ICEID EYE CENTRE

Patient Information

A. Presenting Complaint

1. What problem with your eyes brought you to the clinic today? 2. Which eye is affected? Right eye Left eye Both eyes 3. How long have you had these symptoms? Select duration < 1 week 1–4 weeks 1–3 months 3–6 months > 6 months > 1 year 4. Did the symptoms begin? Select Suddenly Gradually Not sure

B. Dry Eye Symptom Questionnaires

Complete the validated dry-eye symptom questionnaire below. Scores are calculated automatically.

DEQ-5 Questionnaire

1. During a typical day in the past month, how often did your eyes feel discomfort?

Select Never - 0 Rarely - 1 Sometimes - 2 Frequently - 3 Constantly - 4

2. When your eyes felt discomfort, how intense was this feeling of discomfort at the end of the day, within two hours of going to bed?

Select Never have it - 0 Not at all intense - 1 2 3 4 Very intense - 5

3. During a typical day in the past month, how often did your eyes feel dry?

Select Never - 0 Rarely - 1 Sometimes - 2 Frequently - 3 Constantly - 4

4. When your eyes felt dry, how intense was this feeling of dryness at the end of the day, within two hours of going to bed?

Select Never have it - 0 Not at all intense - 1 2 3 4 Very intense - 5

5. During a typical day in the past month, how often did your eyes look or feel excessively watery?

Select Never - 0 Rarely - 1 Sometimes - 2 Frequently - 3 Constantly - 4

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OSDI - Ocular Surface Disease Index

During the last week:

1. Eyes that are sensitive to light?

Select All of the time - 4 Most of the time - 3 Half of the time - 2 Some of the time - 1 None of the time - 0

2. Eyes that feel gritty?

Select All of the time - 4 Most of the time - 3 Half of the time - 2 Some of the time - 1 None of the time - 0

3. Painful or sore eyes?

Select All of the time - 4 Most of the time - 3 Half of the time - 2 Some of the time - 1 None of the time - 0

4. Blurred vision?

Select All of the time - 4 Most of the time - 3 Half of the time - 2 Some of the time - 1 None of the time - 0

5. Poor vision?

Select All of the time - 4 Most of the time - 3 Half of the time - 2 Some of the time - 1 None of the time - 0

Have problems with your eyes limited you in performing any of the following during the last week?

6. Reading?

Select All of the time - 4 Most of the time - 3 Half of the time - 2 Some of the time - 1 None of the time - 0 N/A

7. Driving at night?

Select All of the time - 4 Most of the time - 3 Half of the time - 2 Some of the time - 1 None of the time - 0 N/A

8. Working with a computer or bank machine (ATM)?

Select All of the time - 4 Most of the time - 3 Half of the time - 2 Some of the time - 1 None of the time - 0 N/A

9. Watching TV?

Select All of the time - 4 Most of the time - 3 Half of the time - 2 Some of the time - 1 None of the time - 0 N/A

Have your eyes felt uncomfortable in any of the following situations during the last week?

10. Windy conditions?

Select All of the time - 4 Most of the time - 3 Half of the time - 2 Some of the time - 1 None of the time - 0 N/A

11. Places or areas with low humidity (very dry)?

Select All of the time - 4 Most of the time - 3 Half of the time - 2 Some of the time - 1 None of the time - 0 N/A

12. Areas that are air conditioned?

Select All of the time - 4 Most of the time - 3 Half of the time - 2 Some of the time - 1 None of the time - 0 N/A

C. Dry Eye Symptoms

During the past week, how often have you experienced each symptom?

