{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,3]],"date-time":"2026-08-03T13:46:23Z","timestamp":1785764783832,"version":"3.56.0"},"reference-count":26,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,8,3]],"date-time":"2026-08-03T00:00:00Z","timestamp":1785715200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Med."],"abstract":"<jats:sec>\n                    <jats:title>Objective<\/jats:title>\n                    <jats:p>Dry eye disease (DED) has been described in axial spondyloarthritis (axSpA), but patterns of tear fluid and ocular surface involvement remain incompletely characterized. This study aims to evaluate tear film instability and tear production in axSpA and explore the heterogeneity of DED manifestations.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>Axial spondyloarthritis patients and healthy controls underwent non-invasive tear break-up time (niTBUT), Schirmer test, and Ocular Surface Disease Index (OSDI)- 6 evaluation. Group differences were assessed using niTBUT thresholds (&amp;lt;10 s and &amp;lt;5 s).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      Mean niTBUT was significantly lower in axSpA patients than controls (7.85 \u00b1 5.63 vs. 10.61 \u00b1 5.27 s;\n                      <jats:italic>p<\/jats:italic>\n                      &amp;lt; 0.001); niTBUT &amp;lt;5 s, but not &amp;lt;10 s, differentiated groups (\n                      <jats:italic>p<\/jats:italic>\n                      = 0.003 and\n                      <jats:italic>p<\/jats:italic>\n                      = 0.105, respectively). ROC analysis identified an optimal niTBUT cut-off of 5.15 s. Schirmer values also discriminated axSpA patients from controls, with an optimal threshold of 4.5 mm. Agreement between niTBUT and Schirmer classification was weak (Cohen \u03ba = 0.18). OSDI-6 scores were not significantly associated with pathological niTBUT. The niTBUT values were significantly associated with patients\u2019 age, but the diagnosis of axSpA accounted for the main determinant of niTBUT &amp;lt;5 s (likelihood ratio test,\n                      <jats:italic>p<\/jats:italic>\n                      = 0.026).\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Within the present cohort, a niTBUT &amp;lt;5 s showed greater discriminative performance than the conventional 10-s cut-off and may identify a subgroup of axSpA patients with more severe tear film instability. Aging contributes to tear film instability, but axSpA independently contributes to severe niTBUT impairment. Tear film instability and reduced tear secretion are both involved in DED affecting axSpA patients.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.3389\/fmed.2026.1851512","type":"journal-article","created":{"date-parts":[[2026,8,3]],"date-time":"2026-08-03T12:58:37Z","timestamp":1785761917000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Dry eye disease in axial spondyloarthritis: heterogeneous ocular surface dysfunction involving tear film instability and tear production from the AIDA network registry"],"prefix":"10.3389","volume":"13","author":[{"given":"Valeria","family":"Caggiano","sequence":"first","affiliation":[{"name":"Department of Medical Sciences, Surgery and Neurosciences, Research Center of Systemic Autoinflammatory Diseases and Beh\u00e7et\u2019s Disease Clinic, University of Siena","place":["Siena, Italy"]},{"name":"European Reference Network for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (ERN-RITA) Center, Azienda Ospedaliero-Universitaria Senese","place":["Siena, Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Antonio","family":"Vitale","sequence":"additional","affiliation":[{"name":"Department of Medical Sciences, Surgery and Neurosciences, Research Center of Systemic Autoinflammatory Diseases and Beh\u00e7et\u2019s Disease Clinic, University of Siena","place":["Siena, Italy"]},{"name":"European Reference Network for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (ERN-RITA) Center, Azienda Ospedaliero-Universitaria Senese","place":["Siena, Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jessica","family":"Sbalchiero","sequence":"additional","affiliation":[{"name":"Department of Medical Sciences, Surgery and Neurosciences, Research Center of Systemic Autoinflammatory Diseases and Beh\u00e7et\u2019s Disease Clinic, University of Siena","place":["Siena, Italy"]},{"name":"European Reference Network for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (ERN-RITA) Center, Azienda Ospedaliero-Universitaria Senese","place":["Siena, Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Abdurrahman","family":"Tufan","sequence":"additional","affiliation":[{"name":"Division of Rheumatology, Department