Diagnosis of dry eye disease in clinical practice: comparison of TFOS international survey outcomes over a 5-year period

Michael T M Wang; Jennifer P Craig; Lyndon Jones; David A Semp; Sònia Travé-Huarte; James S Wolffsohn

doi:10.1016/j.clae.2026.102712

Diagnosis of dry eye disease in clinical practice: comparison of TFOS international survey outcomes over a 5-year period

Michael T M Wang
, Jennifer P Craig^*
, Lyndon Jones
, David A Semp
, Sònia Travé-Huarte
, James S Wolffsohn

^*Corresponding author for this work

University of Auckland
Aston University
University of Waterloo

Research output: Contribution to journal › Article › peer-review

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Abstract

PURPOSE: To describe global clinical practice patterns in diagnostic and subtype classification testing for dry eye disease, and explore evolution in practices over a 5-year period, based on responses to an open survey of international eye care practitioners.

METHODS: An anonymous online survey seeking to establish opinions and practices regarding clinical tests for the diagnosis and subtype classification of dry eye disease was developed in consultation with dry eye subspecialists, translated into 14 languages, and distributed to eye care practitioners around the world in 2018-2019 and again in 2023-2024.

RESULTS: A total of 2044 survey responses from 54 countries were received across the 2018-2019 and 2023-2024 survey periods. The battery of clinical tests most frequently cited as critical for diagnosis of dry eye disease (a median of seven tests) did not significantly differ between the two time points, and included verbal symptoms (69% versus 74%, p = 0.07), fluorescein breakup time (67% versus 68%, p = 0.90), and corneal staining (64% versus 67%, p = 0.51). The use of validated symptomology questionnaires (37 to 42%, p = 0.03) and non-invasive tear film stability (44 to 50%, p = 0.02) increased between 2018-2019 and 2023-2024 (both p < 0.05), although both of these tests were considered 'critical' by less than 50% of respondents at both time points. No single clinical test was used by more than 40% of participants to aid subtype classification, although lipid layer interferometry and meibography both became more commonly used in 2023-2024 than in 2018-2019 (both p < 0.01).

CONCLUSIONS: There was almost no agreement in the test battery for dry eye diagnosis and considerable variation and limited agreement in subclassification testing among eye care practitioners at both time points. Greater uptake of streamlined, evidence-based diagnostic algorithms may reduce perceived complexity and support more consistent diagnostic practice, but this remains to be formally tested.

Original language	English
Article number	102712
Number of pages	7
Journal	Contact Lens & Anterior Eye : The Journal of the British Contact Lens Association
Volume	49
Issue number	5
Early online date	19 Jul 2026
DOIs	https://doi.org/10.1016/j.clae.2026.102712
Publication status	E-pub ahead of print - 19 Jul 2026

Bibliographical note

Copyright © 2026 The Authors. Published by Elsevier Ltd on behalf of British Contact Lens Association. This is an open access article under the CC BY license
( https://creativecommons.org/licenses/by/4.0/ ).

Keywords

Aetiological subtype
Diagnosis
Dry eye disease
Ocular surface
Tear film

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10.1016/j.clae.2026.102712Licence: CC BY 4.0

Diagnosis of dry eye disease in clinical practice
Copyright © 2026 The Authors. Published by Elsevier Ltd on behalf of British Contact Lens Association. This is an open access article under the CC BY license ( https://creativecommons.org/licenses/by/4.0/ ).
Final published version, 558 KBLicence: CC BY 4.0

Cite this

Wang, M. T. M., Craig, J. P., Jones, L., Semp, D. A., Travé-Huarte, S., & Wolffsohn, J. S. (2026). Diagnosis of dry eye disease in clinical practice: comparison of TFOS international survey outcomes over a 5-year period. Contact Lens & Anterior Eye : The Journal of the British Contact Lens Association, 49(5), Article 102712. Advance online publication. https://doi.org/10.1016/j.clae.2026.102712

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abstract = "PURPOSE: To describe global clinical practice patterns in diagnostic and subtype classification testing for dry eye disease, and explore evolution in practices over a 5-year period, based on responses to an open survey of international eye care practitioners.METHODS: An anonymous online survey seeking to establish opinions and practices regarding clinical tests for the diagnosis and subtype classification of dry eye disease was developed in consultation with dry eye subspecialists, translated into 14 languages, and distributed to eye care practitioners around the world in 2018-2019 and again in 2023-2024.RESULTS: A total of 2044 survey responses from 54 countries were received across the 2018-2019 and 2023-2024 survey periods. The battery of clinical tests most frequently cited as critical for diagnosis of dry eye disease (a median of seven tests) did not significantly differ between the two time points, and included verbal symptoms (69\% versus 74\%, p = 0.07), fluorescein breakup time (67\% versus 68\%, p = 0.90), and corneal staining (64\% versus 67\%, p = 0.51). The use of validated symptomology questionnaires (37 to 42\%, p = 0.03) and non-invasive tear film stability (44 to 50\%, p = 0.02) increased between 2018-2019 and 2023-2024 (both p < 0.05), although both of these tests were considered 'critical' by less than 50\% of respondents at both time points. No single clinical test was used by more than 40\% of participants to aid subtype classification, although lipid layer interferometry and meibography both became more commonly used in 2023-2024 than in 2018-2019 (both p < 0.01).CONCLUSIONS: There was almost no agreement in the test battery for dry eye diagnosis and considerable variation and limited agreement in subclassification testing among eye care practitioners at both time points. Greater uptake of streamlined, evidence-based diagnostic algorithms may reduce perceived complexity and support more consistent diagnostic practice, but this remains to be formally tested.",

