October 18, 2013
2 min read

BLOG: Should Schirmer testing alone be the standard of care in oculoplastic surgery?

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Read more from Mark R. Levine, MD.

Should Schirmer testing alone be the standard of care in oculoplastic surgery cases? The immediate answer is no. But it can be helpful, as ocular surface disorders can lead to an unsatisfactory outcome.

Ophthalmic literature has been inundated with articles on ocular surface disorders cautioning us to evaluate patients for dry eye disorders that compromise a good surgical outcome, be it post-cataract surgery, refractive surgery, or ptosis and blepharoplasty surgery.

We are all intuitively versed in the dry eye literature, pointing out that dry eye syndrome is caused by a decrease in tear volume and/or meibomian gland dysfunction, leading to cytokine release and an inflamed ocular surface. Our goal is to have a happy patient with a successful outcome.

In oculoplastic procedures (ptosis repair and blepharoplasty), immediate postoperative complications may be lid lag, lagophthalmos, incomplete blink and mild ectropion. In a borderline dry eye patient, this may tip the balance to significant dry eye symptoms in the first 30 days postoperatively, with patient discomfort, unhappiness and concern.

So does the Schirmer test have any value? I definitely think it does because it makes the physician aware of potential problems.
Of course, the test needs to be interpreted according to patient symptoms, and the two don’t always correlate.

However, the patient becomes aware of this potential postoperative complication and is therefore more understanding if it does occur, both short term and long term. Pretreating the patient with artificial tears, antibiotic ointment at night, flaxseed oil capsules or fish oil capsules may prevent or lessen the early postoperative course of discomfort.

I know the Schirmer test is not always reproducible. I perform a 1-minute Schirmer test with anesthesia and multiply by three. If less than 10 mm of wetting, it guides me to ask other questions about fluctuation in vision, eyes burning in the morning, etc. I look more closely at the meibomian glands for turbidity and plugging and then explain to the patient why I am pretreating the patient prior to surgery. The patient appreciates that a lot.

At a recent interdisciplinary conference with plastic surgery, I asked the plastic surgeons how often they do Schirmer testing, and very few did.

I then remembered an article by Drs. Espinoza, Israel and Holds in Ophthalmic Plastic and Reconstructive Surgery in 2009. The authors surveyed members of the American Society of Ophthalmic Plastic and Reconstructive Surgery on the perceived role of Schirmer testing. Forty-eight percent of those surveyed responded. Of the respondents, 36% performed no additional tear production test, 33% performed the test if indicated by signs and symptoms, and 29% always performed the test.
Most physicians performed the test with anesthesia for 5 minutes.

The authors’ conclusion was that the Schirmer test alone was unreliable in detecting dry eyes. It needed to be supplemented with good clinical history and slit-lamp exam. It makes good academic sense to me.

I agree that Schirmer testing should not be the standard of care; however, for my practice, the Schirmer test keeps my awareness of ocular surface disorders and hopefully makes for a happier patient.


Espinoza GM, et al. Ophthal Plast Reconstr Surg. 2009;doi:10.1097/IOP.0b013e3181a1d4a5.