Volume 15, Issue 1, Pages 65-76 (January 2017) New Perspectives on Dry Eye Definition and Diagnosis: A Consensus Report by the Asia Dry Eye Society  Kazuo Tsubota, MD, PhD, Norihiko Yokoi, MD, PhD, Jun Shimazaki, MD, PhD, Hitoshi Watanabe, MD, PhD, Murat Dogru, MD, PhD, Masakazu Yamada, MD, PhD, Shigeru Kinoshita, MD, PhD, Hyo-Myung Kim, MD, PhD, Hung-Won Tchah, MD, PhD, Joon Young Hyon, MD, PhD, Kyung-Chul Yoon, MD, PhD, Kyoung Yul Seo, MD, PhD, Xuguang Sun, MD, PhD, Wei Chen, MD, PhD, Lingyi Liang, MD, PhD, Mingwu Li, MD, PhD, Zuguo Liu, MD, PhD Zuguo Liu, Xuguang Sun, Wei Chen, Yingping Deng, Jing Hong, Ying Jie, Mingwu Li, Ying Li, Lingyi Liang, Hong Qi, Hua Wang, Xiaoming Yan, Wenzhao Yang, Yufeng Ye, Jin Yuan, Hong Zhang, Hui Zhan, Mingchang Zhang, Shaozhen Zhao, Hyo-Myung Kim, Hungwon Tchah, Chul Young Choi, Eui-Sang Chung, Joon Young Hyon, Hyun-Seung Kim, Mee Kum Kim, Myoung-Joon, Tae-Im Kim, Do-Hyung Lee, Hyung-Keun Lee, Kyoung Yul Seo, Jong Suk Song, Kyung-Chul Yoon, Kazuo Tsubota, Norihiko Yokoi, Shiro Amano, Reiko Arita, Murat Dogru, Yuichi Hori, Tetsuya Kawakita, Motoko Kawashima, Shizuka Koh, Kohji Nishida, Yoko Ogawa, Jun Shimazaki, Hitoshi Watanabe, Masakazu Yamada, Masahiko Yamaguchi Kazuo Tsubota, MD, PhD, Norihiko Yokoi, MD, PhD, Jun Shimazaki, MD, PhD, Hitoshi Watanabe, MD, PhD, Murat Dogru, MD, PhD, Masakazu Yamada, MD, PhD, Shigeru Kinoshita, MD, PhD, Hyo-Myung Kim, MD, PhD, Hung-Won Tchah, MD, PhD, Joon Young Hyon, MD, PhD, Kyung-Chul Yoon, MD, PhD, Kyoung Yul Seo, MD, PhD, Xuguang Sun, MD, PhD, Wei Chen, MD, PhD, Lingyi Liang, MD, PhD, Mingwu Li, MD, PhD, Zuguo Liu, MD, PhD Zuguo Liu, Xuguang Sun, Wei Chen, Yingping Deng, Jing Hong, Ying Jie, Mingwu Li, Ying Li, Lingyi Liang, Hong Qi, Hua Wang, Xiaoming Yan, Wenzhao Yang, Yufeng Ye, Jin Yuan, Hong Zhang, Hui Zhan, Mingchang Zhang, Shaozhen Zhao, Hyo-Myung Kim, Hungwon Tchah, Chul Young Choi, Eui-Sang Chung, Joon Young Hyon, Hyun-Seung Kim, Mee Kum Kim, Myoung-Joon, Tae-Im Kim, Do-Hyung Lee, Hyung-Keun Lee, Kyoung Yul Seo, Jong Suk Song, Kyung-Chul Yoon, Kazuo Tsubota, Norihiko Yokoi, Shiro Amano, Reiko Arita, Murat Dogru, Yuichi Hori, Tetsuya Kawakita, Motoko Kawashima, Shizuka Koh, Kohji Nishida, Yoko Ogawa, Jun Shimazaki, Hitoshi Watanabe, Masakazu Yamada, Masahiko Yamaguchi  The Ocular Surface  Volume 15, Issue 1, Pages 65-76 (January 2017) DOI: 10.1016/j.jtos.2016.09.003 Copyright © 2016 The Author(s) Terms and Conditions