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author = "Wang, \{Michael T M\} and Craig, \{Jennifer P\} and Lyndon Jones and Semp, \{David A\} and S{\`o}nia Trav{\'e}-Huarte and Wolffsohn, \{James S\}",

note = "Copyright {\textcopyright} 2026 The Authors. Published by Elsevier Ltd on behalf of British Contact Lens Association. This is an open access article under the CC BY license ( https://creativecommons.org/licenses/by/4.0/ ).",

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Diagnosis of dry eye disease in clinical practice: comparison of TFOS international survey outcomes over a 5-year period. / Wang, Michael T M; Craig, Jennifer P; Jones, Lyndon et al.
In: Contact Lens & Anterior Eye : The Journal of the British Contact Lens Association, Vol. 49, No. 5, 102712, 01.10.2026.

Research output: Contribution to journal › Article › peer-review

TY - JOUR

T1 - Diagnosis of dry eye disease in clinical practice: comparison of TFOS international survey outcomes over a 5-year period

AU - Wang, Michael T M

AU - Craig, Jennifer P

AU - Jones, Lyndon

AU - Semp, David A

AU - Travé-Huarte, Sònia

AU - Wolffsohn, James S

N1 - Copyright © 2026 The Authors. Published by Elsevier Ltd on behalf of British Contact Lens Association. This is an open access article under the CC BY license ( https://creativecommons.org/licenses/by/4.0/ ).

PY - 2026/7/19

Y1 - 2026/7/19

N2 - PURPOSE: To describe global clinical practice patterns in diagnostic and subtype classification testing for dry eye disease, and explore evolution in practices over a 5-year period, based on responses to an open survey of international eye care practitioners.METHODS: An anonymous online survey seeking to establish opinions and practices regarding clinical tests for the diagnosis and subtype classification of dry eye disease was developed in consultation with dry eye subspecialists, translated into 14 languages, and distributed to eye care practitioners around the world in 2018-2019 and again in 2023-2024.RESULTS: A total of 2044 survey responses from 54 countries were received across the 2018-2019 and 2023-2024 survey periods. The battery of clinical tests most frequently cited as critical for diagnosis of dry eye disease (a median of seven tests) did not significantly differ between the two time points, and included verbal symptoms (69% versus 74%, p = 0.07), fluorescein breakup time (67% versus 68%, p = 0.90), and corneal staining (64% versus 67%, p = 0.51). The use of validated symptomology questionnaires (37 to 42%, p = 0.03) and non-invasive tear film stability (44 to 50%, p = 0.02) increased between 2018-2019 and 2023-2024 (both p < 0.05), although both of these tests were considered 'critical' by less than 50% of respondents at both time points. No single clinical test was used by more than 40% of participants to aid subtype classification, although lipid layer interferometry and meibography both became more commonly used in 2023-2024 than in 2018-2019 (both p < 0.01).CONCLUSIONS: There was almost no agreement in the test battery for dry eye diagnosis and considerable variation and limited agreement in subclassification testing among eye care practitioners at both time points. Greater uptake of streamlined, evidence-based diagnostic algorithms may reduce perceived complexity and support more consistent diagnostic practice, but this remains to be formally tested.

AB - PURPOSE: To describe global clinical practice patterns in diagnostic and subtype classification testing for dry eye disease, and explore evolution in practices over a 5-year period, based on responses to an open survey of international eye care practitioners.METHODS: An anonymous online survey seeking to establish opinions and practices regarding clinical tests for the diagnosis and subtype classification of dry eye disease was developed in consultation with dry eye subspecialists, translated into 14 languages, and distributed to eye care practitioners around the world in 2018-2019 and again in 2023-2024.RESULTS: A total of 2044 survey responses from 54 countries were received across the 2018-2019 and 2023-2024 survey periods. The battery of clinical tests most frequently cited as critical for diagnosis of dry eye disease (a median of seven tests) did not significantly differ between the two time points, and included verbal symptoms (69% versus 74%, p = 0.07), fluorescein breakup time (67% versus 68%, p = 0.90), and corneal staining (64% versus 67%, p = 0.51). The use of validated symptomology questionnaires (37 to 42%, p = 0.03) and non-invasive tear film stability (44 to 50%, p = 0.02) increased between 2018-2019 and 2023-2024 (both p < 0.05), although both of these tests were considered 'critical' by less than 50% of respondents at both time points. No single clinical test was used by more than 40% of participants to aid subtype classification, although lipid layer interferometry and meibography both became more commonly used in 2023-2024 than in 2018-2019 (both p < 0.01).CONCLUSIONS: There was almost no agreement in the test battery for dry eye diagnosis and considerable variation and limited agreement in subclassification testing among eye care practitioners at both time points. Greater uptake of streamlined, evidence-based diagnostic algorithms may reduce perceived complexity and support more consistent diagnostic practice, but this remains to be formally tested.

KW - Aetiological subtype

KW - Diagnosis

KW - Dry eye disease

KW - Ocular surface

KW - Tear film

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U2 - 10.1016/j.clae.2026.102712

DO - 10.1016/j.clae.2026.102712

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C2 - 42472535

SN - 1367-0484

VL - 49

JO - Contact Lens & Anterior Eye : The Journal of the British Contact Lens Association

JF - Contact Lens & Anterior Eye : The Journal of the British Contact Lens Association

IS - 5

M1 - 102712

ER -

Diagnosis of dry eye disease in clinical practice: comparison of TFOS international survey outcomes over a 5-year period

Abstract

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Keywords

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