of Internal Medicine, Gazi University Hospital","place":["Ankara, T\u00fcrkiye"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Guillermo Arturo","family":"Guaracha-Basa\u00f1ez","sequence":"additional","affiliation":[{"name":"Department of Immunology and Rheumatology, Instituto Nacional de Ciencias M\u00e9dicas y Nutrici\u00f3n Salvador Zubir\u00e1n","place":["Mexico City, Mexico"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Perla Ayumi","family":"Kawakami-Campos","sequence":"additional","affiliation":[{"name":"Department of Ophthalmology, Instituto Nacional de Ciencias M\u00e9dicas y Nutrici\u00f3n Salvador Zubir\u00e1n","place":["Mexico City, Mexico"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andrea","family":"Hinojosa-Azaola","sequence":"additional","affiliation":[{"name":"Department of Immunology and Rheumatology, Instituto Nacional de Ciencias M\u00e9dicas y Nutrici\u00f3n Salvador Zubir\u00e1n","place":["Mexico City, Mexico"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rahime","family":"Duran","sequence":"additional","affiliation":[{"name":"Division of Rheumatology, Department of Internal Medicine, Gazi University Hospital","place":["Ankara, T\u00fcrkiye"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hamit","family":"Kucuk","sequence":"additional","affiliation":[{"name":"Division of Rheumatology, Department of Internal Medicine, Gazi University Hospital","place":["Ankara, T\u00fcrkiye"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gaafar","family":"Ragab","sequence":"additional","affiliation":[{"name":"Rheumatology and Clinical Immunology Unit, Department of Internal Medicine, Faculty of Medicine, Cairo University","place":["Giza, Egypt"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Piero","family":"Ruscitti","sequence":"additional","affiliation":[{"name":"Rheumatology Unit, Department of Biotechnological and Applied Clinical Sciences, University of L\u2019Aquila","place":["L\u2019Aquila, Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Giuseppe","family":"Lopalco","sequence":"additional","affiliation":[{"name":"Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), Policlinic Hospital, University of Bari","place":["Bari, Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anastasios","family":"Karamanakos","sequence":"additional","affiliation":[{"name":"Department of Rheumatology, Evangelismos General Hospital","place":["Athens, Greece"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lampros","family":"Fotis","sequence":"additional","affiliation":[{"name":"Department of Pediatrics, Attikon General Hospital, National and Kapodistrian University of Athens","place":["Athens, Greece"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mahmoud","family":"Ghanema","sequence":"additional","affiliation":[{"name":"Rheumatology and Clinical Immunology Unit, Department of Internal Medicine, Faculty of Medicine, Cairo University","place":["Giza, Egypt"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Paola","family":"Cipriani","sequence":"additional","affiliation":[{"name":"Rheumatology Unit, Department of Biotechnological and Applied Clinical Sciences, University of L\u2019Aquila","place":["L\u2019Aquila, Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Maria","family":"Morrone","sequence":"additional","affiliation":[{"name":"Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), Policlinic Hospital, University of Bari","place":["Bari, Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Aikaterini","family":"Dimouli","sequence":"additional","affiliation":[{"name":"Department of Rheumatology, Evangelismos General Hospital","place":["Athens, Greece"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Katerina","family":"Kourtesi","sequence":"additional","affiliation":[{"name":"Department of Pediatrics, Attikon General Hospital, National and Kapodistrian University of Athens","place":["Athens, Greece"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Samar","family":"Tharwat","sequence":"additional","affiliation":[{"name":"Rheumatology and Immunology Unit, Department of Internal Medicine, Mansoura University","place":["Mansoura, Egypt"]},{"name":"Department of Internal Medicine, Faculty of Medicine, Horus University","place":["New Damietta, Egypt"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Abdelhfeez","family":"Moshrif","sequence":"additional","affiliation":[{"name":"Department of Rheumatology, Faculty of Medicine, Al-Azhar University","place":["Assiut, Egypt"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jurgen","family":"Sota","sequence":"additional","affiliation":[{"name":"Department of Medical Sciences, Surgery and Neurosciences, Research Center of Systemic