History
Depending on the severity of dry eye disease (DED), or keratoconjunctivitis sicca (KCS), the following are the most common patient complaints:
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Foreign-body, burning, gritty, or itching sensation.
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Redness
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Mucoid discharge
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Ocular irritation
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Ocular dryness
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Excessive tearing (secondary to reflex secretion)
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Photophobia
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Itching
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Fluctuating or blurry vision that may improve with blinking
These symptoms are often exacerbated in smoky or dry environments, by indoor heating, by fans, or by excessive reading or computer use. Often, the symptoms also worsen as the day goes on.
These symptoms are quantified objectively in the Ocular Surface Disease Index (OSDI) questionnaire, which lists 12 symptoms and grades each on a scale of 1 to 4.
Patients with meibomian gland dysfunction (MGD) may complain of redness of the eyelids and conjunctiva, but in these patients, the symptoms are often worse upon awakening in the morning.
Paradoxically, some patients with dry eye disease complain of too much tearing. When evidence of dry eye disease exists, this symptom often is explained by excessive reflex tearing due to severe corneal surface disease from the dryness. Epiphora may also accompany conjunctivochalasis, which demands consideration of surgical intervention.
The patient’s medical history may be significant for coexisting connective tissue disease (CTD), rheumatoid arthritis (RA), or thyroid abnormalities. A thorough review of systems should be obtained, focusing specifically on dry mouth, arthritis, cutaneous changes, malaise, weight loss, and lymphadenopathy. Within the veteran population, a study found an increased incidence of dry eye disease in both men and women that was also strongly connected to cases of posttraumatic stress disorder and depression. [31]
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Eye tear system anatomy: a. tear gland / lacrimal gland, b. superior lacrimal punctum, c. superior lacrimal canal, d. tear sac / lacrimal sac, e. inferior lacrimal punctum, f. inferior lacrimal canal, g. nasolacrimal canal.
Tables
Variable |
Dry Eye Severity Level |
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1 |
2 |
3 |
4 (must have signs and symptoms) |
|
Discomfort (severity and frequency) |
Mild, episodic; occurs under environmental stress |
Moderate, episodic or chronic; occurs with or without stress |
Severe, frequent, or constant; occurs without stress |
Severe or disabling, constant |
Visual symptoms |
None or episodic mild fatigue |
Annoying or activity-limiting, episodic |
Annoying, chronic, or constant; activity-limiting |
Constant and possibly disabling |
Conjunctival injection |
None to mild |
None to mild |
+/– |
+/++ |
Conjunctival staining |
None to mild |
Variable |
Moderate to marked |
Marked |
Corneal staining (severity and location) |
None to mild |
Variable |
Marked central |
Severe punctate erosions |
Corneal and tear signs |
None to mild |
Mild debris, decreased meniscus |
Filamentary keratitis, mucus clumping, increased tear debris |
Filamentary keratitis, mucus clumping, increased tear debris, ulceration |
Lid and meibomian glands |
MGD variably present |
MGD variably present |
MGD frequent |
Trichiasis, keratinization, symblepharon |
Tear breakup time |
Variable |
≤ 10 s |
≤ 5 s |
Immediate |
Schirmer score |
Variable |
≤ 10 mm/5 min |
≤ 5 mm/5 min |
≤ 2 mm/5 min |
MGD=meibomian gland dysfunction. |
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