break-up time < 7 s; (5) Schirmer test < 7 mm in 5 min; (6) the presence of blepharitis or meibomitis. Tear film osmolarity, as measured by Tearlab, did not show any correlation with the 6 clinical signs of dry eye. Moreover, tear film osmolarity testing could not discriminate between patients with DES (308.9 +/- 14.0 mosm/l) and the control group (307.1 +/- 11.3 mosml/l). Tear film osmolarity did not correlate to artificial tear use. Technical problems with the Tearlab, reflex tearing, or the difficulty in establishing a dry eye diagnosis with the recommended tests may account for these results. Further investigations are necessary before recommending this tool for daily clinical practice.

Tear film profile in dry eye

Tear film profile was studied in 100 consecutive patients with dry eye along with 100 age and sex matched controls. The frequency of abnormal tear function tests observed in patients with dry eye and controls was: marginal tear strip 93% and 11%, rose bengal staining 89% and 0%, lissamine green staining 87% and 0%, BUT 79% and 14%, Schirmer test 79% and 3% and fluorescein staining 69% and 0%, respectively. No significant difference was observed between tear pH of patients with dry eye and that of normal healthy subjects. A new, simple and effective objective criteria of confirming and grading dry eye based upon a points scoring system derived from the results of various tear film tests is suggested.

The conjunctival epithelium in dry eye subtypes: effect of preserved and non-preserved topical treatments

PURPOSE

To determine the effect of topical treatments on the conjunctiva in dry eye.

METHODS

N = 134 dry eye subjects were diagnosed using a protocol of McMonnies dry eye symptom survey score > 14, fluorescein break up time (FBUT) < 10 s and presence of rose Bengal staining. Differential diagnosis of dry eye subtypes was based on biomicroscopic signs and ocular/medical history. Superficial perilimbal bulbar conjunctival epithelial samples were collected using impression cytology. The nucleo-cytoplasmic ratio (N/C), goblet cell density (GCD) and expression of monoclonal antibodies HLA DR and CD23 were determined. The ocular surface characteristics of untreated subjects, those receiving preserved dry eye treatments and those receiving non-preserved treatments were compared with each other and with controls. Ocular surface characteristics of dry eye subtypes were also examined.

RESULTS

An increase in N/C (p = 0.011), reduction in GCD (p = 0.0001) and increase in expression of HLA DR (p = 0.0001) and CD23 (p = 0.0001) were detected in the untreated group compared to controls. No significant differences were found between the group receiving non-preserved dry eye treatments and untreated dry eye group. The group receiving preserved treatments had a reduced GCD (p = 0.0003) and increased expression of HLA DR (p = 0.0003) and CD23 (p = 0.0001) compared to the group receiving non-preserved treatments. Dry eye subtype specific differences in HLA DR and CD23 expression were noted.

CONCLUSIONS

The conjunctival inflammation and reduced goblet cell density of dry eye is exacerbated by use of preserved topical agents, and is not significantly improved by use of non-preserved artificial tear supplements alone. Therapeutic strategies for dry eye should aim to increase goblet cell density and control ocular surface inflammation.

The Agreement Between Self-Assessment and Clinician Assessment of Dry Eye Severity

PURPOSE

The purpose of this analysis was to measure the degree of agreement between clinicians' assessment and subjects' self-assessment of dry eye severity in a cross-sectional, observational dry eye study. A secondary purpose was to identify the role of gender and age in that concordance.

METHODS

In a cross-sectional observational study, 162 dry eye subjects and 48 controls were recruited from clinical databases of ICD-9 codes in 6 clinical sites. Before examination, subjects gave a global self-assessment of the severity of their dry eye from "none" to "extremely severe." After a clinical examination that included dry eye tests, the clinician discussed the subjects' symptoms and then gave global clinician assessment of dry eye from "none" to "severe." We measured the degree of agreement in these global measures.

RESULTS

Although the correlation and agreement between clinician and self-assessment was significant (r = 0.720, P = 0.000; weighted K = 0.471; 95% CI = 0.395, 0.548; P = 0.000), the clinician assessment underestimated the severity in 40.9% of the subjects by at least 1 grade compared with the subjects' self-assessment. Over 54% of subjects over age 65 and 43% of the female subjects had their condition underestimated by the clinician (P < 0.05).

CONCLUSIONS

Clinicians often relatively underestimated the severity of the subjects' self-assessment of dry eye in this clinical study, especially among the elderly and women. Eye care practitioners need better, more quantitative tools for the assessment of ocular surface symptoms to improve the concordance in severity assessment and to meet the needs of this symptomatic patient population by offering them appropriate treatments.

