Diagnostic Agreement Between Invasive and Non-invasive Assessments for Preoperative Dry Eye Disease Screening in Patients with Cataracts

INTRODUCTION: The aim was to assess the incidence of dry eye disease (DED) and determine the cut-off value for non-invasive keratography tear break-up time (NIKBUT) in patients of European descent with cataracts and without significant comorbidities and to test the diagnostic agreement between invasive and non-invasive protocols. METHODS: DED symptoms and signs were evaluated preoperatively, including the SPEED II questionnaire, fluorescein break-up time (FBUT), ocular surface staining (OSS), and NIKBUT first (NIKBUT-f) and average (NIKBUT-avg). DED diagnosis was based on a SPEED score > 5 and FBUT ≤ 5 s or OSS > 1. The receiver-operating characteristic curves were determined for NIKBUT's detection of DED. The established NIKBUT-f cut-off was used instead of FBUT for alternative DED diagnostic protocols. RESULTS: Out of 715 patients, 217 were eligible, with a mean age of 70.9 ± 7.9 years. Thirty per cent of patients manifested both signs and symptoms of DED; 21% had symptoms only and 22% signs only. Forty-five per cent of asymptomatic patients presented abnormal FBUT and/or OSS. FBUT was shorter than NIKBUT-f (p < 0.001, Wilcoxon) with a mean difference of 2.5 s and narrower limits of agreement for shorter BUT. The optimal diagnostic cut-off for NIKBUT-f was 7.3 s, with 69.7% sensitivity and 62.3% specificity. Replacing FBUT with the optimised NIKBUT-f threshold resulted in 2% false negatives and the highest (91%) agreement compared with other studied protocols. The fully non-invasive protocol based on SPEED and NIKBUT alone resulted in 9% of patients not being assigned to DED diagnosis. CONCLUSIONS: To maximise the agreement with eye care professional diagnosis and to minimise the number of false negatives, it is recommended to decrease the standard NIKBUT-f cut-off value of 10 s for patients with cataracts. A fully non-invasive approach will result in fewer patients being referred for preoperative eye surface treatment. Ocular staining should not be omitted from the DED diagnosis.