Proposed cut-off points of each group are those with the highest specificity after setting the sensitivity at a value above 0. Discussion To our knowledge, this is the first multicenter study with a large sample investigating the diagnostic efficacy of the McMonnies questionnaire. Our results suggest that the instrument shows poor internal consistency, excellent validity, and moderate discriminating ability as a screening survey for dry eye in Chinese outpatients. The McMonnies questionnaire was initially developed by reviewing literature, and scores of each item were tabulated based on clinical experience [ 10 ]. Several reports evaluating the diagnostic efficacy of the questionnaire have been published since then. The results were deemed biased, because they were derived from the same sample from which the cut-off value was determined.

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This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. This article has been cited by other articles in PMC. Abstract Purpose.

To evaluate the diagnostic performance of the McMonnies questionnaire as a screening survey for dry eye in Chinese outpatients. The questionnaire was self-administered by 27, patients with dry eye symptoms. A thorough ophthalmic examination including tear break-up time TBUT , fluorescein staining, and Schirmer I test was completed to make a clinical diagnosis of dry eye.

Reliability, validity, and accuracy of the McMonnies questionnaire were assessed. Analysis of the ROC curves also revealed that different cut-off points should be employed for each subgroup to achieve the same level of accuracy.

The McMonnies questionnaire demonstrates moderate diagnostic value, and different cut-off points should be selected for various study populations.

Introduction Dry eye is a multifactorial disease of the tears and ocular surface that results in symptoms of discomfort, visual disturbance, and tear film instability with potential damage to the ocular surface [ 1 ].

Dry eye could be either a separated clinical entity or a condition associated with other systemic or ocular surface diseases. Currently, it belongs to the most frequently encountered ocular problems in clinical practice. The International Dry Eye Workshop recommended confirming the diagnosis of dry eye based on a combination of symptoms and objective clinical tests [ 2 ].

Accordingly, the Chinese diagnostic criteria of dry eye were published by the Corneal Disease Study Group of Chinese Ophthalmological Society in , offering a more defined standard [ 3 ]. The subjective symptoms of dry eye, along with certain risk factors, were advised to be screened by validated questionnaires [ 2 ]. As one of the most long-standing instruments, the McMonnies questionnaire is widely used in numerous prevalence studies [ 4 — 6 ] and clinical trials [ 7 — 9 ].

It contains 14 questions that revolve around the risk factors of dry eye, including age, gender, previous dry eye treatments, dry eye-related symptoms both primary and secondary to environmental triggers , and systemic conditions associated with dry eye dryness of mucous membranes, arthritis, thyroid disease, and medication use [ 10 ]. Moreover, this instrument was originally devised from a sample of Australian women aged above 45 years with or without keratoconjunctivitis sicca syndrome [ 10 , 11 ].

Subsequent studies [ 12 — 14 ] evaluating the reliability and validity of the instrument continued to focus on non-Asian populations. Thus, it is anticipated that variations in the diagnostic efficacy are likely to occur when applying the instrument to a Chinese cohort. Therefore, we carried out a study in multiple ophthalmological centers across China to investigate the diagnostic performance of the McMonnies questionnaire as a screening survey for dry eye in Chinese outpatients.

Method 2. Patient Sample The study was carried out in 94 ophthalmological centers, distributed in 45 cities, 23 provinces across China. Consecutive outpatients in general eye clinics were enrolled from July to November, , if they presented with one or more of the following chief complaints: dryness, grittiness, burning sensation, tiredness, soreness, and visual disturbance. Participants are excluded if they exhibited any active infection of the eye, evidence of ocular chemical or thermal burn, ocular surgeries within 6 months before the screening, and pregnancy or lactation.

Informed consents were obtained for each patient at each clinical site. Assessment of Dry Eye The McMonnies questionnaire, translated into Mandarin in advance, was self-administered by all participants. Then, each patient would be assessed by an ophthalmologist.

