Symptoms
- OSDI-6 score ≥ 4
The OSDI-6 keeps six of the original OSDI questions and is the screening questionnaire TFOS DEWS III recommends. Dry eye is always symptomatic, so a positive screen comes first.
ToolsOSDI-6 questionnaire
Learn · Dry eye diagnostics
Dry Eye Diagnostics Screen, confirm and subtype at one visit.
A practical workup that follows the TFOS DEWS III Diagnostic Methodology (2025). Screen for symptoms, confirm lost homeostasis with a single objective sign, then pin down the drivers that shape treatment. Each step points to the test, the instrument and the supplies.
≥ 4OSDI-6 positive screen
< 10 snon-invasive tear breakup time
≥ 308mOsm/L osmolarity in either eye
> 5corneal fluorescein spots
Making the diagnosis
A positive screen and one objective sign.
TFOS DEWS III calls for a brief symptom questionnaire followed by at least one objective sign that tear film or ocular surface homeostasis has been lost.
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Tear film stability and osmolarity
- NIBUT under 10 s
- Osmolarity of 308 mOsm/L or more in either eye, or more than 8 mOsm/L between eyes
The non-invasive method is preferred because it does not disturb the tear film. With fluorescein, the breakup time cut-off drops to < 5 s. If no osmometer is on hand, an unstable tear film is enough on its own.
Surface staining
- More than 5 fluorescein spots on the cornea
- More than 9 lissamine green spots on the conjunctiva
- Lissamine green on the lid margin at least 2 mm long and 25% wide
Use fluorescein for the cornea and lissamine green for the conjunctiva and lid margin. Both dyes can go on together.
A positive OSDI-6 together with any single marker beyond its cut-off supports a dry eye diagnosis. Next, subclassify to guide treatment.
One visit, from least to most invasive.
Four stations in this order, so no test disturbs the tear film before the next one runs.
Ask
In the waiting room, before the exam starts.
- Six-question OSDI-6
Sample
Collect tears before the slit lamp, any drops or any dyes.
- Tear osmolarity
- MMP-9 if inflammation is suspected
Image
Non-contact and dye-free, on a single platform.
- Blink quality and completeness
- Tear meniscus height
- Non-invasive tear breakup time
- Interferometry of the lipid layer
- Bulbar redness
Touch and stain
Contact and dye tests come last.
- Gland expression plus a lid margin and lash exam
- Fluorescein staining and breakup time
- Lissamine green staining
- Gland imaging (meibography)
- Corneal sensitivity
Order based on the TFOS DEWS III Diagnostic Methodology report.
Sequence the point-of-care tests
Both ScoutPro and InflammaDry need a tear film nobody has touched. Taking the osmolarity sample first and the MMP-9 sample second, straight after the questionnaire and before the slit lamp, satisfies both sets of instructions.
- ScoutPro: allow 2 hours after eye drops or topical medication and 15 minutes after a slit lamp exam, anesthetic, dilating drops, other invasive testing or crying, and never sample after staining.
- InflammaDry: test ahead of any anesthetic, dye or Schirmer strip, and allow at least 2 hours after topical medication.
Subclassify
Identify the drivers behind each case.
Rather than splitting dry eye into aqueous-deficient and evaporative, TFOS DEWS III classifies it by etiological driver. Most patients have several, and the dominant ones steer management.
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Lipid layer
Meibomian gland dysfunction and abnormal blinking thin the lipid layer and increase evaporation.
- Interferometry of the lipid layer
- Expression at blink-level force
- Gland imaging (meibography)
Aqueous
Reduced lacrimal gland output lowers tear volume, often because of systemic autoimmune disease.
- Tear meniscus height
- Schirmer test
Mucin and glycocalyx
Loss of goblet cells and damage to the epithelial glycocalyx destabilize the tear film at the surface.
- Lissamine green staining of the conjunctiva
Eyelid
Incomplete or infrequent blinks, a poor lid seal, and lid margin or eyelash disease.
