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Dysfunctional Tear Syndrome (DTS)

A new term for dry eye disease, originally proposed by a Delphi panel chaired by Peter McDonnell MD in April 2003.

DTS is finally gaining some momentum after a slow start. The September 2006 issue of Cornea included the latest installment from the Delphi panel discussing new treatment guidelines for DTS, and the April 2007 issue has a report from two leading specialists evaluating how those treatment recommendations have panned out in practice when used consistently.


"Dry eye" is a grossly inaccurate and misleading term. That is established fact and well accepted by the medical community, at least in theory. However, not all professionals agree on whether it should be renamed and if so whether DTS is the right name.

The original Delphi panel argued in favor of the term on the basis of, among other things, the following considerations:

- Not all dry eye patients actually have dry eyes, as opposed to lid margin disease, unstable tear film, etc.
- Continuing to use the term "dry eye" could "misdirect clinicians into thinking erroneously about its underlying cause, techniques for diagnosis, and proper treatment."
- The term DTS could help doctors and patients communicate better.

However, DTS also has its detractors. The September 2006 issue of Cornea included an editorial by three leading corneal specialists who argued that:

- The term "dry eye" is well recognized by both the profession and the public;
- Even if it's a misnomer in some sense, well, so is the word "stroke" which refers to three different types of events; and
- Donations to dry eye research would probably drop because of confusion if the term "dry eye" were no longer used;
- Trying to be precise is a good idea but not if it comes at the cost of confusing people.

My thoughts?


I don't know about you, but I have never heard of a stroke patient complaining that the word "stroke" fails to convey the seriousness of what happened to them. I also think it's not common practice for physicians to write in their chart "Patient complained of having a stroke". I also have to kind of stretch my imagination pretty far to understand why replacing a dumb, inaccurate, innocuous sounding disease name with a meaningful, accurate, serious sounding disease name would have a negative impact on contributions to or interest in research.


Purpose: The term dry eye is too simplistic and does not reflect the pathology, clinical features or prognosis of the condition. It is a symptom as well as a diagnosis. Our purpose was to rationalise the nomenclature and classification of Dry eye disease.

Method: Review of the literature and report of the Delphi panel on dry eye, meeting held at Baltimore, USA in April 2003 (chairman Dr. Peter J McDonnell MD).

Results: The term Dysfunctional tear syndrome (DTS) was felt to be more accurate and proposed as an alternative to 'Dry eye'. The current classifications are varied and the divisions within them often overlapping. The NIH classification into 'evaporative' and 'Tear deficient' was proposed over 10 years age and does not take into account any underlying inflammatory pathology. Etiological classification systems are extensive, elaborate and cumbersome for routine clinical usage. A more rational classification system is proposed: 1. DTS without associated lid margin disease 2. DTS with associated lid margin disease and 3. DTS with disturbance of distribution of tears. To guide treatment, it is imperative to further divide DTS within each class, in to levels of severity. Severity levels are determined primarily on the symptoms and clinical features. Each symptom and clinical feature is scored and four levels of severity determined. Treatment can be progressively tailored to match severity.

Conclusions: The new proposed nomenclature 'Dysfunctional Tear Syndrome' takes into account the diversity in etiology and presentation within 'Dry eye disease' and the classification incorporates all recent knowledge on the disease. Together they present a practical, clinical approach to documentation, diagnosis and treatment of the condition.


Dysfunctional Tear Syndrome: A Delphi Approach to Treatment Recommendations. Behrens, Ashley MD et al, Cornea Vol 25(8) Sept 2006 pp 900-907. Click here for abstract.

Agreement of physician treatment practices with the international task force guidelines for diagnosis and treatment of dry eye disease. Wilson SE, Stulting RD, Cornea 2007 Apr;26(3):284-9. Click here for abstract.


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