Autoinflammatory Diseases and Beh\u00e7et\u2019s Disease Clinic, University of Siena","place":["Siena, Italy"]},{"name":"European Reference Network for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (ERN-RITA) Center, Azienda Ospedaliero-Universitaria Senese","place":["Siena, Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Adri\u00e1n","family":"Mayo-Juanatey","sequence":"additional","affiliation":[{"name":"Department of Rheumatology, Doctor Peset University Hospital","place":["Valencia, Spain"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Oksana","family":"Boyarchuk","sequence":"additional","affiliation":[{"name":"Department of Children\u2019s Diseases and Pediatric Surgery, Ternopil Regional Children\u2019s Hospital, I. Horbachevsky Ternopil National Medical University","place":["Ternopil, Ukraine"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Amr","family":"Edrees","sequence":"additional","affiliation":[{"name":"Division of Rheumatology, University of Missouri\u2013Kansas City","place":["Kansas City, MO, United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Patrizia","family":"Barone","sequence":"additional","affiliation":[{"name":"Pediatric Rheumatology Unit, Department of integrated Maternal-Child and Reproduction Activity, AOU \u201cPoliclinico-San Marco\u201d","place":["Catania, Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Francesco","family":"Carubbi","sequence":"additional","affiliation":[{"name":"Internal Medicine and Nephrology Division, Department of Life, Health and Environmental Sciences, ASL1 Avezzano-Sulmona-L\u2019Aquila, San Salvatore Hospital, University of L\u2019Aquila","place":["L\u2019Aquila, Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Maria Sole","family":"Chimenti","sequence":"additional","affiliation":[{"name":"Rheumatology, Allergology and Clinical Immunology Unit, Department of Systems Medicine, University of Rome Tor Vergata","place":["Rome, Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alessandro","family":"Conforti","sequence":"additional","affiliation":[{"name":"U.O. Medicina Generale, Ospedale San Paolo di Civitavecchia, ASL Roma 4","place":["Civitavecchia, Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Maissa","family":"Thabet","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, Farhat Hached University Hospital, Faculty of Medicine of Sousse, University of Sousse","place":["Sousse, Tunisia"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Daniela","family":"Opris-Belinski","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine and Rheumatology, Carol Davila University of Medicine and Pharmacy","place":["Bucharest, Romania"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"\u015e\u00fckran","family":"Erten","sequence":"additional","affiliation":[{"name":"Department of Rheumatology, Ankara Y\u0131ld\u0131r\u0131m Beyaz\u0131t University","place":["Ankara Bilkent City Hospital, Ankara-T\u00fc\u00fcrkiy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mohamed Tharwat","family":"Hegazy","sequence":"additional","affiliation":[{"name":"Rheumatology and Clinical Immunology Unit, Department of Internal Medicine, Faculty of Medicine, Cairo University","place":["Giza, Egypt"]},{"name":"Rheumatology Unit, Department of Internal Medicine, Jahra Hospital","place":["Al Jahra, Kuwait"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Maria Antonietta","family":"Mazzei","sequence":"additional","affiliation":[{"name":"European Reference Network for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (ERN-RITA) Center, Azienda Ospedaliero-Universitaria Senese","place":["Siena, Italy"]},{"name":"Unit of Diagnostic Imaging, Department of Medical, Surgical and Neuro Sciences, University of Siena","place":["Siena, Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Chiara","family":"Piscitello","sequence":"additional","affiliation":[{"name":"European Reference Network for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (ERN-RITA) Center, Azienda Ospedaliero-Universitaria Senese","place":["Siena, Italy"]},{"name":"Unit of Diagnostic Imaging, Department of Medical, Surgical and Neuro Sciences, University of Siena","place":["Siena, Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bruno","family":"Frediani","sequence":"additional","affiliation":[{"name":"Department of Medical Sciences, Surgery and Neurosciences, Research Center of Systemic Autoinflammatory Diseases and Beh\u00e7et\u2019s Disease Clinic, University of Siena","place":["Siena, Italy"]},{"name":"European Reference Network for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (ERN-RITA) Center, Azienda Ospedaliero-Universitaria