Symptom	No	Sometimes	Frequently	Almost always
Dryness
Gritty / sandy feeling
Foreign-body sensation
Burning
Stinging
Pain / soreness
Redness
Itching
Excessive watering
Sticky / stringy mucus
Sensitivity to light
Heavy / tired eyes
Difficulty opening eyes
Fluctuating blurred vision

5. Does your vision become clearer after blinking? Select Yes No Sometimes 6. Do your eyes become more uncomfortable as the day progresses? Select Yes No If yes, when are symptoms worst? Select Morning Afternoon Evening Throughout the day 7. Are your symptoms worse immediately after waking? Select Yes No 8. Do your eyes water even though they sometimes feel dry? Select Yes No

D. Effect on Daily Activities

Activity	No difficulty	Mild	Moderate	Severe
Reading
Using a phone
Using a computer / laptop
Watching television
Driving during the day
Driving at night
Working
Usual daily activities

E. Screen and Reading History

9. Approximately how many hours do you spend looking at screens each day? Select < 2 hours 2–4 hours 4–6 hours 6–8 hours > 8 hours 10. Which devices do you use regularly? Mobile phone Computer / laptop Tablet Television Other 11. Do your symptoms worsen after prolonged screen use? Select Yes No Not sure 12. Do your symptoms worsen after prolonged reading? Select Yes No

F. Environmental Triggers

Do your symptoms become worse in any of the following situations?

Air-conditioned rooms Direct fan exposure Windy conditions Hot weather Dust Smoke Chemical exposure Dry environment Outdoors None noticed Other trigger

G. Contact Lens History

13. Do you wear contact lenses? Select Yes No If yes, type 14. Have your contact lenses become uncomfortable? Select Yes No 15. Do you sometimes remove them earlier than planned because of dryness or discomfort? Select Yes No

H. Previous Eye History

16. Have you previously been diagnosed with dry eye? Select Yes No If yes, when? 17. Have you previously been told you have any of the following? Blepharitis Meibomian gland dysfunction Eye allergy Recurrent conjunctivitis Corneal disease Glaucoma Other 18. Have you had any previous eye surgery? Select No Cataract surgery LASIK / refractive surgery Glaucoma surgery Other 19. Are you currently using any eye drops? Select Yes No If yes, list the eye drops

I. Previous Dry Eye Treatment

20. Have you used any treatment for dry eye before? No Artificial tears Preservative-free tears Gel / ointment Warm compress Eyelid cleansing Thermal eye mask Prescription anti-inflammatory eye drops Punctal plugs Other 21. Did the treatment help? Select Very much Somewhat Very little Not at all

J. General Medical History

22. Have you been diagnosed with any of the following? Diabetes mellitus Thyroid disease Rheumatoid arthritis Lupus Other autoimmune / connective-tissue disease Vitamin A deficiency Skin / rosacea problems Other significant illness Other illness / details

K. Dry Mouth / Sjögren Screening

23. Does your mouth frequently feel dry? SelectYesNo 24. Have you had persistent dry mouth for more than 3 months? SelectYesNo 25. Do you frequently need to drink water to swallow dry food? SelectYesNo 26. Have you experienced persistent dry eyes for more than 3 months? SelectYesNo 27. Do you frequently feel as though you have sand or gravel in your eyes? SelectYesNo Clinician Flag Select Possible Sjögren / systemic dry eye – consider further review No systemic dry-eye concern identified

L. Medication History

28. Are you currently taking any regular medications? Select Yes No If yes, list medications

Specifically ask about:

Antihistamines Antidepressants Diuretics Beta-blockers Anticholinergic medication Hormonal treatment Other

M. Patient's Own Assessment

29. Overall, how troublesome are your eye symptoms?

0 = no symptoms    10 = worst imaginable

Score: 0/10

30. Which symptom bothers you the MOST? 31. What would you most like treatment to improve?

N. Clinical Examination & Diagnostic Results

Baseline Ocular Examination

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DEA520 Pro Dry Eye Analyser - Complete Assessment

Other DEA520 Finding / Impression

NIBUT guide: <10 seconds suggests tear-film instability; <5 seconds suggests definite dry eye.

