Schirmer Tear Test


Schirmer Tear Test

Synonym/acronym: N/A.

Common use

To assess tear duct function.

Area of application

Eyes.

Contrast

N/A.

Description

The tear film, secreted by the lacrimal, Krause, and Wolfring glands, covers the surface of the eye. Blinking spreads tears over the eye and moves them toward an opening in the lower eyelid known as the punctum. Tears drain through the punctum into the nasolacrimal duct and into the nose. The Schirmer tear test simultaneously tests both eyes to assess lacrimal gland function by determining the amount of moisture accumulated on standardized filter paper or strips held against the conjunctival sac of each eye. The Schirmer test measures both reflex and basic secretion of tears. The Schirmer II test measures basic tear secretion and is used to evaluate the accessory glands of Krause and Wolfring. The Schirmer test is performed by instilling a topical anesthetic before insertion of filter paper. The topical anesthetic inhibits reflex tearing of major lacrimal glands by the filter paper, allowing testing of the accessory glands. The Schirmer II test is performed by irritating the nostril with a cotton swab to stimulate tear production.

This procedure is contraindicated for

    N/A

Indications

  • Assess adequacy of tearing for contact lens comfort and for successful LASIK surgery
  • Assess suspected tearing deficiency

Potential diagnosis

Normal findings

  • 10 mm of moisture on test strip after 5 min. It may be slightly less than 10 mm in elderly patients.

Abnormal findings related to

  • Tearing deficiency related to aging, dry eye syndrome, or Sjögren’s syndrome
  • Tearing deficiency secondary to leukemia, lupus erythemastosus, lymphoma, rheumatoid arthritis, or scleroderma

Critical findings

    N/A

Interfering factors

  • Factors that may impair the results of the examination

    • Inability of the patient to remain still and cooperative during the test may interfere with the test results.
    • Rubbing or squeezing the eyes may affect results.
    • Clinical conditions such as pregnancy may temporarily result in dry eye due to hormonal fluctuations.

Nursing Implications and Procedure

Pretest

  • Positively identify the patient using at least two unique identifiers before providing care, treatment, or services.
  • Patient Teaching: Inform the patient this procedure can assist in evaluating tear duct function.
  • Obtain a history of the patient’s complaints, including a list of known allergens, especially topical anesthetic eyedrops.
  • Obtain a history of the patient’s known or suspected vision loss; changes in visual acuity, including type and cause; use of glasses or contact lenses; eye conditions with treatment regimens; eye surgery; and other tests and procedures to assess and diagnose visual deficit.
  • Obtain a history of the patient’s symptoms and results of previously performed laboratory tests and diagnostic and surgical procedures.
  • Obtain a list of the patient’s current medications, including herbs, nutritional supplements, and nutraceuticals (see Effects of Natural Products on Laboratory Values online at DavisPlus).
  • Instruct the patient to remove contact lenses or glasses, as appropriate. Instruct the patient regarding the importance of keeping the eyes open for the test.
  • Review the procedure with the patient. Address concerns about pain and explain that no pain will be experienced during the test, but there may be moments of discomfort. Explain to the patient that some discomfort may be experienced after the test when the numbness wears off from anesthetic drops administered prior to the test. Inform the patient that the test is performed by a health-care provider (HCP) and takes about 15 min to complete.
  • Sensitivity to social and cultural issues, as well as concern for modesty, is important in providing psychological support before, during, and after the procedure.
  • Note that there are no food, fluid, or medication restrictions unless by medical direction.

Intratest

  • Potential complications:

  • Corneal abrasion caused by patient rubbing the eye before topical anesthetic has worn off.

  • Observe standard precautions, and follow the general guidelines in Patient Preparation and Specimen Collection. Positively identify the patient.
  • Instruct the patient to cooperate fully and to follow directions. Ask the patient to remain still during the procedure because movement produces unreliable results.
  • Seat the patient comfortably. Instruct the patient to look straight ahead, keeping the eyes open and unblinking.
  • Instill topical anesthetic in each eye, as ordered, and provide time for it to work. Topical anesthetic drops are placed in the eye with the patient looking up and the solution directed at the six o’clock position of the sclera (white of the eye) near the limbus (gray, semitransparent area of the eyeball where the cornea and sclera meet). Neither the dropper nor the bottle should touch the eyelashes. Insert a test strip in each eye. The strip should be folded over the midportion of both lower eyelids. Instruct the patient to gently close both eyes for approximately 5 minutes then remove the strips and measure the amount of moisture on the strips.

Post-Test

  • Inform the patient that a report of the results will be made available to the requesting HCP, who will discuss the results with the patient.
  • Assess for corneal abrasion caused by patient rubbing the eye before topical anesthetic has worn off.
  • Instruct the patient to avoid rubbing the eyes for 30 min after the procedure.
  • If appropriate, instruct the patient not to reinsert contact lenses for 2 hr.
  • Recognize anxiety related to test results, and be supportive of pain related to decreased lacrimation or inflammation. Discuss the implications of abnormal test results on the patient’s lifestyle. Provide teaching and information regarding the clinical implications of the test results, as appropriate. Provide contact information, if desired, for a general patient education Web site on the topic of eye care (e.g., www.allaboutvision.com).
  • Reinforce information given by the patient’s HCP regarding further testing, treatment, or referral to another HCP. Answer any questions or address any concerns voiced by the patient or family.
  • Instruct the patient in the use of any ordered medications. Explain the importance of adhering to the therapy regimen. As appropriate, instruct the patient in significant side effects and systemic reactions associated with the prescribed medication. Encourage him or her to review corresponding literature provided by a pharmacist.
  • Depending on the results of this procedure, additional testing may be performed to evaluate or monitor progression of the disease process and determine the need for a change in therapy. Evaluate test results in relation to the patient’s symptoms and other tests performed.

Related Monographs

  • Related tests include antibodies ANA, refraction, rheumatoid factor, and slit-lamp biomicroscopy.
  • Refer to the Ocular System table at the end of the book for related tests by body system.