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Ocular Immunology and Inflammation, 15:389–393, 2007
Copyright cInforma Healthcare USA, Inc.
ISSN: 0927-3948 print; 1744-5078 online
DOI: 10.1080/09273940701486803
ORIGINAL ARTICLE
Ocular Surface Disease Index for the
Diagnosis of Dry Eye Syndrome
Fatih ¨
Ozcura, MD,
and Sayime Aydin, MD
Department of Ophthalmology,
Hospital of the Dumlupinar
University, Kutahya, Turkey
Mehmet Rami Helvaci, MD
Department of Internal
Medicine, Hospital of the
Dumlupinar University,
Kutahya, Turkey
ABSTRACT Purpose: Evaluation of ocular surface disease index (OSDI) question-
naire for the diagnosis of dry eye syndrome. Methods: Sixty-eight patients admitted
to the Ophthalmology Polyclinic of the Dumlupinar University between Decem-
ber 2005 and April 2006 were randomly studied. The OSDI questionnaire was
performed before, and the Schirmer and tear film breakup time (TBUT) tests were
performed after the routine ophthalmologic examination. Results:There was a sig-
nificant inverse correlation between the OSDI and TBUT test scores, but no cor-
relation between the Schirmer test scores and OSDI (r=−.296, p=.014, r=
−.182, p=.138, respectively). Although there was a significant difference between
the low and high OSDI having cases according to the TBUT test scores (p=.043),
there was not according to the Schirmer test scores. Conclusions:The OSDI is a
standardized instrument to evaluate symptoms, and can easily be performed and
used to support the diagnosis of dry eye syndrome.
KEYWORDS Dry eye syndrome; ocular surface disease index; Schirmer test; tear film
breakup time
Dry eye syndrome (DES) represents a heterogeneous group of disorders, char-
acterized by inadequate lubrication of the ocular surface. There are two distinct
categories of the dry eye disease: one is related to an insufficient production of
tears and the other, more common disease results from increasing evaporation.1
Recent studies show that the prevalence of DES has a wide range, between 0.39
and 33.7%. The most important reason for the difference is the absence of any
objective criteria for the diagnosis. However, epidemiological studies report that
DES is more commonly seen in women and elders.2−5
Various questionnaires have been applyied during the history taking for the
diagnosis of DES. The ocular surface disease index (OSDI) is the best validated
questionnaire. The OSDI, developed by the Outcomes Research Group at Al-
lergan, is a 12-item questionnaire designed to provide a rapid assessment of the
symptoms of ocular irritation consistent with DES and their impact on vision-
related functioning. The initial questionnaire including 40-items was reduced
later to the final 12 questions on the basis of validity and reliability of data from
the patients.6
There are various traditional tests and noninvasive instruments used to di-
agnose the DES beside the questionnaire. However, there is no specific test or
Accepted 29 May 2007.
Correspondence and reprint requests
to: Fatih ¨
Ozcura, MD, Deparment of
Ophthalmology, Hospital of the
Dumlupinar University, DPU Central
Campus 43270, Kutahya, Turkey;
e-mail: fatihozcura@yahoo.com
389
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standardized criterion for the diagnosis, yet. Schirmer
and tear film breakup time (TBUT) tests and ocu-
lar surface stainings by using fluorescein, rose ben-
gal and lissamine green are the most preferable di-
agnostic tests. Tear interferometry, fluorophotometry,
meibography, meibometry, meniscometry, and Clifton
osmometry are the more quantitative but more expen-
sive diagnostic methods, which are not routinely used
in clinics.7,8
There are a limited number of studies about the reli-
ability and usage of the OSDI for the diagnosis of DES
in literature.6,9,10 In this study, we aimed to evaluate
the OSDI for the diagnosis of DES by using the TBUT
and Schirmer tests.
MATERIALS AND METHODS
This study was performed prospectively among the
patients admitted to the Ophthalmology Polyclinic of
the Dumlupinar University between December 2005
and April 2006. All patients gave verbal informed con-
sent after they received an explanation about the study.
Subjects
Patients 18 years or older were included in the study.
Patients diagnosed as DES before were excluded. Ad-
ditionally, patients who had any ocular surface or in-
traocular surgery before, having allergy to any agent
used including fluorescein, or having pterygium or na-
solacrimal ducts obstruction were excluded. Beside that
we did not study cases with topical ophthalmic treat-
ment other than DES due to the chance of any effect
on symptoms and/or measurements.
Ocular Surface Disease Index and
Scoring Algorithm
The OSDI is a questionnaire including 12 questions,
which are subdivided into three groups. The first group
contains questions about the ocular symptoms of DES,
the second about the ocular symptoms while watching
television or reading a book, and the third group con-
tains the questions about ocular symptoms induced by
environmental factors (Figure 1).
