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What Is Schirmer's Test?

Schirmer's Test is one of the oldest and most widely used diagnostic tests for dry eye syndrome (Keratoconjunctivitis Sicca). It was originally described by Otto Schirmer in 1903. The test measures the aqueous (watery) volume of the tear film. It involves placing a thin strip of specialized filter paper, usually 5 mm wide and 35 mm long, inside the lower eyelid (the inferior fornix). The paper acts like a wick. It absorbs the tears pooling in the eye. After a set time, typically 5 minutes, the doctor removes the paper and measures how many millimeters of the strip have become wet.

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What Is Schirmer's Test?

Schirmer's Test is one of the oldest and most widely used diagnostic tests for dry eye syndrome (Keratoconjunctivitis Sicca). It was originally described by Otto Schirmer in 1903. The test measures the aqueous (watery) volume of the tear film. It involves placing a thin strip of specialized filter paper, usually 5 mm wide and 35 mm long, inside the lower eyelid (the inferior fornix). The paper acts like a wick. It absorbs the tears pooling in the eye. After a set time, typically 5 minutes, the doctor removes the paper and measures how many millimeters of the strip have become wet.

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Schirmer I vs. Schirmer II

There are two variations of this test used to measure different types of tears.

Schirmer I - This is performed without anesthesia. It measures total tear secretion, which includes both "basal" tears (constant lubrication) and "reflex" tears (tears caused by the irritation of the paper). This is the most common version.

Schirmer II - This is performed with anesthetic drops to numb the eye and typically involves stimulating the inside of the nose with a cotton swab. This specifically measures the maximum output of the lacrimal gland (reflex tearing) to see if the gland is capable of producing tears when pushed.

Interpreting the Numbers

The results are read directly from the scale printed on the paper strip. While standards vary slightly, general guidelines for a 5-minute Schirmer I test are:

Normal - More than 10 mm of wetting.

Mild Dryness - 6 to 10 mm of wetting.

Severe Dry Eye - Less than 5 mm of wetting. Some patients with severe conditions like Sjögren's Syndrome may have a result of 0 mm, meaning the paper remains completely dry.

Limitations and Variability

While useful, Schirmer's test is known for being variable. Results can change based on the time of day, the humidity in the room, or the patient's anxiety level. Because the paper itself is irritating, it often causes reflex tearing that can mask an underlying dry eye problem. For this reason, doctors rarely rely on Schirmer's test alone. They usually combine it with other diagnostics like Tear Breakup Time (TBUT) and corneal staining to get a complete picture of ocular surface health.

The Role in Systemic Disease

Schirmer's test is a critical diagnostic criteria for systemic autoimmune diseases. If a patient complains of dry mouth and dry eyes, a Schirmer result of less than 5 mm is one of the key markers used by rheumatologists to diagnose Sj?gren's Syndrome. It serves as objective proof that the exocrine glands are not functioning correctly.

FAQs on Schirmer's Test

Does it hurt?

It can be uncomfortable. The paper feels like a large eyelash or a grain of sand stuck in the eye. It usually causes tearing and mild irritation, but it is not painful in the sense of sharp pain.

Can I wear contacts during the test?

No. Contact lenses must be removed because they would interfere with the paper placement and could absorb the tears themselves, invalidating the results.

Is it accurate for everyone?

Not always. In older patients with loose eyelids (lid laxity), the paper might not touch the eye surface properly. In these cases, newer tests like tear osmolarity or MMP-9 testing might be more accurate.

When to See Your Eye Doctor

If you use artificial tears more than 3 times a day or if you wake up with eyelids sticking together, you should ask for a dry eye evaluation. A Schirmer test can determine if your problem is a lack of water (Aqueous Deficiency) or just poor oil quality (Evaporative Dry Eye).

References

https://eyewiki.aao.org/Schirmer_Test https://pubmed.ncbi.nlm.nih.gov/22076388/ https://www.ncbi.nlm.nih.gov/books/NBK482142/ https://cornea.org/properties-of-tears/