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67 Copyright 2018 ASCRS Ophthalmic Corporation. All rights reserved. The views expressed here do not necessarily reflect those of the editor, editorial board, or the publisher, and in no way imply endorsement by EyeWorld or ASCRS. Taking a diagnostic approach to dysfunctional tear syndrome The CEDARS algorithm stresses that while these are distinct categories, they frequently overlap. You should aim to identify a specific category and target your treatment for that, with the understand- ing that you may be treating more than one category. The first four categories are self-explanatory. The co-conspirators cate- gory refers to pathologies that exacerbate or masquerade as DTS, such as superior limbic keratoconjunctivitis (SLK); medica- mentosa (topical medication toxicity); superficial punctate keratitis of Thygeson; mucous fishing syndrome; contact lens-re- by Kenneth Beckman, MD lated toxicity; chemical toxicity, such as hairspray toxicity often seen in hairdress- ers; allergic/atopic conjunctivitis; conjunc- tivochalasis; and floppy eyelid syndrome. Most of us are familiar with DTS testing methods such as the Tear Osmolar- ity System (TearLab, San Diego), MMP-9 (InflammaDry, Quidel, San Diego), lipid layer analysis and meibography (LipiView, Johnson & Johnson Vision, Santa Ana, California), and Sjögren's test (Sjö, Bausch + Lomb, Bridgewater, New Jersey). Of course, there are also traditional methods such as slit lamp examination of the tear meniscus and meibomian gland function, as well as utilizing corneal and conjunctival staining. The CEDARS algorithm utilizes the information provided by these tests and evaluations to guide treatment. For instance, in tear osmolarity testing anything under about 300 mOsm/L is considered normal. The CEDARS algorithm ventures beyond the normal/abnormal classifications; anything in the 300–320 mOsm/L range is considered mild, 320–340 mOsm/L is moderate, and greater than 340 mOsm/L is severe. In addition, the difference of 8 mOsm/L or more between the eyes is abnormal. That is why it's imperative to check both eyes when you do osmolarity testing. The CEDARS diagnosis tree (Figure 1) is quite useful in honing in on a treatment plan. For instance, with decreased tear pro- duction on Schirmer's test, decreased tear lake, and keratoconjunctivitis sicca pattern staining with fluorescein, rose bengal, or lissamine green, treat for tear deficiency; rapid TBUT, conjunctival scarring, and goblet cell deficiency, treat for goblet cell/ mucin deficiency; anterior blepharitis, pos- terior blepharitis, and lid erythema/debris, treat for blepharitis/MGD; lagophthalmos, poor or partial blink, lid function problems, treat for exposure keratopathy. In the case of goblet cell disease, rapid TBUT—partic- ularly in the absence of lid margin disease and presence of conjunctival staining— could be useful, as not all evaporative dry eye is related to lid margin disease. Conclusion Use testing to arrive upon a diagnosis, then use the diagnosis to guide your treat- ment plan. Keep in mind that you may have more than one diagnosis—they can overlap—and that you should treat the co-existing pathologies in a logical stepwise approach. Reference 1. Milner MS, et al. Dysfunctional tear syndrome: dry eye disease and associated tear film disorders – new strategies for diagnosis and treatment. Current Opin Ophthalmol. 2017;27 Suppl 1:3–47. Editors' note: Dr. Beckman is director of corneal services, Comprehensive EyeCare of Central Ohio, Westerville, Ohio, and clinical assistant professor of ophthalmology, Ohio State University, Columbus. He has financial interests with Allergan, Bausch + Lomb, Shire, Alcon, TearLab, Sun, Ocular Science, Avedro, Omeros, EyeVance, Kala, iCare, Calhoun, RPS, EyeXpress, Bruder, Zeiss, Refocus, Eye Point, Mallinckrodt, and Percept Corp. He can be contacted at Kenbeckman22@aol.com. A s the inci- dence of ocular surface disease (OSD) continues to rise, the array of preopera- tive tests aimed at identifying the type and extent of OSD is growing as well. Judicious use of these preoperative tests is integral to the CEDARS Dysfunctional Tear Syndrome Algorithm, a practical approach to targeting treatment for OSD that Mark Milner, MD, Jodi Luchs, MD, and I developed on behalf of the Cornea, External Disease, and Refractive Society (CEDARS) Dysfunctional Tear Syn- drome Panel. 1 The foundation for the CEDARS al- gorithm is the separation of dysfunctional tear syndrome (DTS) into five diagnostic categories. Treatment is based on which category—or categories—best represents the patient's pathology. 1. Aqueous deficiency 2. Evaporative dry eye based on goblet cell/ mucin deficiency 3. Blepharitis/meibomian gland dysfunc- tion (evaporative and non-evaporative) 4. Exposure keratopathy 5. Co-conspirators Case study with Kenneth Beckman, MD T his case supports the critical need to take a careful patient history. A 65-year-old female presented complaining of dry eyes. Her regimen included antihistamines and antidepressants, and she had previously had blepharoplasty. Exam revealed excellent vision bilaterally, and Schirmer test results measuring basal and reflex tearing were 2 OD and 3 OS after 5 minutes, without anesthesia. The patient had significant MGD with toothpaste-like secretions (Figure 1), and 2 mm of lagophthalmos reflective of earlier blepharoplasty. She had moderate staining with rose bengal consis- tent with keratoconjunctivitis sicca, and a tear breakup time of 7 OD and 8 OS, signi- fying an evaporative component. Techni- cally, this TBUT would be considered low, although in cold climates such as Ohio, where I practice, low TBUT is pervasive. The patient was treated with cyc- losporine drops b.i.d. (to help with tear production and inflammation), warm compresses, oral omega-3 supplements, and erythromycin ointment (to help with lid margin disease and with expo- sure). She noted significant improve- ment within a few weeks. Before OSD treatment • VA: 20/20 OU • Schirmer: 2 OD; 3 OS after 5 minutes without anesthesia • Lids: • 2+ MGD with "toothpaste-like secretions" • 2 mm of lagophthalmos OU • Conjunctiva: moderate rose bengal staining consistent with keratocon- junctivitis sicca • Cornea: no fluorescein staining • TBUT: 7 seconds OD; 8 seconds OS After OSD treatment • VA: 20/20 OU • Lids: • Improved secretions • Conjunctiva: Staining resolved • Cornea: Still no staining • TBUT: 9 seconds OD; 9 seconds OS Figure 1: An example of a patient with MGD with toothpast-like secretions Source: Sam Garg, MD Figure 1. The CEDARS diagnostic tree offers a practical path from diagnosis to treatment plan. 1. Decreased Schirmer 2. Decreased tear lake 3. Keratoconjunctivitis sicca rose bengal staining Tear deficiency 1. Rapid TBUT 2. Conjunctival scarring 3. Goblet cell deficiency Goblet cell/ mucin deficiency 1. Anterior blepharitis 2. Posterior blepharitis 3. Lid erythema/debris Blepharitis/ MGD 1. Lagophthalmos 2. Poor or partial blink 3. Lid function Exposure keratopathy

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