The OSDI questionnaire is graded on a scale from 0
to 4, where 0 indicates none of the time; 1, some of the
time; 2, half of the time; 3, most of the time; 4, all of
the time. The total score of OSDI is calculated on the
basis of the following formula: OSDI =[(sum of scores
for all questions answered) ×100] / [(total number of
questions answered) ×4].
Ophthalmologic Examination
and Measurements
Patients underwent a detailed ophthalmic examina-
tion, including uncorrected and corrected visual acu-
ity, intraocular pressure measurement with noncontact
tonometer, anterior segment and fundus examination
with a slit-lamp biomicroscope. After the routine oph-
thalmic examinations, TBUT and Schirmer tests were
performed.
Sterile strips of fluorescein were used for the TBUT
measurement. While the patients were looking upward,
the fluorescein paper was smoothly touched to the
primary right inferior fornix conjunctiva and then re-
moved. The patients were directed to blink three times,
and then look straight forward without blinking. The
tear film was observed under cobalt blue filtered light of
the slit-lamp biomicroscope, and the time that elapsed
between the last blink and appearance of the first break
in the tear film was recorded with a stopwatch. Measure-
ments were repeated three times and the mean TBUT
was calculated. These steps were also applied to the left
eye. The mean TBUT scores of the right and left eyes
were used for the statistical analysis.
Five minutes after the TBUT test, a Schirmer I test
(without anesthesia) was performed to patients for eval-
uation of basal and reflex tear secretion. In the Schirmer
I test, a 35 ×5-mm-size filter paper strip was used to
measure the amount of tears produced over a period of
5 min. The strip was placed at the junction of the mid-
dle and lateral thirds of the lower eyelid. The test was
performed under an ambient light. The patients were
directed to look forward and to blink normally during
the course of the test (5 min), and then wetting of the
filter paper in 5 min was recorded. The mean Schirmer
test scores of the right and left eyes were used for the
statistical analysis.
Study Protocol
The questionnaire of the OSDI was given to cases
during the history taking by the same physician (F ¨
O)
and the OSDI scores were calculated. After the routine
ophthalmologic examination, the TBUT and Schirmer
tests were performed by the other physician (SA). The
correlation analysis was performed between the OSDI
and TBUT and Schirmer test scores. Furthermore, the
F. ¨
Ozcura et al. 390
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FIGURE 1 Ocular surface disease index.
patients were divided into 3 groups according to the
OSDI scores. Group 1 had a low OSDI score (0–20
points), group 2 had a moderate OSDI score (21–45
points), group 3 had a high OSDI score (46–100 points),
and any significant difference between the two tests
scores in the groups was researched.
Statistical Analysis
Statistical analyses were performed with SPSS for
Windows version 11.0 (SPSS, Chicago, IL, USA). The
correlation analysis between the OSDI and TBUT and
Schirmer test scores was performed by the Pearson cor-
relation analysis. The TBUT and Schirmer tests scores of
the three groups were compared via the Mann-Whitney
Utest.
RESULTS
Fifty-four (79.4%) of patients were female and 14
(20.6%) of them were male, and their mean age was
44.25 ±11.13 (ranging 19–77) years. The mean OSDI
and TBUT and Schirmer tests’ scores were detected as
34.77 ±22.37 (ranging 0–81.82), 4.91 ±3.69 (rang-
ing 1.0–15.0) s, 13.29 ±4.89 (ranging 2.5–26.0) mm,
respectively.
There was a statistically significant inverse correlation
between the OSDI and TBUT test scores, whereas no
391 Ocular Surface Disease Index and Dry Eye Syndrome
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TABLE 1 Correlation analyses between OSDI, TBUT, and
Schirmer test scores
OSDI–TBUT OSDI–Schirmer TBUT–Schirmer
rvalue −.296 −.182 .152
pvalue .014∗.138 .217
Note. OSDI, ocular surface disease index; TBUT, tear film breakup time.
∗Statistically significant (p<.05).
significant correlation between the OSDI and Schirmer
test scores (Table 1).
While there was a statistically significant difference
between TBUT test scores of patients with low and high
OSDI scores (p=.043), there was no significant differ-
ence between Schirmer test scores of the there groups.
The mean OSDI points and demographic data of the
patients are summarized in Table 2. The mean TBUT
and Schirmer tests’ scores and significance levels of the
intergroup comparisons are given in Tables 3 and 4,
respectively.
DISCUSSION
The ocular surface, the main and accessory lacrimal
glands, and the neuronal network providing the com-
munication among them were described as a lacrimal
functional unit. The components of the functional
unit are in anatomic continuity and share feedback
mechanisms, which results in simultaneous reactions
to a single stimulus. Thus, the tear film composed
of lipid, aqueous, and mucin was released to be con-
trolled. Therefore, any disease disturbing the action of
the lacrimal functional unit may lead to DES.11
The complaints of DES are frequently encountered
in ophthalmology polyclinics, and diagnosis of the dry
eye begins with the patient history. Some diagnostic
questionnaires are provided for the evaluation of the
symptoms objectively and support the diagnosis of
DES.10 The OSDI is the best-validated recent question-
naire, including few questions and more easily applied
than most questionnaires.
