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Review Ocular Surface Disease Diagnostic Tools for Dry Eye Disease Sarah Dougherty Wood and Shahzad I Mian Department of Ophthalmology and Visual Sciences, Medical School, University of Michigan, Ann Arbor, Michigan, US D ry eye disease is multifactorial in aetiology and complex in pathophysiology that makes its diagnosis clinically challenging. Although there are numerous tools for assessment of dry eye disease, no single test is sufficient for the diagnosis. Typically a combination of subjective symptoms and objective tests are used. The aim of this article is to review the available tests, including traditional tools and emerging technologies. This review includes a description of the test methodology, type of data collected, diagnostic reliability of data, benefits and limitations of each test, expected outcomes and tips for practical application. Keywords Dry eye disease, dry eye diagnosis, tear film Disclosure: Sarah Dougherty Wood and Shahzad I Mian do not have financial or proprietary interest in any materials or methods mentioned. No funding was received in the publication of this article. This study involves a review of the literature and did not involve any studies with human or animal subjects performed by any of the authors. Authorship: All named authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship of this manuscript, take responsibility for the integrity of the work as a whole, and have given final approval to the version to be published. Open Access: This article is published under the Creative Commons Attribution Noncommercial License, which permits any non-commercial use, distribution, adaptation and reproduction provided the original author(s) and source are given appropriate credit. Received: 2 November 2016 Accepted: 7 December 2016 Citation: European Ophthalmic Review, 2016;10(2):101–7 Corresponding Author: Shahzad I Mian, WK Kellogg Eye Center, 1000 Wall Street, Ann Arbor, MI, 48105, US. E: The International Dry Eye Workshop Dry Eye Workshop (DEWS) defined dry eye as “a multifactorial disease of the tears and ocular surface that results in symptoms of discomfort, visual disturbance and tear film instability with potential damage of the ocular surface. It is accompanied by increased osmolarity of the tear film and inflammation of the ocular surface”. 1 This condition is divided into two general types: deficient aqueous production by the lacrimal gland and increased evaporation of the tear film, with the latter being more prevalent. It is also common for patients to exhibit a combination of both types of dry eye disease. Despite the seemingly clear definition of the disease, the diagnosis presents many challenges to the practitioner. First, no gold standard protocol for diagnosis exists 2 and no one test is sufficient for diagnosis due to poor reliability for many common tests, multiple causative components of the disease and lack of well-defined cut-off values to distinguish disease from normal. 2 To further complicate the diagnosis, the signs and symptoms do not always correlate and both can vary based on influences, such as diurnal or seasonal fluctuations. 3 In addition, many of the tests are invasive in nature and this may influence the outcome. Lastly, other conditions can mimic dry eye such as ocular allergy. Due to these challenges, alternatives to traditional dry eye testing have emerged. The purpose of this article is to describe the traditional and emerging tests for diagnosis that are clinically useful, including the benefits and limitations and practical pearls. Table 1 lists both the traditional and emerging tests categorised by test objective. Traditional tests Symptom questionnaires Subjective symptoms and their quality of life impact are a critical component of dry eye evaluation. The clinical signs and symptoms do not always correlate and the patients’ experience of their condition is ultimately the most important measure and will cause them to seek treatment. Symptom questionnaires are one of the most repeatable of the dry eye diagnostic tests 4 and allow for diagnosis screening, assessment of treatment efficacy and grading of disease severity. Symptom questionnaires are also a critical part of dry eye clinical research trials. The Ocular Surface Disease Index (OSDI) is commonly used, validated and includes 12 questions related to experience during the previous week regarding ocular symptoms, the severity, how these affect visual function and the ocular response to environmental triggers. The score can range from 0–100 with a higher score being worse. A score of 15 has moderate sensitivity and specificity, 60% and 83%, respectively, for the diagnosis of dry eye disease. 5 The Standard Patient Evaluation of Eye Dryness (SPEED) questionnaire helps identify symptoms and focuses on their severity and frequency. 6 Table 2 provides a summary of popular questionnaires including links to obtain the questionnaires for use. Practical pearls • Symptom questionnaires should be used in combination with objective findings to aid in diagnosis. • These questionnaires can easily be given by a trained technician. • The The International Dry Eye Workshop Dry Eye Workshop (DEWS) report recommends adopting one of the questionnaires to be used routinely in the clinic setting for screening purposes. 4 TOU CH MED ICA L MEDIA 101