There is no shortage of patients with dry eye disease (DED) walking into our clinics daily. A major challenge for both optometry and ophthalmology is creating a streamlined approach to identifying patients that may need treatment without significantly disrupting clinic flow. In this article, I will outline what I have been doing in my OD-MD multispecialty practice over the past few years.
Who Should We Screen?
Patients coming to see me generally fall into 3 buckets:
- General clinic visit with a primary diagnosis or chief complaint of something other than DED
- Cataract/refractive evaluation
- Ocular surface disease (OSD)-focused visit
With prevalence as high as 60-80% in some populations,1 I screen everyone presenting for a comprehensive evaluation. I take a slightly different approach for each patient type, as goals of the visit vary considerably for both the patient and the doctor. I rely heavily on protocols that are implemented by my technician team when symptoms are present, or a DED diagnosis has been made in the past. What follows are the diagnostics that I currently use.
The Basics/Must-Haves
Patient History and Questionnaires
Tools like the Ocular Surface Disease Index (OSDI), Standardized Patient Evaluation of Eye Dryness (SPEED), and 5-Item Dry Eye Questionnaire (DEQ-5) help quantify symptom frequency and severity. The recently released TFOS DEWS III report recommends OSDI-6.2 I have found the SPEED questionnaire to be particularly useful, as it focuses on identifying patients with symptoms of evaporative dry eye. I recommend utilizing a questionnaire for both screening and monitoring. The presence of symptoms identified on a questionnaire should trigger a more comprehensive diagnostic workup and deeper dive into patient history. Questionnaires are administered and completed at the check-in desk.
Ocular Surface Staining/Tear Breakup Time
I recommend utilizing fluorescein sodium (NaFl) as part of any comprehensive ocular examination. I consider lissamine green in DED-focused exams or in symptomatic patients with minimal signs. Sodium fluorescein stains areas of epithelial disruption, highlighting corneal surface damage, while lissamine green stains devitalized or dead cells and mucins, making it more useful for evaluating conjunctival health. Together, they provide complementary information in dry eye assessment. Technicians will instill the dye with a saline-moistened strip shortly before I enter the exam room. This saves me 15-20 seconds on every patient.
Dry Eye Testing: What Technicians and Staff Need to Know
Technicians should understand that dry eye testing involves both subjective symptom assessment and objective clinical evaluation. In our clinic, we’ve designed protocols to empower our technician team to obtain objective dry eye diagnostic testing prior to the evaluation by the doctor. Additionally, our technicians provide education on dry eye and common medications and procedures that we utilize regularly. A team-based approach—where technicians, eyecare providers, and support staff collaborate—ensures comprehensive care and improves outcomes through consistent patient education and follow-up.
Eyelid/Physical Evaluation
Don’t forget to assess for common entities such as Demodex blepharitis, ocular rosacea, lid laxity, and conjunctivochalasis (to name a few). The Look, Lift, Pull, Push method advocated by ASCRS is a great sequence to follow as well.3
Meibomian Gland Evaluation
Expressibility and secretion quality are assessed manually at the slit lamp. Multiple methods exist, ranging from pressing with a thumb/finger, cotton tip applicator, or a Mastrota paddle, to name a few. I suggest picking one method and sticking to it. I assess meibomian glands utilizing the TearScience Meibomian Gland Evaluator (Johnson & Johnson) to determine the number of meibomian glands yielding liquid secretions (MGYLS).
The MGYLS method delivers a standardized, gentle pressure—mimicking a deliberate blink—on the lower eyelid while viewing the gland orifices under a slit lamp to assess secretion quality and expressibility. In just a few seconds per lid, clinicians are able to assess gland function and monitor treatment response with repeatable consistency.
Korb and Blackie demonstrated that there is a strong correlation between the number of MGYLS in the lower eyelid and dry eye symptoms.4 Consistent and repeatable evaluation of meibomian gland function has been perhaps the most important dry eye diagnostic I have incorporated into my clinic over the past decade. This can be accomplished on any patient in 10-20 seconds. It’s worth it.
Advanced Diagnostics/Nice-to-Haves
MMP-9 Testing
This test detects matrix metalloproteinase-9 (MMP-9), a biomarker for ocular surface inflammation. MMP-9 testing provides a positive/negative result in about 10 minutes and helps guide anti-inflammatory treatment. I have moved away from obtaining this test routinely, strictly from an efficiency standpoint because it takes a couple of minutes for a technician to perform.
Tear Osmolarity Testing
This test measures the osmolarity of tears using a 50-nanoliter sample. Values above 308 mOsm/L or an inter-eye difference greater than 8 mOsm/L indicate hyperosmolarity and tear film instability. As an objective test, tear osmolarity provides a precise, numerical value, is sensitive and specific for DED,5 and often is elevated prior to the presence of structural damage or other visible signs.6 This test takes less than a minute to perform, provides actionable data, and is reimbursed at a reasonable rate.
