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Classifying signs and symptoms of dry eye disease according to underlying mechanism via the Delphi method: the DIDACTIC study
  1. Marc Labetoulle1,2,
  2. Tristan Bourcier3,4,
  3. Serge Doan5,6
  4. The DIDACTIC group
    1. 1 Department of Ophthalmology, APHP, South Paris University, Le Kremlin-Bicêtre, France
    2. 2 Center for Immunology of Viral infections and Autoimmune diseases (IMVA), IDMIT Infrastructure CEA, Université Paris Sud, Fontenay-aux-Roses Cedex, France
    3. 3 Department of Ophthalmology, New Civil Hospital, Strasbourg University Hospital, Strasbourg, France
    4. 4 Fédération de Médecine Translationnelle de Strasbourg, Strasbourg, France
    5. 5 Department of Ophthalmology, APHP—Bichat-Claude-Bernard Hospital, Paris, France
    6. 6 Ophthalmological Foundation Adolphe de Rothschild, Paris, France
    1. Correspondence to Professor Marc Labetoulle, Service d'Ophtalmologie, AP-HP, 78, rue du Général Leclerc, Le Kremlin-Bicêtre cedex 94725, France; marc.labetoulle{at}


    Background/aims Dry eye disease (DED) is categorised by pathophysiology as aqueous deficient dry eye (ADDE), evaporative dry eye (EDE) or mixed. Treatment should be tailored to DED pathophysiology, but this is challenging to determine. This Delphi consultation aimed to categorise and weight signs and symptoms to help identify the evaporative or aqueous deficient DED origin.

    Methods A panel of French DED experts created an initial list of 77 DED signs and symptoms. In a Delphi consultation, experts categorised items by DED pathophysiology. Likert scoring was used to indicate whether items were strongly or moderately indicative of ADDE or EDE. Items could also be judged non-applicable to DED, with the opportunity to suggest alternative diagnoses.

    Results Experts attributed 19 items (of which 11 were strongly indicative) to a pathophysiology of EDE and 12 items (of which four were strongly indicative) to ADDE. Items scored strongly indicative with agreement >90% for EDE were previous chalazia, rosacea/rhinophyma, telangiectasias of eyelid margin and thick non-expressible meibomian gland secretions, and for ADDE were Sjögren syndrome or associated disease, and Schirmer <5 mm after 5 min (without anaesthesia). Seventeen items indicated neither pathophysiology and 18 items were found to be suggestive of alternative diagnoses.

    Conclusions This Delphi consultation categorised signs and symptoms, using an innovative weighting system to identify DED pathophysiology. An algorithm integrating the weighting of each sign and symptom of an individual patient would be valuable to help general ophthalmologists to classify the DED subtype and tailor treatment to DED underlying mechanism.

    • ADDE
    • delphi
    • dry eye disease
    • mechanism
    • EDE
    • lacrimal deficiency
    • pathophysiology
    • signs
    • symptoms
    • tears
    • Sjögren

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    • Collaborators Christophe Baudouin; Diane Bernheim; Nicolas Bonnin; TB; Emmanuelle Brasnu de Cenival; Dominique Brémond-Gignac; Frédéric Chiambaretta; Véronique Cloché; Catherine Creuzot-Garcher; Vincent Daïen; Bernard Delbosc; Marie Delfour-Malecaze; Alexandre Denoyer; SD; Brigitte Girard; Philippe Gohier; Louis Hoffart; Antoine Labbé; ML; Jacques Lagier; Florence Malet; Nicolas Mesplié; Bruno Mortemousque; Frédéric Mouriaux; Marc Muraine; Isabelle Orignac; Philippe Partouche; Pierre-Jean Pisella; Alain Retout; Pierre-Yves Robert; Antoine Rousseau; Eric Sarfati; Sophie Stephan; David Touboul; Patricia Wagrez.

    • Contributors ML has participated in the design of the study, the Delphi procedure, the data analysis, the redaction of the manuscript and the revision process. TB has participated in the Delphi procedure, the data analysis, the redaction of the manuscript and the revision process. SD has participated in the design of the study, the Delphi procedure, the data analysis, the redaction of the manuscript and the revision process. All members of the DIDACTIC study group have participated in the Delphi procedure, the data analysis and the conception of the manuscript.

    • Funding The Delphi process was conceived by ML and was sponsored and funded by Novartis France. Correspondence with ophthalmologists, organisation of meetings and collection of data were performed by Margaux Orange, France. Paid assistance for manuscript editing was funded by Novartis France and was provided by Dr Fiona Dunlevy and Matrix Consultants.

    • Disclaimer The authors were involved in the entire process, from design to critical revision of the manuscript, and maintained complete control over the direction and content of the paper. Novartis did not have any influence on the manuscript content.

    • Competing interests SD has acted as an occasional consultant for Alcon-Novartis, Allergan, Bausch & Lomb, Horus, Santen and Thea. ML has acted as an occasional consultant for Alcon, Allergan, Bausch & Lomb, Dompe, MSD, Novartis, Santen, Shire and Thea. TB has acted as an occasional consultant for Allergan, Dompe, Horus, Johnson & Johnson, Novartis, Santen, Shire and Thea.

    • Patient consent for publication Not required.

    • Ethics approval Ethics approval was unnecessary since no patient data were used.

    • Provenance and peer review Not commissioned; externally peer reviewed.

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