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Slit-Lamp & Meibomian Gland Assessment

Grade each eye: None / Mild / Moderate / Severe

Slit-Lamp / MGD Other Findings & Notes

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Schirmer Test

Protocol Used Anaesthetic Used? NoYes

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MMP-9 / InflammaDry

Inflammatory DED Suspected? NoYes

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Ocular Surface Staining

Scale Used OxfordNEIOther Pattern / Notes

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Diagnostic Synthesis

Does this patient meet the clinical criteria for Dry Eye Disease? Indeterminate / Needs Further Assessment Yes No

Supporting Evidence

Positive symptom screen: DEQ-5 >= 6 and/or OSDI >= 13 Tear-film instability / reduced NIBUT Positive ocular-surface staining Reduced aqueous production / abnormal Schirmer Meibomian gland dysfunction / abnormal meibography MMP-9 / InflammaDry positive Dry Eye Type Aqueous-deficient Evaporative / MGD Mixed Exposure-related Other Severity MildModerateSevere Inflammatory Status MMP-9 positiveMMP-9 negativeNot tested Associated Condition None specified Blepharitis Allergy Sjogren / systemic suspicion Contact lens related Other Working / Final Diagnosis Clinician Diagnostic Statement

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Management Plan

Patient education / environmental modification Preservative-free artificial tears / lubricant Gel / ointment Warm compress / thermal mask Lid hygiene / lid cleansing Meibomian gland expression / MGD treatment Anti-inflammatory treatment prescribed Treat allergy / blepharitis / associated ocular-surface disease Consider punctal occlusion when appropriate Advanced therapy / cornea or ocular-surface referral Systemic / rheumatology evaluation for possible Sjogren syndrome Medication / Treatment Details

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Follow-Up & Outcome Plan

OSDI / DEQ-5 Target NIBUT Target Staining Target MMP-9 / Inflammation Target Review Interval 1-2 weeks 4-6 weeks 6-12 weeks Other Follow-Up Notes

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DEA520 Pro Dry Eye Analysis

DEA520 Pro Impression

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Schirmer Test

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MMP-9 / InflammaDry

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Ocular Surface Staining

Lid-margin staining / other staining findings

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Slit-Lamp & Meibomian Gland Examination

Lid margin / blepharitis findings Meibomian gland expressibility Select Normal Mildly reduced Moderately reduced Severely reduced Non-expressible Meibum quality Select Clear Cloudy Granular Thick / toothpaste-like No secretion Other anterior segment / ocular-surface findings

O. TFOS DEWS II Diagnostic Interpretation

Diagnostic principle: Dry Eye Disease is confirmed when there is a positive symptom screen together with at least one positive marker of tear-film homeostasis loss, after excluding mimicking conditions.

Measure	Positive Threshold / Interpretation
DEQ-5	≥6 = positive symptom screen
OSDI	≥13 = positive symptom screen
NIBUT	<10 seconds = positive homeostasis marker
Corneal staining	>5 spots = positive homeostasis marker
Conjunctival staining	>9 spots = positive homeostasis marker
Schirmer	Reduced tear production supports aqueous-deficient DED; ≤5 mm/5 min indicates marked deficiency
MMP-9 / InflammaDry	Positive result supports ocular-surface inflammation; not diagnostic of DED by itself

Final Clinician Diagnostic Decision

DED CONFIRMED – positive symptom screen + at least one positive homeostasis marker DED NOT YET CONFIRMED – symptoms positive but no positive homeostasis marker SIGNS WITHOUT SIGNIFICANT SYMPTOMS – evaluate corneal sensitivity / alternative ocular-surface disease Dry Eye Disease not supported by current findings

Dry Eye Subtype

Aqueous-deficient DED Evaporative / MGD DED Mixed DED Other Other diagnosis / differential diagnosis

Inflammatory Status

MMP-9 positive MMP-9 negative Not performed

P. Clinician Summary

Primary symptom Duration Main aggravating factor(s) Relevant ocular history Relevant systemic history Relevant medication history Clinical impression / diagnosis

Q. Management Plan

Patient Education & Environmental Measures

Dry eye education provided Screen / blink modification advised Environmental modification advised Hydration / lifestyle advice

Lubrication

Artificial tears Preservative-free lubricants Gel / ointment Lubricant / dosage instructions

Meibomian Gland / Lid Management

Warm compress Thermal eye mask Eyelid cleansing / lid hygiene MGD treatment indicated

Inflammation / Advanced Treatment

Anti-inflammatory therapy considered / prescribed Punctal occlusion considered Further ocular-surface treatment required Referral / systemic evaluation indicated Medication / treatment prescribed Additional management instructions

Clinician Sign-Off

Signature / initials