Senese","place":["Siena, Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alberto","family":"Balistreri","sequence":"additional","affiliation":[{"name":"European Reference Network for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (ERN-RITA) Center, Azienda Ospedaliero-Universitaria Senese","place":["Siena, Italy"]},{"name":"Bioengineering and Biomedical Data Science Lab, Department of Medical Biotechnologies, University of Siena","place":["Siena, Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Carlos","family":"Cifuentes-Gonz\u00e1lez","sequence":"additional","affiliation":[{"name":"Department of Ocular Immunology, Ophthalmology Research Center, SIGMA Clinic","place":["Cali, Colombia"]},{"name":"Centre of Excellence in Ocular Inflammation, Colombian Visual Science and Translational Eye Research Institute (CERI)","place":["Bogot\u00e1, Colombia"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alejandra","family":"de-la-Torre","sequence":"additional","affiliation":[{"name":"Neuroscience Research Group (NEUROS), Neurovitae Center for Neuroscience, Institute of Translational Medicine (IMT), School of Medicine and Health Sciences, Universidad del Rosario","place":["Bogot\u00e1, Colombia"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Luca","family":"Cantarini","sequence":"additional","affiliation":[{"name":"Department of Medical Sciences, Surgery and Neurosciences, Research Center of Systemic Autoinflammatory Diseases and Beh\u00e7et\u2019s Disease Clinic, University of Siena","place":["Siena, Italy"]},{"name":"European Reference Network for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (ERN-RITA) Center, Azienda Ospedaliero-Universitaria Senese","place":["Siena, Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Claudia","family":"Fabiani","sequence":"additional","affiliation":[{"name":"European Reference Network for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (ERN-RITA) Center, Azienda Ospedaliero-Universitaria Senese","place":["Siena, Italy"]},{"name":"Ophthalmology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena","place":["Siena, Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2026,8,3]]},"reference":[{"key":"B1","doi-asserted-by":"publisher","first-page":"276","DOI":"10.1016\/j.jtos.2017.05.008","article-title":"TFOS DEWS II definition and classification report.","volume":"15","author":"Craig","year":"2017","journal-title":"Ocul Surf"},{"key":"B2","doi-asserted-by":"publisher","first-page":"334","DOI":"10.1016\/j.jtos.2017.05.003","article-title":"TFOS DEWS II epidemiology report.","volume":"15","author":"Stapleton","year":"2017","journal-title":"Ocul Surf"},{"key":"B3","doi-asserted-by":"publisher","first-page":"539","DOI":"10.1016\/j.jtos.2017.05.001","article-title":"TFOS DEWS II diagnostic methodology report.","volume":"15","author":"Wolffsohn","year":"2017","journal-title":"Ocul Surf"},{"key":"B4","doi-asserted-by":"publisher","first-page":"387","DOI":"10.1016\/j.ajo.2025.05.033","article-title":"TFOS DEWS III: diagnostic methodology.","volume":"279","author":"Wolffsohn","year":"2025","journal-title":"Am J Ophthalmol"},{"key":"B5","doi-asserted-by":"publisher","first-page":"366","DOI":"10.1016\/j.jtos.2017.03.006","article-title":"TFOS DEWS II tear film report.","volume":"15","author":"Willcox","year":"2017","journal-title":"Ocul Surf"},{"key":"B6","doi-asserted-by":"publisher","first-page":"777","DOI":"10.1136\/ard.2009.108233","article-title":"The development of assessment of spondyloarthritis international society classification criteria for axial spondyloarthritis (part II): validation and final selection.","volume":"68","author":"Rudwaleit","year":"2009","journal-title":"Ann Rheum Dis"},{"key":"B7","doi-asserted-by":"publisher","first-page":"16296","DOI":"10.3390\/ijerph192316296","article-title":"The presence of ankylosing spondylitis and the incidence of subsequent external eye diseases: a population-based cohort study.","volume":"19","author":"Lee","year":"2022","journal-title":"Int J Environ Res Public Health"},{"key":"B8","doi-asserted-by":"publisher","first-page":"1535","DOI":"10.1016\/j.semarthrit.2020.08.013","article-title":"Microvascular changes of the retina in ankylosing spondylitis, and the association with cardiovascular disease - the eye for a heart study.","volume":"50","author":"van Bentum","year":"2020","journal-title":"Semin Arthritis Rheum"},{"key":"B9","doi-asserted-by":"publisher","first-page":"1267","DOI":"10.1016\/s0161-6420(94)31179-1","article-title":"Posterior segment ocular manifestations in patients with HLA-B27-associated uveitis.","volume":"101","author":"Rodriguez","year":"1994","journal-title":"Ophthalmology"},{"key":"B10","doi-asserted-by":"publisher","first-page":"24","DOI":"10.31138\/mjr.34.1.24","article-title":"Ocular