Dry eyes and mouth syndrome--a subgroup of patients presenting with sicca symptoms

OBJECTIVE

To evaluate the characteristics of patients presenting with symptoms suggestive of Sjögren's syndrome (SS) but failing to satisfy diagnostic criteria.

METHODS

Clinical, serological and histological data were collected on 34 patients presenting with dry eyes and/or mouth who did not satisfy the Vitali criteria for the diagnosis of SS. They were compared with 136 patients with primary SS, 38 patients with secondary SS, and 13 patients without SS. Questionnaires on symptoms from each group were compared with 43 healthy controls.

RESULTS

The 34 patients who did not satisfy the diagnostic criteria for SS or any other connective tissue disease were designated dry eyes and mouth syndrome (DEMS). Their demography including age was similar to that of a primary SS group and there was no more atrophy seen on their biopsies compared with SS and non-SS controls. They scored highly on visual analogue scales of symptoms but had few objective signs. All were negative for anti-Ro and anti-La although the prevalence of antinuclear antibodies (19%) was increased compared with a normal population. There was no excess of SS-associated tissue types.

CONCLUSION

There was no evidence that age, salivary gland atrophy or subclinical SS accounted for the symptoms in DEMS. Most of the patients fitted into a spectrum of disease which tended more towards fibromyalgia and/or chronic fatigue syndrome.

The Triple Classification of Dry Eye for Practical Clinical Use

PURPOSE

"Dry Eye is a condition produced by the inadequate interrelation between lacrimal film and ocular surface epithelium, and is caused by quantitative and qualitative deficits in one or both of them. It can be produced by one or combined etiologic causes, affecting one or several of the secretions of the glands serving the ocular surface, and producing secondary manifestations of different grades of severity". Clinicians need a practical classification to face diagnosis, prognosis and treatment. Dry eyes have many etiologies and pathogenesis, different affectation of the various dacryoglands and ocular surface epithelium, and diverse grades of severity. The specialists in xero-dacryology must know these three parameters to evaluate any case of dry eye, and to establish an adequate treatment.

METHODS

To facilitate this, an open session in the 8th congress of the International Society of Dacryology and Dry Eye (Madrid, April, 2005) proposed modifying the Triple Classification of dry eye approved in the XIV congress of the European Society of Ophthalmology (Madrid, June, 2003). There was consensus of all conclusions.

CONCLUSIONS

The following classification has been established: First, a classification of the etio-pathogenesis, distributed in ten groups: age-related, hormonal, pharmacologic, immunopathic, hyponutritional, dysgenic, infectious/inflammatory, traumatic, neurologic and tantalic. Second, a classification of the affected glands and tissues, which under the acronym of ALMEN includes the Aqueo-serousdeficient, Lipodeficient, Mucindeficient and Epitheliopatic dry eyes, and the Non dacryological affected exocrine glands (saliva, nasal secretion, tracheo-pharyngeal secretion, etc). And thirdly, a classification of severity, in three grades: Grade 1 or mild (symptoms without slitlamp signs), grade 2 or moderate (symptoms with reversible signs), and grade 3 or severe (symptoms with permanent signs).

Topical 0.05% cyclosporin in the treatment of dry eye

Dry eye disease is a common and often underdiagnosed condition that affects > 10% of the adult population, > 65 years of age in the US. This condition has been classified into two separate, but overlapping, categories--aqueous deficiency and evaporative loss. Diagnosis is confused by the lack of a single diagnostic test. Fluorescein break-up time is one of the best screening tests and is augmented by Lissamine green supravital staining. New concepts of pathogenesis have shown that dry eye disease appears to be caused by inflammation mediated by T-cell lymphocytes. This finding led to the study and FDA-approval of topical 0.05% cyclosporin A (Restasis) for the treatment of dry eye disease. 0.05% Cyclosporin A offers the first therapeutic treatment for patients with moderate-to-severe dry eye disease due to aqueous deficiency.

Agreement of Physician Treatment Practices With the International Task Force Guidelines for Diagnosis and Treatment of Dry Eye Disease

PURPOSE

To evaluate the clinical implementation of guidelines for the treatment of dysfunctional tear syndrome (DTS) developed by the International Task Force (ITF) of dry eye disease experts.

METHODS

Nine physicians implemented the ITF guidelines for 3 months. Newly diagnosed patients with DTS rated their ocular symptoms and were clinically examined. Using the guidelines, physicians determined the DTS severity level (0-4, where 4 is most severe) and made their therapeutic choices.