Figure 1 2006 Japanese Diagnostic Criteria for Dry Eye. The Ocular Surface 2017 15, 65-76DOI: (10.1016/j.jtos.2016.09.003) Copyright © 2016 The Author(s) Terms and Conditions

Figure 2 The Delphi Panel Clinical Sign Recommendations in Dysfunctional Tear Syndrome in Severity Assessment. Reproduced from Behrens A, Doyle J, Stern L, et al. Dysfunctional tear syndrome: a Delphi approach to treatment recommendations. Cornea 2006; 25(8):900-7, with permission from Wolters Kluwer Health, Inc. The Ocular Surface 2017 15, 65-76DOI: (10.1016/j.jtos.2016.09.003) Copyright © 2016 The Author(s) Terms and Conditions

Figure 3 The ODISSEY European Consensus-derived scoring algorithm for severe DED diagnosis. Reproduced from Baudouin G, Aragona P, Van Setten G, et al. Diagnosing the severity of dry eye: a clear and practical algorithm. Br J Ophthalmol 2014; 98:1168-76, with permission from BMJ Publishing Group Ltd. The Ocular Surface 2017 15, 65-76DOI: (10.1016/j.jtos.2016.09.003) Copyright © 2016 The Author(s) Terms and Conditions

Figure 4 Distribution of TFBUT, Schirmer test value, and ocular surface staining in dry eye patients in the Osaka study. Of 368 people who had a diagnosis of dry eye syndrome, the number of subjects with abnormal TFBUT (94.6%) is more than that with abnormal Schirmer test value (19.3%) and with ocular surface staining positive (24.2%). Data from Uchino M, et al, 2013.9 The Ocular Surface 2017 15, 65-76DOI: (10.1016/j.jtos.2016.09.003) Copyright © 2016 The Author(s) Terms and Conditions

Figure 5 Four subtypes of dry eye patients in the Osaka study. Top left quadrant: TFBUT≤5 sec, Schirmer test value >5 mm; bottom left quadrant: TFBUT≤5 sec, Schirmer test value ≤5 mm; bottom right quadrant: TFBUT>5 sec, Schirmer test value ≤5 mm; top right quadrant: TFBUT>5 sec, Schirmer test value >5 mm. The majority of dry eye subtype (79.9%) is TFBUT≤5 sec, Schirmer test value >5 mm. Data from Yokoi, et al, 2015.11 The Ocular Surface 2017 15, 65-76DOI: (10.1016/j.jtos.2016.09.003) Copyright © 2016 The Author(s) Terms and Conditions

Figure 6 Dry eye disease is diagnosed by the combination of symptoms and unstable tear film. The Ocular Surface 2017 15, 65-76DOI: (10.1016/j.jtos.2016.09.003) Copyright © 2016 The Author(s) Terms and Conditions

Figure 7 Various risk factors affect precorneal tear film. The Ocular Surface 2017 15, 65-76DOI: (10.1016/j.jtos.2016.09.003) Copyright © 2016 The Author(s) Terms and Conditions

Figure 8 Comparison of functional visual acuity for non-dry eye and short TFBUT-type dry eye. The Ocular Surface 2017 15, 65-76DOI: (10.1016/j.jtos.2016.09.003) Copyright © 2016 The Author(s) Terms and Conditions

Figure 9 The concept of TFOT (Tear Film Oriented Therapy). *Diquafosol sodium may increase the function of the tear film lipid layer by promoting spreading of the lipid layer through lipid and tear fluid secretion. **Rebamipide may suppress the inflammation of the ocular surface in dry eye by its anti-inflammatory action. Figure provided by Dry Eye Society Japan. The Ocular Surface 2017 15, 65-76DOI: (10.1016/j.jtos.2016.09.003) Copyright © 2016 The Author(s) Terms and Conditions

Figure 10 Symptoms of short TFBUT-type and staining-type dry eye. The symptoms were comparable for the two groups, suggesting that patients with short TFBUT-type dry eye suffer greatly, despite the lack of ocular surface damage. Reprinted from Toda I, Shimazaki J, Tsubota K Ophthalmology 1995;102(2):302-9, with permission from Elsevier.55 The Ocular Surface 2017 15, 65-76DOI: (10.1016/j.jtos.2016.09.003) Copyright © 2016 The Author(s) Terms and Conditions