What is the recommended workup and treatment for dry eyes?

Workup for Dry Eyes

Begin with a detailed symptom assessment using validated questionnaires (OSDI or NEI-VFQ25), followed by slit-lamp examination with specific diagnostic tests including tear break-up time, ocular surface staining, and tear osmolarity or MMP-9 testing to confirm the diagnosis. 1

Initial Clinical Assessment

Symptom Evaluation

• Document specific symptoms: irritation, burning, stinging, foreign body sensation, photophobia, blurred vision, contact lens intolerance, redness, mucous discharge, eye fatigue, and diurnal fluctuation (typically worsening later in the day) 1
• Use validated questionnaires: the Ocular Surface Disease Index (OSDI) has demonstrated good specificity (0.83) and moderate sensitivity (0.60) for distinguishing dry eye from normal subjects 1
• Identify exacerbating factors: air travel, low humidity, air drafts from fans or air conditioner vents, prolonged screen time, reading, digital device use, and poorly fitted sleep apnea devices 1

Comprehensive History

• Medication review: Identify systemic medications that decrease tear production (antihistamines, decongestants, antidepressants, antihypertensics, hormonal therapies) 1
• Systemic disease screening: Ask about dry mouth, joint pain, skin rashes, thyroid symptoms, or family history of autoimmune disorders 1
• Ocular history: Previous eye surgeries (particularly LASIK or cataract surgery), contact lens wear, and prior ocular surface disease 1
• Environmental exposures: Screen time duration, occupational exposures, smoking status, and living/working environment humidity 1

Slit-Lamp Examination

Essential Findings to Document

• Tear meniscus height: Reduced height suggests aqueous deficiency 1
• Lid margin abnormalities: Meibomian gland obstruction, telangiectasia, lid margin irregularity, or signs of blepharitis 1
• Conjunctival changes: Injection, chemosis, scarring, keratinization, or mucous plaques 1
• Corneal findings: Punctate epithelial erosions, filaments, epithelial defects, basement membrane irregularities, thinning, infiltrates, ulceration, or neovascularization 1

Diagnostic Testing Algorithm

First-Tier Tests (Perform in All Suspected Cases)

• Tear break-up time (TBUT): Apply fluorescein dye and measure time until first break in tear film; less than 10 seconds is abnormal 1
  • A rapid TBUT may indicate unstable tear film with normal aqueous production and minimal ocular surface staining 1
• Ocular surface staining: Use fluorescein, lissamine green, or rose bengal to assess epithelial damage; staining of inferior cornea and bulbar conjunctiva within the palpebral fissure is typical 1

Second-Tier Tests (Select Based on Clinical Presentation)

• Tear osmolarity: Elevated osmolarity (>308 mOsm/L) or inter-eye differences (>8 mOsm/L) confirm diagnosis 1

  • Normal subjects have exceptionally stable tear film osmolarity, whereas dry eye patients lose homeostasis quickly with environmental changes 1
  • Correlation with clinical findings over time is more informative than a single measurement 1

• Point-of-care MMP-9 test: Binary test indicating presence of inflammation; aids in diagnosis and can assess disease state changes 1

  • Does not differentiate dry eye from other inflammatory ocular surface diseases 1

• Schirmer test without anesthesia (Schirmer I): Measures both basic and reflex tearing; less than 5.5 mm of wetting after 5 minutes is diagnostic of aqueous tear deficiency 1

• Meibomian gland assessment: Evaluate expressibility and quality of meibum secretions 1

Corneal Sensation Testing

• Assess when trigeminal nerve dysfunction is suspected (history of herpes zoster, diabetes, contact lens wear, or refractive surgery) 1

Laboratory Workup for Systemic Disease

Indications for Serologic Testing

Order laboratory tests when patients have:

• Significant dry eye with other autoimmune symptoms (particularly dry mouth) 1
• Family history of autoimmune disorders 1
• Severe dry eye in younger patients or males (atypical demographics) 1

Specific Testing by Suspected Condition

For Sjögren Syndrome (approximately 10% of clinically significant aqueous deficient dry eye cases) 1:

• Anti-Sjögren syndrome A antibody (SSA/anti-Ro)
• Anti-Sjögren syndrome B antibody (SSB/anti-La)
• Antinuclear antibody (ANA)
• Rheumatoid factor (RF)
• Salivary protein 1 (SP1)
• Carbonic anhydrase 6 (CA6)
• Parotid secretory protein (PSP) 1

For Thyroid Eye Disease:

• Antithyroid peroxidase antibody
• Antithyroglobulin antibody
• Orbital imaging (CT or MRI) if proptosis or lid retraction present 1

For Sarcoidosis:

• Serum lysozyme
• Angiotensin-converting enzyme (ACE)
• Chest CT to determine disease extent
• Consider conjunctival biopsy
• Consult pulmonology as necessary 1

For Ocular Mucous Membrane Pemphigoid:

• Conjunctival biopsy with light microscopy and immunofluorescent or immunohistochemical studies 1

Classification of Disease Severity

Mild Dry Eye

• Symptoms: Intermittent irritation, itching, soreness, ocular discomfort, burning, or intermittent blurred vision 1
• Signs: Inconsistent correlation between symptoms and clinical findings 1

Moderate Dry Eye

• Increased discomfort and frequency of symptoms
• More consistent negative effect on visual function 1

Severe Dry Eye

• Constant or potentially disabling visual symptoms
• Risk of complications: ocular surface keratinization, conjunctival fibrosis, limbal stem cell deficiency, corneal scarring, thinning, neovascularization, microbial or sterile corneal ulceration with possible perforation 1

Critical Pitfalls to Avoid

• Don't rely on a single diagnostic test: The diagnosis is difficult because of inconsistent correlation between symptoms and signs; combine at least two tests 1, 2
• Don't miss underlying systemic disease: Ophthalmologists should have a high index of suspicion for Sjögren syndrome (associated with increased lymphoma risk) and low threshold for serologic workup 1
• Don't overlook meibomian gland dysfunction: Most patients have evaporative or mixed-mechanism dry eye rather than pure aqueous deficiency 1
• Don't dismiss pediatric presentations: Children may present with chronic recurrent blepharokeratoconjunctivitis and subtle rosacea signs before cutaneous manifestations 1
• Recognize post-surgical dry eye: All patients undergoing cataract or refractive surgery should be evaluated preoperatively, as baseline parameters predict postoperative risk 1