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Modification of the tear function index and its use in the diagnosis of Sjögren's syndrome
  1. Stephen B Kayea,
  2. Gillian Simsa,
  3. Colin Willoughbya,
  4. Anne E Fieldb,
  5. Lesley Longmanb,
  6. Malcolm C Brownc
  1. aSt Paul's Eye Unit, Royal Liverpool University Hospital, Prescot Street, Liverpool L12 2AP, UK, bDepartment of Oral Medicine, cDepartment of Clinical Engineering
  1. Mr S B Kayesuzannelee{at}


BACKGROUND The tear function index (TFI) has been shown to be of value in the diagnosis of patients suffering from Sjögren's syndrome. It is dependent, however, on introducing into the conjunctival fornix the correct concentration of fluorescein in at least one and a half times the normal tear volume. The stimulus and effect of this added volume on the tear dynamics is likely to vary between individuals. These factors, together with the method of performing the test, limit its general applicability.

AIM To devise a method of performing the TFI with less variability and more general applicability. To present a theoretical and in vitro assessment of the dynamics of the TFI.

METHOD The study was divided into three parts. The first part was to compare the results obtained using a prepared strip containing 1.3 μl of 0.5% fluorescein with the introduction of the same amount of fluorescein as a drop. The second part was to compare the results obtained with prepared strips with the standard method of performing the TFI, both with and without topical anaesthetic. The third part was an in vitro study of the rate of flow of graded volumes on a filter paper strip. 42 subjects with a diagnosis of Sjögren's syndrome according to the European criteria and 126 without Sjögren's syndrome were included.

RESULTS There was no significant difference between the results obtained with a prepared strip and the introduction of 1.3 μl into the eye before performing the Schirmer's test and TFI (0.1<p<0.93). There was, likewise, no significant difference between using the prepared strips and the standard method of performing the TFI (0.36<p<0.93). There was, however, less interocular difference (p=0.01) and variability (p=0.001) using the prepared strips than using a drop of fluorescein. Patients with Sjögren's syndrome had mean TFIs of 11.7 and 8.61 with upper 95% confidence values of 15 and 12 without and with topical anaesthetic, respectively. The theoretical calculation of the TFI was similar to the observed values. The in vitro results allow the filter paper to be removed from the eye at any interval and to estimate the volume of tears that the filter paper was in contact with.

CONCLUSION The proposed method of performing the TFI is easy to perform, reliable, and therefore has general applicability for primary care and general practitioners. It allows the rapid identification of subjects who may be suffering from Sjögren's syndrome.

  • tear function index
  • Sjögren's syndrome
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