The examining doctor had no knowledge of the results of the completed questionnaires. All subjects were required to remove their contact lens and discontinue any artificial tears for at least 2 hours before the assessment. Ophthalmic examinations were conducted in the following order: Inquiry of Medical History. Information on ophthalmic and systemic disease was collected. A standard fluorescein stripe was moistened and used to lightly touch the inferior palpebral conjunctiva.

The patient would be asked to blink several times. Under cobalt blue light of a slit-lamp, the time interval between the last blink and the appearance of the first desiccation spot would be recorded as TBUT.

Keratoconjunctival Staining. After TBUT test, any fluorescein staining of the corneas and interpalpebral conjunctiva was also recorded. Schirmer I Test. Without anesthesia, a precalibrated standard stripe was placed in the lateral one-third of each lower fornix for 5 minutes. During this time, the patients were instructed to look downward or gently close their eyes.

The length of the wetting was measured after removing the stripe. Slit-Lamp Exam. Eyelid margins, including meibomian gland orifices and secretions, were evaluated under slit-lamp for pathological changes.

Test results of the more severely affected eye were recorded for further analyses. Subjects conformed to either of the two criteria were clinically diagnosed with dry eye; otherwise they were classified as non-dry eye control. Statistical Analyses Data analyses were performed using Statistical Package for the Social Sciences software, version A P value less than 0.

Factor Analysis The Kaiser-Meyer-Olkin measure was first calculated to test the degree of common variance, an assessment of whether the sample is adequate for factor analysis. Any value below 0. The Bartlett test of sphericity was also conducted to determine whether the items were sufficiently intercorrelated for factor analysis. After weighing the adequacy, factor analysis with varimax rotation was performed to find out whether the items of the McMonnies questionnaire tend to cluster into certain domains.

Therefore, the average interitem correlation was also calculated, which is not affected by the number of items. Due to the large sample size of our study, all participants only completed the questionnaire once. So we were unable to assess the test-retest reliability in this study. Validity Concurrent validity was assessed by examining the correlation between scores of the questionnaire and 2 quantitative dry eye test results i.

Discriminant validity was evaluated using 2-sample t-test to determine the differences in scores between the dry eye and the control group. Accuracy In order to maximize the diagnostic efficacy of the McMonnies questionnaire, receiver-operating characteristics ROC curves of both the entire sample and different gender and age groups were generated. ROC curves express the diagnostic accuracy of a test variable by plotting the sensitivity of the test against the specificity at all possible thresholds.

This method was employed to select the most appropriate cut-off point for our study population. We compared the ROC curves of different gender and age groups using z tests to see if the diagnostic performance is compromised when applying the instrument to certain subpopulations.

Results 3. Study Population This study recruited 31, outpatients from the ophthalmology departments of 94 tertiary hospitals, distributed in 45 cities, 23 provinces across China. Among these participants, 27, The demographics of the study population are listed in Table 1. The majority of our sample Females accounted for The overall prevalence of dry eye according to the Chinese diagnostic criteria was


Accuracy of McMonnies Questionnaire as a Screening Tool for Chinese Ophthalmic Outpatients

Have you ever had drops prescribed or other treatment for dry eye? Soreness 2. Scratchiness 3. Dryness 4. Grittiness 5. The version of the McMonnies questionnaire was used in the present study. It is presented on a single page and includes 12 questions that focus on clinical risk factors for DES.


Dry Eye Syndrome questionnaires

This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. This article has been cited by other articles in PMC. Abstract Purpose. To evaluate the diagnostic performance of the McMonnies questionnaire as a screening survey for dry eye in Chinese outpatients.


All relevant data are within the paper and Supporting Information files. Methods We recruited cases from 94 hospitals research centers , randomly selected from 45 cities in 23 provinces from July to November in Only symptomatic outpatients were included and they were in a high risk of DE. Outpatients meeting the criteria filled out questionnaires and then underwent clinical examinations by qualified medical practitioners.

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