The Importance of Staging Dry Eye Disease

The Importance of Staging Dry Eye Disease

Gary N. Foulks, MD, FACS

Dry Eye Column:

Staging dry eye disease is based on the presence or absence of signs and symptoms, as well as on their frequency and severity.

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Staging dry eye disease is based on the presence or absence of signs and symptoms, as well as on their frequency and severity. The consensus on staging that exists today grew out of the work of a Delphi Panel that was subsequently incorporated in the 2007 Report of the International Dry Eye WorkShop (DEWS).1,2 That staging paradigm has since become the primary reference for staging the disease and selecting therapeutic interventions. However, prior to these groundbreaking consensus documents, early dry eye experts, such as R. Linsy Farris, MD, had recommended a stepwise approach to managing dry eye, paying close attention to disease severity and the patient’s response to therapy.

Working with a consensus document enables comparison of treatment options (whereas before, many studies used terms like “mild,” “moderate,” and “severe” to describe disease stages, without universally accepted definitions of the terms). Additionally, consensus on severity levels provides a clearer path toward appropriate treatment choices for clinicians.

Understanding the Grading Scheme

Today’s accepted dry eye grading scheme has four levels of severity (Figure 1). Within the staging criteria, there are two symptom categories: discomfort and visual impairment. Traditionally, discomfort was thought of as the primary symptom of dry eye disease, but in the last decade it became increasingly clear that interference with visual performance is also characteristic of dry eye disease.

Signs also play a significant role in staging severity. While there are several signs taken into account, they all fall under the products of decreased tear function or damage to the ocular surface.

Once dry eye disease severity level has been identified, it can be used to identify appropriate treatment recommendations (Figure 2). These recommendations build upon one another. That is, recommendations from Level 1, for example, are appropriate in all higher levels as well.