RESULTS

Of 183 patients enrolled (mean age, 65.1 years; range, 25-91 years), 67% presented without lid margin disease, and 68% had no apparent ocular surface inflammation. Symptoms were significantly more severe in patients with altered tear distribution or evident inflammation (P < 0.05). Most patients diagnosed at severity level 1 did not have lid margin disease (56/61, 92%), and inflammation was not apparent (53/58, 91%); 43% of severity level 1 patients (27/63) were treated at level 2 (therapeutic choices include unpreserved tears or topical cyclosporine). Most patients presenting with inflammation were diagnosed at severity level 2 (74%, 32/43). More than 9 in 10 severity level 2 patients were treated at level 2 (100/106; 94%). Physicians reported that 96% of their treatment recommendations were consistent with management they would have recommended if they had not consulted the ITF guidelines. They spent an average of 4.5 minutes per patient applying the guidelines.

CONCLUSIONS

Implementation of the ITF guidelines was simple and not time consuming. Many practitioners chose to treat patients diagnosed at severity level 1 with treatments at level 2 that include unpreserved tears and topical cyclosporine.

Cluster Analysis of Patients With Ocular Surface Disease, Blepharitis,and Dry Eye

OBJECTIVE

To develop a classification system for blepharitis and dry eye based on a classification-tree model of a large group of subjects who were given a variety of objective physiologic tests.

METHODS

We evaluated 513 subjects, some healthy and some with blepharitis and dry eye,with tests for tear volume, tear flow, and tear turnover and the Schirmer test for dry eye. Meibomian gland function was evaluated by meibomian gland lipid expression for lipid volume and lipid viscosity, evaporation, and eyelid transillumination for meibomian gland drop out. We subjected these data to cluster analysis and formulated a classification tree.

MAIN OUTCOME MEASURE

The outcome measure of this study was the statistically valid groups of subjects with and without ocular surface symptoms identified by their physiologic characteristics.

RESULTS

Cluster analysis most successfully grouped subjects by initially dividing them into 2 groups based on the presence or absence of gland drop out and then by lipid viscosity and volume, Schirmer test results, and evaporation. The analysis created 9 categories. This division created an objective classification system that was found to have clinical relevance. Normal subjects were distributed across several groups.

CONCLUSIONS

Using a classification tree, blepharitis and dry eye can be classified with objective physiologic tests into clinically relevant groups that have common characteristics. The analysis establishes the central role of meibomian gland dysfunction in blepharitis and demonstrates the diverse characteristics of the normal population.

The Diagnosis and Characteristics of Moderate Dry Eye in Non-Contact Lens Wearers

PURPOSE

To identify and characterize moderate dry eye in non-contact lens wearers with a new scoring system-based dry eye questionnaire and to determine which objective tests better differentiate patients with moderate dry eye from healthy patients.

METHODS

Fifty-two healthy subjects (21 women and 31 men with a mean age of 27.8 +/- 9.2 years) and 37 subjects with moderate dry eye (33 women and 4 men with a mean age of 36.4 +/- 12.9 years) completed a 42-item dry eye questionnaire. Seventeen healthy subjects (11 women and 6 men with a mean age of 30.5 +/- 9.7 years) and 28 subjects with moderate dry eye (24 women and 4 men with a mean age of 38.50 +/- 3.8 years) underwent additional objective assessment of ocular surface health, tear osmolality, tear stability, and tear volume.

RESULTS

Subjects with moderate dry eye scored significantly higher (49.8 +/- 20.3, P<0.0001) on the dry eye questionnaire than did normal subjects (11.7 +/- 10.3). Ocular irritation symptoms worsened with progression of time of day in both groups of subjects. Internal reliability (0.95 Cronbach alpha) was excellent, and concurrent validity (Spearman rho 0.507) was acceptable when compared to the McMonnies and Ho dry eye questionnaire. Significant differences in tear osmolality (P<0.00001), invasive tear breakup time (P<0.034), and corneal vital dye staining (P<0.0001) were detected between the two groups of subjects. A stepwise linear regression on objective clinical tests, however, did not account for 77% of the total variance in the questionnaire scores.

CONCLUSIONS

A unique scoring system-based dry eye questionnaire was validated to separate non-contact lens wearers with moderate dry eye from healthy subjects. Objective tests of tear osmolality and stability and ocular surface integrity were better than other clinical measures at identifying differences between the two subject groups. The results strongly support the evidence that the diagnosis and treatment of moderate dry eye requires a detailed assessment of self-perceived symptoms and that objective clinical testing alone may be insufficient.