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The Schirmer test is to measure tear volume production. Lacrimal glands produce tear-located at the upper outer corner of your eyes. For your eyes to feel comfortable, you need sufficient tear plus tear quality.

How Schirmer’s Test Works for Diagnosis of Dry Eye Disease

To measure tear volume, the primary test for dry eyes is Schirmer’s Test. Schirmer’s test is performed by putting a topical anesthetic and then placing a thin filter paper in the inferior cul-de-sac. Soft tissue paper can wick up all liquid by capillary attraction before placing the paper strip. The patients’ eyes are then closed for 5 minutes, and the amount of wetting in the paper strip is measured. Less than 5 mm of wetting is abnormal; 5-10 mm is normal.

.The Schirmer I test, without anesthetics, measures both basic and reflex tearing; less than 10 mm of wetting after 5 minutes is diagnostic of dry eyes.

The Schirmer II test, which measures reflex tearing, may be done if the initial Schirmer test yields abnormal results. It is essentially similar to the basic secretion test but with the addition of nasal mucosal irritation induced with a cotton tip applicator. Wetting of less than 15 mm after 5 minutes is consistent with abnormalities of reflex secretion.

The absence of nasal lacrimal reflex tearing, presence of serum autoantibodies, and severe ocular surface disease demonstrated by rose bengal or fluorescein staining argue strongly in favor of a diagnosis of Sjogren’s Syndrome-associated dry eye disease.

Most eye doctors prefer modifying the Schirmer I test to measure basal tear secretion with an anesthetic.

Schirmer’s Test With or Without Anesthetics

The Schirmer test has its place in clinical care. One of its strengths, aside from being the key discriminating factor between the aqueous-deficient and evaporative dry eye. It can gain insight into some knowledge about the function of a patient’s lacrimal glands.

To anesthetize or not to anesthetize? Some argue that an anesthetic is required to prevent reflex tearing; others contend that the capacity to measure reflex tears. The right approach, though, may vary depending on the person. If you want to know if the lacrimal glands can produce aqueous tears as a means to differentiate among dry eye subtypes, then Schirmer without anesthesia would be preferred. If you want to reduce reflex tearing and measure basal tear production, Schirmer with anesthesia may be preferable. Basal tear production is stimulated by the activation of cold fibers on the ocular surface as tears evaporate from the eye. Basal tear production is affected when one has suppressed sensory fibers.

Schirmer’s Test – Open or Closed Eyes?

Should Schirmer’s test be done with open or closed eyes? How to do Schirmer’s test depends on the differences in interpretation. Suppose the eyes are open (with regular blinking) for the patient to casually look at a large 20/400 target. In that case, there will be more reflex tearing, which may be your intent. The ocular surface will also be exposed and could theoretically stimulate some desired basal tear production. If the eyes are closed, however, basal and reflex production would be decreased. The test then becomes more of a measure of tear volume on the ocular surface than a measure of tear production.

Most eye doctors opt to perform Schirmer without anesthesia (to assess tear production capacity). Doing Schirmer’s test with a closed eyelid is preferred.

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