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Accuracy of Tests for Diagnosing Dry Eye Disease
TAKE-HOME MESSAGE
- An analysis of the diagnostic tests available and recommended by the TFOS DEWS II report showed that the most accurate single test to give a correct diagnosis of dry eye disease was corneal staining, followed by tear film osmolarity and conjunctival staining tests. Thus, it was concluded that assessing both corneal and conjunctival staining tests is quite useful. Using the Ocular Surface Disease Index to assess symptoms was the least likely method to accurately diagnose dry eye disease.
- Although many practitioners rely on only one clinical measure to diagnose dry eye disease, the author shows that the use of multiple clinical measures, along with a measure of symptoms, will afford the best accuracy.
abstract
This abstract is available on the publisher's site.
Access this abstract now Full Text Available for ClinicalKey SubscribersPURPOSE
To demonstrate how the likelihood of making a correct diagnosis of dry eye disease varies according to the clinical test methods used.
METHODS
The probability of a person having dry eye, given that they return a positive test, was calculated for a range of standard tests, using the Bayes-Price rule. Global specificity and sensitivity values for each test were estimated by employing the Beta distribution to combine all relevant data obtained from a literature review.
RESULTS
At an assumed prevalence of 11.6%, the single test with the highest probability of a correct diagnosis was corneal staining (probability = 0.28) and the lowest was the ocular surface disease index - OSDI (0.14). The best combination of symptoms with a single test of tear film homeostasis was the 5-item dry eye questionnaire (DEQ-5) + corneal staining (0.42) while OSDI + tear film break up time (TBUT) was the worst (0.23). The simultaneous observation of conjunctival and corneal staining was associated with a probability of 0.49. The probability of a correct diagnosis increased with the number of positive tests, up to a maximum of 0.90 when all of DEQ-5, conjunctival and corneal staining, osmolarity and TBUT were positive.
CONCLUSION
A significant risk of misdiagnosis is associated with using any single test for dry eye disease, or the minimum TFOS DEWS II criterion of symptoms plus any single test of tear film homeostasis. To minimize this risk, the maximum number of tests available should be performed and the results used to inform diagnosis. The simultaneous occurrence of conjunctival and corneal staining should be considered a key outcome and be specified in future guidelines.
Additional Info
Disclosure statements are available on the authors' profiles:
Diagnosing dry-eye: Which tests are most accurate?
Cont Lens Anterior Eye 2023 Aug 04;[EPub Ahead of Print], EB PapasFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
It is not entirely surprising that no single test is definitive in diagnosing dry eye disease and that multiple tests must be used for an accurate differential diagnosis. The authors cautioned that, although it is unclear how often clinicians rely on a single test for diagnosing dry eye disease, it is probable that many do. What is somewhat surprising is that corneal staining as a stand-alone test performs incorrectly in 72% of the cases. Conjunctival staining, coupled with corneal staining, exhibited a significantly increased likelihood of correctly diagnosing dry eye disease. Of note, symptom checklists, such as the Ocular Surface Disease Index questionnaire and the 5-item Dry Eye Questionnaire, heavily relied on in research, are not discriminative since positive responses overlap with other conditions and, in particular, with binocular vision disorders. The author of this paper is a co-author of an article published in Optometry and Vision Science in 2021 demonstrating this overlap. The bottom line is that multiple positive tests are required to correctly diagnose dry eye disease, which, although clinically intuitive, was objectively demonstrated in this paper.