TABLE 2 Mean OSDI point and demographic data of the
patients
Group 1 Group 2 Group 3
OSDI point 9.8 ±7.1 32.9 ±6.8 60.4 ±10.7
Age, years 45.5 ±10.9 43.6 ±14.1 43.6 ±7.8
Sex 18 female, 18 female, 18 female,
5 male 5 male 4 male
Note. OSDI, ocular surface disease index.
TABLE 3 Mean TBUT and Schirmer scores of the patients
TBUT (s) Schirmer (mm)
Group 1 6.0 ±4.2 13.6 ±5.1
Group 2 5.4 ±4.0 14.5 ±4.5
Group 3 3.3 ±2.0 11.7 ±4.7
Note. TBUT, tear film breakup time.
In this study, we aimed to evaluate the OSDI for
the diagnosis of DES by using the TBUT and Schirmer
tests, and detected that there was an inverse correlation
between the OSDI and TBUT test scores but no cor-
relation between the OSDI and Schirmer test scores.
Additionally, there was a statistically significant differ-
ence between TBUT test scores of patients with low and
high OSDI.
Many physicians generally perform the TBUT and
Schirmer tests and ocular surface staining pattern after
history taking for the diagnosis of DES.12 The TBUT
test demonstrating the tear film stability is the best
screening test for the dry eye disease. The TBUT test
varies among individuals and even in the same persons
at different periods of the day. In general, TBUT less
than 10 s suggests an unstable tear film. If the result of
this test is abnormal, i.e., under 5 s, there is usually some
form of ocular surface disease; most commonly dry eye
disease. TBUT is reduced in all forms of the DES.8,12 In
this study, we found that the mean TBUT (3.37 s) was
below 5 s in patients with high OSDI scores, and sta-
tistically significant differences between the TBUT test
scores of the patients with low and high OSDI scores
were detected.
Beside the reduced TBUT in all forms of the DES,
the Schirmer test provides meaningful results to show
decreased tear production as in Sjogren syndrome. Less
than 5 mm of wetting after 5 min indicates a diagno-
sis of tear deficiency.8Although the reduction of tear
production, ocular symptoms may not occur. Nichols
et al. reported that there was no correlation between
TABLE 4 The pvalues for TBUT and Schirmer changes: inter-
group comparison
TBUT Schirmer
Group 1–2 .665 .328
Group 1–3 .043* .285
Group 2–3 .131 .071
Note. TBUT, tear film breakup time. ∗Statistically significant (p<.05).
F. ¨
Ozcura et al. 392
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the symptoms and diagnostic tests in 75 patients with
DES.13 Tsubota surprisingly learned that his Schirmer
test scores of both eyes were 0 mm in a study of DES.
Since he had no any symptoms beside tiredness of eyes,
he applied this test after one day; he found the same
score again.14
As a cause of the absence of any correlation between
ocular symptoms and test scores, decreased corneal sen-
sitivity in patients with severe DES secondary to ocular
surface inflammation was shown.15 Thus, OSDI alone
is not a good descriminator of aqueous deficient dry
eye. Parallel to our results, Singh Bhinder et al. reported
that the Schirmer test results change according to reflex
epiphora, and therefore there was no correlation with
symptoms in DES. In the same study, significant cor-
relations between ocular symptoms and the TBUT test
scores were reported as in ours.16 But absence of the
Schirmer test with anesthesia may be thought as a defi-
ciency of our study. Hence, reflex epiphora developed
during the Schirmer test may be the underlying cause
of the absence of correlation between the OSDI and
Schirmer test scores in our study.
There were a limited number of studies associated
with reliability and value of the OSDI. In one of them,
Schiffman et al. studied 109 cases with DES and 30 con-
trol subjects. The scores according to answers of both of
the OSDI and other available questionnaires (McMon-
nies Dry Eye Questionnaire and National Eye Insti-
tute Visual Functioning Questionnaire- NEI VFQ-) were
compared, and a significant correlation was observed.6
Similarly, according to Nichols et al. and Vitale et al.,
there were significant correlations between the OSDI
and NEI-VFQ, too.9,10 By comparing the control group
and DES cases, Schiffman et al. found that the sensi-
tivity and specificity of OSDI were 0.60 and 0.83, re-
spectively, but there were limited correlations between
the TBUT and Schirmer tests’ scores, flourescein and
lisamin green staining, and OSDI.6It was found in our
study that there was a significant inverse correlation be-
tween the OSDI and TBUT test scores, whereas there
was no correlation between the OSDI and Schirmer test
scores.
As a conclusion, although there is no internationally
accepted criterion for the diagnosis of DES at the mo-
ment, the OSDI is a standardized instrument to eval-
uate symptoms, and can easily be performed and used
to support the diagnosis of DES.
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