title: Dysfunctional tear syndrome: a Delphi approach to treatment recommendations.
abstract: OBJECTIVE
  To develop current treatment recommendations for dry eye disease from consensus of expert advice.
  
  
  METHODS
  Of 25 preselected international specialists on dry eye, 17 agreed to participate in a modified, 2-round Delphi panel approach. Based on available literature and standards of care, a survey was presented to each panelist. A two-thirds majority was used for consensus building from responses obtained. Treatment algorithms were created. Treatment recommendations for different types and severity levels of dry eye disease were the main outcome.
  
  
  RESULTS
  A new term for dry eye disease was proposed: dysfunctional tear syndrome (DTS). Treatment recommendations were based primarily on patient symptoms and signs. Available diagnostic tests were considered of secondary importance in guiding therapy. Development of algorithms was based on the presence or absence of lid margin disease and disturbances of tear distribution and clearance. Disease severity was considered the most important factor for treatment decision-making and was categorized into 4 levels. Severity was assessed on the basis of tear substitute requirements, symptoms of ocular discomfort, and visual disturbance. Clinical signs present in lids, tear film, conjunctiva, and cornea were also used for categorization of severity. Consensus was reached on treatment algorithms for DTS with and without concurrent lid disease.
  
  
  CONCLUSIONS
  Panelist opinion relied on symptoms and signs (not tests) for selection of treatment strategies. Therapy is chosen to match disease severity and presence versus absence of lid margin disease or tear distribution and clearance disturbances.
authors.affiliation: Wilmer Ophthalmological Institute, Johns Hopkins University School of Medicine, Baltimore, MD 21287-9278, USA. abehrens@jhmi.edu
authors.forename: Ashley
authors.initials: A
authors.lastname: Behrens
authors.forename: John J
authors.initials: JJ
authors.lastname: Doyle
authors.forename: Lee
authors.initials: L
authors.lastname: Stern
authors.forename: Roy S
authors.initials: RS
authors.lastname: Chuck
authors.forename: Peter J
authors.initials: PJ
authors.lastname: McDonnell
authors.forename: Dimitri T
authors.initials: DT
authors.lastname: Azar
authors.forename: Harminder S
authors.initials: HS
authors.lastname: Dua
authors.forename: Milton
authors.initials: M
authors.lastname: Hom
authors.forename: Paul M
authors.initials: PM
authors.lastname: Karpecki
authors.forename: Peter R
authors.initials: PR
authors.lastname: Laibson
authors.forename: Michael A
authors.initials: MA
authors.lastname: Lemp
authors.forename: David M
authors.initials: DM
authors.lastname: Meisler
authors.forename: Juan Murube
authors.initials: JM
authors.lastname: Del Castillo
authors.forename: Terrence P
authors.initials: TP
authors.lastname: O'Brien
authors.forename: Stephen C
authors.initials: SC
authors.lastname: Pflugfelder
authors.forename: Maurizio
authors.initials: M
authors.lastname: Rolando
authors.forename: Oliver D
authors.initials: OD
authors.lastname: Schein
authors.forename: Berthold
authors.initials: B
authors.lastname: Seitz
authors.forename: Scheffer C
authors.initials: SC
authors.lastname: Tseng
authors.forename: Gysbert
authors.initials: G
authors.lastname: van Setten
authors.forename: Steven E
authors.initials: SE
authors.lastname: Wilson
authors.forename: Samuel C
authors.initials: SC
authors.lastname: Yiu
mesh_terms: D000465:Algorithms; D003697:Delphi Technique; D003941:Diagnostic Techniques, Ophthalmological; D015352:Dry Eye Syndromes / Q000145:classification / Q000175:diagnosis / Q000378:metabolism / Q000628:therapy*; D006801:Humans; D017410:Practice Guidelines as Topic; D013666:Tears / Q000378:metabolism*; D009626:Terminology as Topic