Establishing Severity of the Disease

The severity of Dry Eye Syndrome, as with other diseases, determines the prescribed course of treatment. An international panel, in its 2006 paper, defined 4 levels of Dry Eye severity, from mild to severe. Severity was assessed on the basis of tear substitute requirements, symptoms of ocular discomfort, and visual disturbance. Clinical signs present in lids, tear film, conjunctiva, and cornea were also used for establishing severity.

A patient’s response to treatment was considered an important indicator of disease severity. The panel determined that a patient, not responding to treatment prescribed for one level, should be assigned to, and prescribed, the treatments for the next higher level of severity.

This approach may explain in part why so many Dry Eye patients with more than the mildest symptoms see many doctors. If each new doctor prescribes treatment appropriate for only mild Dry Eye, or lower than the actual severity, the treatment will be ineffective and the patient may become frustrated, choosing to seek care elsewhere. In these cases, diagnosing co-morbidities, and prescribing targeted treatments, may be more important than establishing a generic severity level.

Although the panel did not consider diagnostic tests important in establishing the severity of the disease, it considered diagnostic tests important in confirming the presence of disease.

TABLE 4. Clinical Signs in DTS to Consider in Severity Assessment

Lids Tear Film Conjunctiva Cornea Vision
Telangiectasia Meniscus Luster Punctate changes Blur
Hyperemia Foam Hyperemia Erosions (micro, macro) Fluctuations
Scales, crusts Mucus Wrinkles Filaments
Lash loss or Debris Staining Ulceration
abnormalities Oil excess Symblepharon Vascularization
Inspissation Cicatrization Scarring
Meibomian gland disease Keratinization
Anatomical abnormalities

TABLE 5. Levels of Severity of DTS Without Lid Margin Disease According to Symptoms and Signs

Severity* Patient Profiles
Level 1 Mild to moderate symptoms and no signs
 Mild to moderate conjunctival signs
Level 2 Moderate to severe symptoms
 Tear film signs
Mild corneal punctate staining
 Conjunctival staining
 Visual signs
Level 3 Severe symptoms
 Marked corneal punctate staining
 Central corneal staining
 Filamentary keratitis
Level 4 Severe symptoms
 Severe corneal staining, erosions
 Conjunctival scarring

*At least one sign and one symptom of each category should be present to qualify for the corresponding level assignment.


Dysfunctional tear syndrome: a Delphi approach to treatment recommendations
Behrens A, et al.
2006 Sep;25(8):900-7.
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