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6 JANUARY 2017 Identifying Dry Eye Advanced diagnostic tools and an objective view should lead the way I n 2007, the International Dry Eye Workshop (DEWS) 1 revised its definition of dry eye dis- ease. e new definition — "Dry eye is a multi- factorial disease of the tears and ocular surface that results in symptoms of discomfort, visual disturbance, and tear film instability with potential damage to the ocular sur- face. It is accompanied by increased osmolarity of the tear film and inflammation of the ocular surface." — reflects an improved understanding of the condition. e addi- tion of the word "multifactorial" is relevant not only to treatment but also to diagnosis, because dry eye mani- fests differently among patients. erefore, as clini- cians, we need to be on the lookout for several signs and symptoms. New diagnostic tools, in conjunction with those that were previously available, are a big help. ey enhance our ability to diagnose dry eye efficiently and precisely. ey can also help motivate patients to be active participants in their treatments, driving home the point that dry eye is a medical condition. USE EVERY DIAGNOSTIC TOOL AVAILABLE Another addition to the DEWS definition of dry eye, "visual disturbance," makes perfect sense to those of us who've noticed it early in a patient's visit, at the pho- ropter. Some patients have trouble deciding which lens is better until they purposefully blink, which alerts me right away that we're likely to uncover other symptoms and signs of dry eye. To identify dry eye in our practice, we use all of the available means of diagnosis. • Case history and questionnaire: Eliciting dry eye-related complaints begins with a thorough case his- tory, including questions about contact lens wear and artificial tear use. A significant number of contact lens patients report some kind of compensating behavior, such as rubbing their eyes or removing the lenses before the end of the day, and many think that's normal. We know that it doesn't have to be. In addition, before patients see a doctor in our practice, they complete a SPEED questionnaire, which typically takes less than a minute. When we see a score of six or above, it's another indication that we'll be exploring dry eye further. • Slit lamp examination: Frothing near the lower lid margin is a sign of dry eye (Figure 1A). Vital dye staining (Figure 1B) is part of our workup as well. It's important to use two stains, either lis- samine green and/or rose bengal and/or fluorescein By Mark Schaeffer, OD Figure 1. Signs of dry eye at the slit lamp: (A) frothing, (B) vital dye staining, (C) clogged meibomian glands.