Ophth - Schirmer

(Schirmer Tear Test Strips)
Standardized Sterile Strips
for the Schirmer Tear Test

Suggested procedure for the Standardized Schirmer I tear test

To relieve apprehension the patient should be informed that a simple and painless, though slightly irritating, test will be performed to “measure the amount of tears produced by your eyes.” the patient is seated in the examining chair with the room lights dimmed and the patient's head against a headrest for comfort. The standardized test (Schirmer I) should be performed before instillation of topical medication or manipulation of the eyelids. Any excess moisture on the eyelid margin should be dried using a sterile cotton- tip applicator. Topical anesthesia is not used to perform the Schirmer I test. Care should be exercised so that the strips are placed at the junction of the middle and temporal one-third of the eyelid margin and do not touch the cornea which can produce increased reflex lacrimation and pain. Bend the round wick end of the test strips at the notch approximately 120° before opening the sterile paper pouch. The strips can be visualized, if necessary, by holding the paper pouch against light. To remove the strips; with the v-shaped end of the pouch pointing upward, tear the pouch horizontally; the non-wick ends will be adjacent to the pouch opening to prevent contamination of the wick ends by handling.

Technique of the test

Ask the patient to look up and draw the lower lid gently downward and temporally. Hook the rounded bent end of the sterile strip over the junction of the temporal and medial one-third of the lower eyelid margin. Again make sure this has been thoroughly dried with a cotton- tip applicator. Next, note the time and keep the room illumination dim for comfort. Patient should continue looking up throughout test so strip does not touch cornea. The patient may continue normal blinking although some will prefer to keep their eyes closed during the test, which is permissible. Squeezing the eyelid should be discouraged. After 5 minutes have elapsed, remove the strips and measure the length of the moistened area from the notch using the millimeter scale on the edge of the envelope. The bent part of the strip with the rounded end serves as a wick and is not included in the final measurement. The result is usually noted on the patient's chart as follows: Schirmer (right: 10 mm in 5 minutes-left: 8 mm in 5 minutes). If the entire strip is wetted within 5 minutes this should be noted on the chart. Placing the results of the Schirmer test in the same place on each chart using a colored pencil will facilitate finding results on follow-up visits.

Evaluation of result

A measurement of 10-15 mm or more (length of moistened area from the bend) in each eye is regarded as standard for normal tear production. The Schirmer I test measures reflex and "basic" tear secretion. Wetting of the entire strip, especially if grossly asymmetric, should prompt further investigation for possible tear drainage dysfunction. Above age 40 the normal values may vary between 10 and 15 mm. A value of less than 5 mm is very suggestive of a true dry eye state. A carefully performed Schirmer test will often reveal a reduced secretion of tears which may be responsible for a number of ocular complaints including gritty or foreign body sensation, burning, dryness, etc. The test is performed frequently to diagnose patients with the dry eye syndrome, to evaluate lacrimal gland function in contact lens wearers, to check tear production prior to eyelid surgery, and prior to corneal transplantation and cataract surgery .A number of patients with dry eye syndrome may demonstrate the “pseudoepiphora” phenomenon. In these patients the reflex lacrimation may demonstrate an adequate tear production (Schirmer I) in response to the constant reflex lacrimation. The "basic secretion" test should be performed using topical proparacaine anesthesia to distinguish those patients with “pseudoepiphora.”

If the moistened portion of the strip cannot be easily visualized, hold the strip against light.

Always place the notch of the strip towards the lateral canthus to aid in reproducibility of measurements.

Several measurements should be made on repeated visits and averaged to obtain an accurate result.

Contact lenses

KThe sterile strips are widely used to determine the adequacy of lacrimal function in evaluating patients for contact lenses.

Schirmer II Tear Test

Lester Jones, M.D. has devised a modification of the Schirmer I test to assess the adequacy of reflex lacrimation. The strips are inserted in the usual manner. The nasal mucosa is then gently irritated with a small cotton- tip applicator to provoke reflex lacrimation. If after 5 minutes the strip shows less than 10 mm of wetting, the patient is unable to produce reflex lacrimation and has demonstrated "reflex secretion failure." If = 10 mm of wetting are shown, the patient has demonstrated adequate reflex lacrimation to a suitable irritative stimulus.

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