A Fresh Look at the OSDI for Dry Eye

A Fresh Look at the OSDI for Dry Eye

Dry eye disease has grown into a major public-health and quality-of-life concern. Patients frequently present with symptoms like irritation, fluctuating or blurry vision, foreign body sensation, and fatigue. 

But, the signs and the symptoms often don’t align neatly. Objective tests (tear breakup time, osmolarity, staining, etc.) capture part of the picture, but patient-reported experience is increasingly recognized as central to diagnosis and management. There are two primary tests used by eye doctors - the OSDI and the SPEED test. 

The OSDI test is an acronym for the Ocular Surface Disease Index. Developed decades ago (the 12-question version was validated in the early 2000s) it remains one of the most widely used symptom questionnaires in DED research and clinical care. 

But recently, an updated or shortened version—a “new OSDI” (commonly referenced as OSDI-6) —has emerged, and it offers several advantages. In this blog I’ll walk through what the new OSDI brings, why it matters, and how it’s better than previous iterations.

What is the “new” OSDI (OSDI-6) and how does it differ?

The original OSDI survey asks 12 items covering three domains: ocular symptoms, vision-related function, and environmental triggers. 

However, some practical issues emerged in everyday clinic use: patients may find the questionnaire somewhat lengthy; some questions may be less relevant in certain settings; and in busy practices a shorter screening instrument may increase adoption.

Recognizing that, researchers developed a shorter six-item version (commonly called the OSDI-6). The updated protocol from Tear Film & Ocular Surface Society (TFOS)’s DEWS III diagnostic methodology report actually recommends starting evaluation with OSDI-6 as a first step in the algorithm. Review of Optometry

Why this is better: key advantages

Here are the ways in which the updated OSDI (OSDI-6) improves on past iterations and why that matters in real-world dry eye care.

1. Faster & simpler for routine clinical use

In a busy ophthalmology or optometry practice, adding yet another questionnaire can be a barrier. The OSDI-6 addresses that by reducing the number of items and simplifying scoring. Shorter completion time means patients are more likely to fill it out correctly, the clinic flow is less disrupted, and results can be quickly available to guide the rest of the exam.

2. Still retains reliability and validity

Even though it’s shorter, studies show that OSDI-6 has repeatability and predicts dry eye status comparably to the full 12-question version. (See Review of Optometry article) This means that you don’t necessarily lose diagnostic power by choosing the shorter form, which is crucial if you’re screening many patients or monitoring over time.

3. Better alignment with modern diagnostic workflows

Dry eye is now recognized (via the TFOS DEWS III report) as a symptomatic disease, emphasizing the role of the patient’s experience alongside objective signs. The fact that OSDI-6 is explicitly included as the first step in the diagnostic algorithm is a strong endorsement of its utility. For example, a recommended sequence: first the OSDI-6 (≥ 4 indicates significance for dry eye) → then objective tear film tests (non-invasive tear breakup time or osmolarity) → then ocular surface staining. 

This suggested sequence is the one at the heart of Peeq Pro’s software and workflows. Our sequence triggers severity signals to offices from the triage process - meaning you test everyone whose survey answers merit review. We recommend testing every patient with a minimum of TBUT and some form of visual review - but many offices only review those that score moderate to severe on the OSDI-6.

Either way, the new OSDI more naturally fits into this modern workflow, rather than treating symptoms as an afterthought.

4. Improved patient-clinician communication & monitoring

A questionnaire like the OSDI (old or new) converts subjective feelings into a numeric score, which helps both clinician and patient “see” progress, compare visits, and monitor treatment response. This is particularly useful as a long-term care management process for review at regular annual visits. So, for example, imagine a woman in her mid-40s who is not yet experiencing perimenopause, but has mild dry eye. Knowing this has remained stable or with slight increases is helpful, when that patient returns with severe symptoms.

Many patients don’t think of their eye doctors as a source of help during menopause, but knowing there has been triggering changes, should alert every clinician to dig deeper about symptoms around dry eye.Because the new OSDI is faster, it's easier to use at every visit or even remotely (pre-visit, online), thereby giving you a clearer trend line of how symptoms are changing over time. That’s a real benefit in chronic conditions like DED.

5. Focus on clinically meaningful items

By reducing the number of items, the OSDI-6 focuses on those questions that had the strongest association with outcomes (e.g., blurred vision, driving at night, environmental triggers). Particularly with dry eye, where discomfort in the lived environment is so critical to managing treatment, it is critical to have clarity around symptom onset and events that trigger exacerbated negative feelings. This means more of each question contributes meaningfully to detecting disease or tracking changes. In contrast, longer questionnaires may include items with lesser discrimination value, which can dilute focus or create noise.