Meibomian Gland Imaging
Meibography provides a powerful, noninvasive method for visualizing the structure of the meibomian glands, utilizing direct infrared imaging and, in some cases, transillumination. Gland dropout or atrophy is commonly seen in meibomian gland dysfunction (MGD), a major contributor to evaporative dry eye. Meibography also supports patient education, as visual evidence of gland loss enhances understanding and compliance with treatment plans. However, from an efficiency standpoint, I only obtain this at a baseline OSD-focused exam and only occasionally thereafter.
Interferometry
Imaging devices that capture noninvasive measurements of tear film dynamics (eg, noninvasive tear breakup time and lipid layer thickness) are becoming increasingly popular and offer value in diagnosing and managing DED. Testing provides accurate, repeatable measurements without disrupting the tear film, leading to more reliable assessments. I reserve this testing for DED-focused visits.
Blink Analysis
Poor blink dynamics are common in DED patients.7 Automated analysis helps detect subtle abnormalities that may be missed during manual observation. Results can be used for patient education and repeat measurements can assess response to treatment.
Many advanced dry eye diagnostic suites offer the ability for a customized report that encompasses results from the imaging software. These can aid in patient education and allow clinicians to have a “roadmap” to create a customized treatment approach.
Corneal Topography
An increase in higher-order aberrations is common in DED and can be detected by topography.8
Practical Implementation
Here is a summary of how I use these tests in an OD-MD referral practice setting:
1. General Clinic
a. SPEED questionnaire for new patients (administered at check-in)
b. Tear osmolarity if any symptoms are present (technician driven)
c. Eyelid and ocular surface assessment utilizing NaFl dye (doctor driven)
2. Cataract/Refractive Evaluation
a. ModifiedSymptom Assessment in Dry Eye (SANDE) questionnaire (included on our intake form)
b. Tear osmolarity if any symptoms are present, including blurry vision9
c. Careful review of corneal topography/wavefront aberrometry
d. Eyelid and ocular surface assessment utilizing NaFl dye
3. Dry Eye Clinic
a. SPEED questionnaire (every visit)
b. Tear osmolarity (every visit if signs/symptoms present)
c. Advanced ocular surface analysis
i. Interferometry (every visit)
ii. Blink Analysis (baseline)
iii. Meibography (baseline)
d. MMP-9 testing as needed (technician performed if doctor orders)
e. Eyelid and ocular surface assessment utilizing NaFl and lissamine green dyes
Conclusion
I have found that having standard protocols, driven by the presence of patient signs and/or symptoms, improves clinic efficiency, diagnostic accuracy, and patient experience. This has been imperative in optimizing outcomes in all patient types that we see routinely in our clinics. OP
Disclosures: Dr. Dierker reports relevant disclosures in dry eye: He is a consultant for AbbVie, Azura Ophthalmics, Bausch + Lomb, BioTissue, Bruder, Dompé, Nordic Pharma, Novoxel, NuSight Medical, ScienceBased Health, Sight Sciences, Sun Pharma, Tarsus Pharmaceuticals, Thea Pharmaceuticals, and Viatris.
References
1. Trattler WB, Majmudar PA, Donnenfeld ED, McDonald MB, Stonecipher KG, Goldberg DF. The prospective health assessment of cataract patients’ ocular surface (PHACO) study: the effect of dry eye. Clin Ophthalmol. 2017;11:1423-1430. doi:10.2147/OPTH.S120159
2. Wolffsohn JS, Benítez-Del-Castillo J, Loya-Garcia D, et al. TFOS DEWS III diagnostic methodology. Am J Ophthalmol. Published online May 30, 2025. doi:10.1016/j.ajo.2025.05.033
3. Starr CE, Gupta PK, Farid M, et al. An algorithm for the preoperative diagnosis and treatment of ocular surface disorders. J Cataract Refract Surg. 2019;45(5):669-684. doi:10.1016/j.jcrs.2019.03.023
4. Korb DR, Blackie CA. Meibomian gland diagnostic expressibility: correlation with dry eye symptoms and gland location. Cornea. 2008;27(10):1142-1147. doi:10.1097/ICO.0b013e3181814cff
5. Lemp MA, Bron AJ, Baudouin C, et al. Tear osmolarity in the diagnosis and management of dry eye disease. Am J Ophthalmol. 2011;151(5):792-798.e1. doi:10.1016/j.ajo.2010.10.032
6. Liu H, Begley C, Chen M, et al. A link between tear instability and hyperosmolarity in dry eye. Invest Ophthalmol Vis Sci. 2009;50(8):3671-3679. doi:10.1167/iovs.08-2689
7. Su Y, Liang Q, Su G, Wang N, Baudouin C, Labbé A. Spontaneous eye blink patterns in dry eye: clinical correlations. Invest Ophthalmol Vis Sci. 2018;59(12):5149-5156. doi:10.1167/iovs.18-24690
8. Nilsen C, Gundersen M, Graae Jensen P, et al. The significance of dry eye signs on preoperative keratometry measurements in patients scheduled for cataract surgery. Clin Ophthalmol. 2024;18:151-161. doi:10.2147/OPTH.S448168
9. Akpek EK, Amescua G, Farid M, et al. Dry eye syndrome preferred practice pattern. Ophthalmology. 2019;126(1):P286-P334. doi:10.1016/j.ophtha.2018.10.023
