Symptoms
- OSDI-6 score ≥ 4
Six questions drawn from the full OSDI. TFOS DEWS III recommends OSDI-6 as the standard screening questionnaire, and a positive screen is required: dry eye is always symptomatic.
What you needOSDI-6 questionnaire
Clinical Playbook · Dry Eye Diagnosis
Dry Eye Testing from screening to subtype, in one visit.
A clinic-ready workup built on the TFOS DEWS III Diagnostic Methodology (2025): screen symptoms, confirm a loss of homeostasis with one objective marker, then identify the drivers that decide treatment. Every step links to the test, the tool and the supplies.
≥ 4OSDI-6 screening cut-off
< 10 snon-invasive breakup time
≥ 308mOsm/L tear osmolarity
> 5corneal fluorescein spots
The diagnosis
Symptoms plus one sign confirms dry eye.
TFOS DEWS III recommends a short screening questionnaire, then at least one objective sign of lost homeostasis of the tear film or the ocular surface.
In stock on Dry Eye RescueManufacturer direct or labGuide
Tear film homeostasis
- Non-invasive breakup time < 10 s
- Osmolarity ≥ 308 mOsm/L in either eye, or > 8 mOsm/L between eyes
Non-invasive breakup time is preferred because it leaves the tear film undisturbed. Measured with fluorescein, the breakup time cut-off is < 5 s. Where no osmometer is available, tear film instability alone is sufficient.
Ocular surface staining
- > 5 corneal fluorescein spots
- > 9 conjunctival lissamine green spots
- Lid margin lissamine green ≥ 2 mm long and ≥ 25% wide
Fluorescein for the cornea, lissamine green for the conjunctiva and lid margin. The two dyes can be used together.
A positive OSDI-6 plus any one marker past its cut-off supports a diagnosis of dry eye. Then subclassify to choose treatment.
Run it in one visit, least invasive first.
Four stops, in this order, so each test leaves the tear film undisturbed for the next.
Ask
Before the exam, in the waiting room.
- OSDI-6 symptom questionnaire
Sample
Tear samples first, before the slit lamp, drops or dyes.
- Tear osmolarity
- MMP-9 when inflammation is suspected
Image
No touch, no dyes. One instrument covers it.
- Blink and lid seal
- Tear meniscus height
- Non-invasive tear breakup time
- Lipid layer
- Redness and lid alignment
Touch and stain
Hands-on and dye tests, saved for last.
- Lid margin, lashes and gland expression
- Fluorescein breakup time and staining
- Lissamine green staining
- Meibography
- Corneal sensation
Sequence adapted from the TFOS DEWS III Diagnostic Methodology report.
Time the point-of-care tests
ScoutPro and InflammaDry both need an undisturbed tear film. Collecting the osmolarity sample first and the MMP-9 sample second, right after the questionnaire and before the slit lamp exam, meets both sets of instructions.
- ScoutPro: not after staining, not within 2 hours of eye drops or topical medication, and not within 15 minutes of a slit lamp exam, anesthetic or dilating drops, other invasive testing or crying.
- InflammaDry: perform before ocular anesthetic, topical dyes or Schirmer testing. After any topical medication, wait at least 2 hours.
Subclassify
Find the drivers that decide treatment.
TFOS DEWS III subclassifies dry eye by its etiological drivers rather than a simple aqueous-deficient versus evaporative split. Most patients have more than one, and the dominant drivers guide management.
In stock on Dry Eye RescueManufacturer direct or labGuide
Lipid layer
Meibomian gland dysfunction and blink abnormalities thin the lipid layer and speed evaporation.
- Lipid layer interferometry
- Diagnostic expression at blink-level force
- Meibography
Aqueous
Lacrimal gland hypofunction reduces tear volume. Systemic autoimmune disease is a common cause.
- Tear meniscus height
- Schirmer test
Treatment pagesPunctal plugs ›
Mucin and glycocalyx
Goblet cell loss and epithelial glycocalyx damage destabilize the tear film from the surface up.
- Conjunctival lissamine green staining
Eyelid
Incomplete or infrequent blinking, poor lid seal and lid margin disease, including the eyelashes.