When & how to use the new OSDI in practice

Here are some practical tips and considerations for deploying the updated OSDI in a dry eye pathway.

  • Screening first: Use OSDI-6 at the start of an eye exam (or in the waiting room) to identify those patients whose symptom burden warrants further investigation.

  • Threshold: According to TFOS DEWS III, an OSDI-6 score ≥ 4 suggests dry eye warranting further study. 

  • Pair with objective tests: A questionnaire alone can’t replace the physical exam. After the OSDI-6, measure noninvasive tear breakup time (NIBUT) or osmolarity, then check ocular surface staining—especially if the questionnaire indicates symptoms.

  • Monitoring: On follow-up visits, re-administer the OSDI-6 to track change in symptoms over time. Because it’s quick, you can repeat it more easily.

  • Patient engagement: Encourage patients to complete it (perhaps online or via a tablet) before the visit. It helps engage them in their own care, allows them to reflect on their symptoms, and gives the clinician a starting point for discussion (What’s changed? What’s still bothering you?).

  • Use alongside full questionnaires if needed: In research settings or complex cases you may still want to use the full 12-item OSDI (or another detailed tool) to get more granularity—but for routine care the shortened version may suffice and has practical benefits.

Limitations & things to keep in mind

No tool is perfect, and the new OSDI has a few caveats:

  • *****Symptom-sign discordance*****: In DED there is well-recognized discord between symptoms and signs. A patient may report few symptoms yet have significant ocular surface damage, or vice versa. So you can’t rely on symptoms alone.

  • Shorter form may lose some nuance: Although OSDI-6 appears valid, reducing from 12 items to 6 inherently means some detail is lost. For example, issues like watering, foreign body sensation, or morning symptoms may not be captured fully.

  • Still subjective: It relies on self-report of symptoms (frequency) rather than measuring physiological signs. Some patients may under- or over-report, or normalize their symptoms. That’s why objective testing remains key.

  • Updates in technology and context: As newer objective tests, imaging and biomarkers become available, symptom questionnaires remain only one piece of the diagnostic puzzle. The OSDI (new or old) must be integrated with evolving protocols and the clinician’s judgement.

Conclusion

The updated OSDI questionnaire (in particular the OSDI-6) is a meaningful improvement in how we assess dry eye disease. By balancing speed with validity, aligning with modern diagnostic workflows, and supporting better communication and monitoring, it offers both clinicians and patients a more user‐friendly tool without sacrificing diagnostic utility.

Dry eye remains a multifactorial, chronic condition — so no questionnaire alone solves everything. But the new OSDI provides a smarter entry point and complements objective measures nicely. If your practice hasn’t adopted it yet, now might be a good time to consider integrating the short form into your screening and monitoring protocol.

What are the OSDI-6 questions?

The six questions are:

Please respond for a “typical day of the last month” by circling the number in the box. Scale: 4 = Constantly, 3 = Mostly, 2 = Often, 1 = Sometimes, 0 = Never

  1. Eyes that are sensitive to light? 

  2. Blurred vision (or vision blurring between blinks with your refractive correction)? 

  3. Driving (or being driven) at night?

  4. Watching TV (or similar)?

  5. Windy conditions? 

  6. Places or areas with low humidity?

Scoring Rubric

  • Total Score = Sum of responses to the 6 questions (each 0-4) → thus the raw total ranges from 0 to 24. Scope Connect

  • Interpretation (based on one commonly used version):

    • 0-3 points: Normal

    • 4-8 points: Mild to Moderate Dry Eye Disease

    • 8 points: Severe Dry Eye Disease

  • Some sources state that a total sum ≥ 4 indicates likely dry eye disease (DED) in screening use. But, as practitioners, these thresholds require some nuance. In particular, when tied with physical exams, many mild sufferers may have no physical symptoms suggesting an alternative issue - such as poor ergonomics or other underlying diseases.

  • Note: This is a simplified rubric specific to this shortened 6-item form. The original 12-item OSDI uses a different calculation (0-100 scale) and severity bands. notadryeye.org

Notes & Practical Tips

  • Ensure the patient understands the timeframe (“typical day of the last month”).

  • Use consistent scoring (0 - 4) and emphasize that higher numbers = greater symptom frequency/severity.

  • For routine screening: the OSDI-6 is quick, but for more detailed assessment or research you may still consider the full 12-item OSDI.

  • Always interpret the score together with objective tests (tear film breakup time, osmolarity, staining) and clinical context; symptom questionnaires are just one part of the assessment.

  • Document any change in the OSDI-6 total score over time to monitor treatment response or progression.

Watch Dr. Cheryl Chapman’s Take on Universal Dry Eye Screening

Even when patients don’t report dryness, underlying gland dysfunction can still be present — and early detection makes all the difference.

Click here to watch

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