- Completeness and rate of blinking
- Exam of the lid margin and lashes
- Keratinization staining of the lid margin
Ocular surface
Lid and globe misalignment, epithelial damage, primary inflammation and nerve dysfunction.
- Staining of the cornea and conjunctiva
- Bulbar redness
- MMP-9 at the point of care
- Corneal sensitivity
Systemic
Autoimmune and endocrine disease, including Sjögren's disease, rheumatoid arthritis and lupus, as well as medications.
- Medical history and medication review
- Autoimmune testing when indicated
Sjö panel
Stock the supplies
The point-of-care tests, dyes and strips this workup relies on, all from your Vision Rescue account.
Questions doctors ask about dry eye testing
What is different in TFOS DEWS III?
Dry eye is now defined as a symptomatic disease involving lost homeostasis of the tear film, the ocular surface or both. The OSDI-6 with a cut-off of 4 becomes the standard screen, and subclassification looks for each patient's etiological drivers instead of an aqueous-deficient versus evaporative split.
What is the OSDI-6?
A shortened Ocular Surface Disease Index made of the six questions that best separate dry eye from normal. It tracks the full OSDI closely and proved repeatable. A score of 4 or higher counts as a positive screen, and the full OSDI and DEQ-5 remain useful.
Is an osmometer required for the diagnosis?
No. A positive OSDI-6 with a non-invasive breakup time below 10 seconds, or the staining criteria, is sufficient. Osmolarity is still valuable because hyperosmolarity sits at the core of the disease, and it gives you a number to track over time.
When should the osmolarity and MMP-9 samples be taken?
Sample before anything touches the tear film. For ScoutPro, allow 2 hours after drops or topical medication and 15 minutes after a slit lamp exam, anesthetic, dilating drops, invasive testing or crying, and never sample after staining. InflammaDry goes ahead of anesthetic, dyes or Schirmer strips. Osmolarity first and MMP-9 second, straight after the questionnaire, works for both.
How does MMP-9 testing help?
InflammaDry detects elevated MMP-9 in tears and aids the diagnosis of dry eye alongside other clinical findings, adding information about inflammation. Topical or oral steroids, systemic immunomodulators, cyclosporine, tetracycline and topical azithromycin all suppress metalloproteinase activity and may lead to a false negative.
Which conditions can look like dry eye?
Thyroid eye disease, exposure keratopathy, allergic conjunctivitis, surface infection, ocular GVHD, contact lens complications, conjunctivochalasis, basement membrane dystrophy and neurotrophic keratopathy can all mimic dry eye. Because they can also occur alongside it, begin with a careful history and exam.
What risk factors belong in the history?
Age and sex, dry or drafty environments, screen and device use, autoimmune and endocrine disease, topical and systemic medications, contact lens wear, previous eye surgery, smoking and diet.
What can I order from Vision Rescue?
ScoutPro and its test cards, InflammaDry and its control set, fluorescein, lissamine green and Schirmer strips, the Meibomian Gland Evaluator and the Meivertor lid everter are on your wholesale account. IDRA, LipiScan and LipiView II and the Brill esthesiometer come directly from their manufacturers, and a lab processes the Sjö panel.
References
- Wolffsohn JS, et al. TFOS DEWS III: Diagnostic Methodology. Am J Ophthalmol. 2025;279:387-450. PubMed
- Jones L, et al. TFOS DEWS III: Management and Therapy. Am J Ophthalmol. 2025;279:289-386. PubMed
- Pult H, Wolffsohn JS. The development and evaluation of the new Ocular Surface Disease Index-6. Ocul Surf. 2019;17(4):817-821. PubMed
Get answers at the chair, not after the visit.
Begin with osmolarity, MMP-9 and the vital dyes, then add imaging as your dry eye patient base expands.
An educational summary of published diagnostic guidance for eye care professionals. It does not replace clinical judgment. Product names are trademarks of their respective manufacturers. Follow each manufacturer's instructions for use, including all warnings, precautions and contraindications.