- Blink rate and completeness
- Lid margin and eyelash exam
- Lid margin keratinization staining
Treatment pagesXDEMVY for Demodex blepharitis ›
Ocular surface
Anatomical misalignment, surface cell damage, primary inflammation and neural dysfunction.
- Corneal and conjunctival staining
- Redness
- Point-of-care MMP-9
- Corneal sensation
Systemic
Sjögren's disease, rheumatoid arthritis, lupus and other autoimmune or endocrine conditions, plus medications.
- History and medication review
- Autoimmune testing when suspected
Stock your diagnostic bench
The point-of-care tests, dyes and strips behind the workup, on one wholesale account.
ScoutPro Osmolarity SystemView product
ScoutPro Osmolarity Test Cards (42)View product
InflammaDry MMP-9 Test (20-pack)View product
Fluorescein Sodium Ophthalmic StripsView product
Lissamine Green Ophthalmic Strips (100)View product
Schirmer Tear Test Sterile StripsView product
Meivertor Lid Eversion Starter KitView product
InflammaDry Control SetView product
Common questions about dry eye testing
What changed in TFOS DEWS III?
The definition now states that dry eye is a symptomatic disease and covers loss of homeostasis of the tear film and/or the ocular surface. Screening is standardized on the OSDI-6 with a cut-off of 4, and subclassification moves from a simple aqueous-deficient versus evaporative split to identifying each patient's etiological drivers.
What is the OSDI-6?
A six-question version of the Ocular Surface Disease Index, built from the most discriminating questions of the full OSDI. It correlates closely with the full OSDI and was found to be repeatable. A score of 4 or more is a positive screen. The full OSDI and the DEQ-5 still have a role.
Do I need an osmometer to diagnose dry eye?
No. A positive OSDI-6 plus a non-invasive breakup time under 10 seconds, or the staining criteria, is enough. Osmolarity remains a key test because hyperosmolarity is central to the disease, and it gives an objective number to follow over time.
When should I collect the osmolarity and MMP-9 samples?
Before anything that disturbs the tear film. ScoutPro tears should not be collected after staining, within 2 hours of eye drops or topical medication, or within 15 minutes of a slit lamp exam, anesthetic or dilating drops, other invasive testing or crying. InflammaDry should be performed before ocular anesthetic, topical dyes or Schirmer testing. Collecting the osmolarity sample first and the MMP-9 sample second, right after the questionnaire, meets both sets of instructions.
Where does MMP-9 testing fit?
InflammaDry detects elevated MMP-9 in tears to aid the diagnosis of dry eye in conjunction with other clinical evaluation. It speaks to the inflammatory component. Systemic immunomodulators, topical or oral steroids, cyclosporine, tetracycline and topical azithromycin inhibit metalloproteinase activity and may cause false negatives.
What conditions can masquerade as dry eye?
Allergic conjunctivitis, ocular surface infection, exposure keratopathy, thyroid eye disease, ocular graft-versus-host disease, contact lens problems, conjunctivochalasis, epithelial basement membrane dystrophy and neurotrophic keratopathy. These can also coexist with dry eye, so a full history and exam come first.
Which risk factors should I ask about?
Age and sex, low humidity and airflow, screen time and digital device use, systemic disease such as autoimmune and endocrine conditions, topical and systemic medications, contact lens wear, ocular surgery, smoking and diet.
Which of these can I order through Dry Eye Rescue?
ScoutPro and its test cards, InflammaDry, fluorescein, lissamine green, rose bengal and Schirmer strips, and the Meivertor lid everter are on the wholesale platform. The Keratograph 5M, LipiScan and LipiView II and the Brill esthesiometer are ordered from the manufacturer, and the Sjö panel is a lab send-out.
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
Build a diagnostic bench that answers at the chair.
Start with osmolarity, MMP-9 and the vital dyes, then add imaging as dry eye volume grows.
This page summarizes published diagnostic guidance for eye care professionals and does not replace clinical judgment. Product names are trademarks of their respective manufacturers. Review each manufacturer's instructions for use before use.
