**5. Assessing the dry eye**

The diagnosis of dry eye depends on the results of several of tests mentioned above, which ideally could be performed at a single clinic visit. It is important to keep in mind that a clinician should carry out the test in an appropriate order. **Table 2** suggests a suitable order for diagnostic test, although there are various and informal data to justify a particular sequence of the tests. Some of the standard tests are specific for subgroup of the disease (**Table 3**). **Table 4** helps the clinician to grade the severity of the DED.


#### **Table 2.** *Practical sequence of dry eye tests.*

	- changes in tear composition (lack of lipid content; primary type: lack of gland and distichiasis; secondary type: bleharitis and MGD);
	- abnormalities of eyelids, reduced blinking rate or incomplete blinking (office workers, Parkinsonism, and schizophrenia);
	- ocular surface irregularities;
	- contact lens wear.

*Adapted from Módis and Szalai [22].*

#### **Table 3.**

*Practical applications of several test for assessing DED.*


#### **Table 4.**

*The severity grading scheme for dry eye disease.*

Despite the wide use in clinical practice, standard tests for assessing DED and ocular surface disorders (including history taking and symptoms recording, TBUT, meibomian gland testing, ocular surface saining, and Schirmer's testing) have shown poor repeatability and lack of efficacy [22, 57]. Moreover, it is well know that subjective symptoms often do not correlate with objective signs. Additional exploratory technique may be required to assess DED and evaluate the severity of the disease. The laboratory test may be required in patient who have subjective complaint


#### **Table 5.**

*Diagnosis criteria for Sjögren's syndrome.*

that is not identified as dry eye (such as fluctuating vision) but do not show a lot of ocular finding such as corneal staining or any other marked conditions.

Patient with xerostomia in addition to dry eye must be investigated for the possible presence of Sjögren's syndrome. The revised criteria of the European-American Consensus Group for the diagnosis of Sjögren's syndrome are summarized in **Table 5**. The diagnosis of Sjögren's syndrome is made if four of the six criteria are fulfilled. If SSA/SSB diagnostic testing is negative, a positive ANA (antinuclear antibody) test or positive rheumatoid factors may be indicative [15].