manifestations of spondyloarthritis.","volume":"34","author":"Pandey","year":"2023","journal-title":"Mediterr J Rheumatol"},{"key":"B11","doi-asserted-by":"publisher","first-page":"284","DOI":"10.1016\/j.jtos.2017.04.001","article-title":"TFOS DEWS II sex, gender, and hormones report.","volume":"15","author":"Sullivan","year":"2017","journal-title":"Ocul Surf"},{"key":"B12","doi-asserted-by":"publisher","first-page":"2147","DOI":"10.3390\/medicina61122147","article-title":"Diagnostic value of conjunctival impression cytology and Nelson grading in evaluating dry eye disease in ankylosing spondylitis.","volume":"61","author":"Yildirim","year":"2025","journal-title":"Medicina"},{"key":"B13","doi-asserted-by":"publisher","first-page":"1422307","DOI":"10.3389\/fmed.2024.1422307","article-title":"Dry eye disease and spondyloarthritis: expanding the spectrum of systemic inflammatory disorders associated with ocular surface disease. data from the international AIDA network spondyloarthritis registry.","volume":"11","author":"Vitale","year":"2024","journal-title":"Front Med"},{"key":"B14","doi-asserted-by":"publisher","first-page":"71","DOI":"10.3238\/arztebl.2015.0071","article-title":"The pathophysiology, diagnosis, and treatment of dry eye disease.","volume":"112","author":"Messmer","year":"2015","journal-title":"Dtsch Arztebl Int."},{"key":"B15","doi-asserted-by":"publisher","first-page":"e54028","DOI":"10.7759\/cureus.54028","article-title":"Dry eye disease: an overview of its risk factors, diagnosis, and prevalence by age, sex, and race.","volume":"16","author":"Deo","year":"2024","journal-title":"Cureus"},{"key":"B16","doi-asserted-by":"publisher","first-page":"1509357","DOI":"10.3389\/fmed.2025.1509357","article-title":"Development and implementation of the international AIDA network spondylarthritis registry.","volume":"12","author":"Caggiano","year":"2025","journal-title":"Front Med"},{"key":"B17","doi-asserted-by":"publisher","first-page":"5167","DOI":"10.1167\/iovs.10-6671","article-title":"Combination of the Schirmer i and phenol red thread tests as a rescue strategy for diagnosis of ocular dryness associated with Sj\u00f6gren\u2019s syndrome.","volume":"52","author":"de Monchy","year":"2011","journal-title":"Invest Ophthalmol Vis Sci"},{"key":"B18","doi-asserted-by":"publisher","first-page":"102048","DOI":"10.1016\/j.clae.2023.102048","article-title":"Diagnosing dry-eye: which tests are most accurate?","volume":"46","author":"Papas","year":"2023","journal-title":"Cont Lens Anterior Eye"},{"key":"B19","doi-asserted-by":"publisher","first-page":"615","DOI":"10.1001\/archopht.118.5.615","article-title":"Reliability and validity of the Ocular Surface Disease Index.","volume":"118","author":"Schiffman","year":"2000","journal-title":"Arch Ophthalmol"},{"key":"B20","doi-asserted-by":"publisher","first-page":"817","DOI":"10.1016\/j.jtos.2019.08.008","article-title":"The development and evaluation of the new Ocular Surface Disease Index-6.","volume":"17","author":"Pult","year":"2019","journal-title":"Ocul Surf"},{"key":"B21","doi-asserted-by":"publisher","first-page":"451","DOI":"10.1016\/j.ajo.2025.05.040","article-title":"TFOS DEWS III digest.","volume":"279","author":"Stapleton","year":"2025","journal-title":"Am J Ophthalmol."},{"key":"B22","doi-asserted-by":"publisher","first-page":"438","DOI":"10.1016\/j.jtos.2017.05.011","article-title":"TFOS DEWS II pathophysiology report.","volume":"15","author":"Bron","year":"2017","journal-title":"Ocul Surf"},{"key":"B23","doi-asserted-by":"publisher","first-page":"199","DOI":"10.1016\/s1542-0124(12)70187-8","article-title":"The association between symptoms of discomfort and signs in dry eye.","volume":"7","author":"Johnson","year":"2009","journal-title":"Ocul Surf"},{"key":"B24","doi-asserted-by":"publisher","first-page":"1247138","DOI":"10.1155\/2017\/1247138","article-title":"Correlation Analysis of ocular symptoms and signs in patients with dry eye.","volume":"2017","author":"Song","year":"2017","journal-title":"J Ophthalmol"},{"key":"B25","doi-asserted-by":"publisher","first-page":"3","DOI":"10.1167\/iovs.65.12.3","article-title":"Predictors of discordance between dry eye symptoms and signs: insights from the Sj\u00f6gren\u2019s international collaborative clinical alliance.","volume":"65","author":"Xiong","year":"2024","journal-title":"Invest Ophthalmol Vis Sci"},{"key":"B26","doi-asserted-by":"publisher","first-page":"409","DOI":"10.1016\/j.exer.2003.09.003","article-title":"The role of the lacrimal functional unit in the pathophysiology of dry eye.","volume":"78","author":"Stern","year":"2004","journal-title":"Exp Eye Res"}],"container-title":["Frontiers in Medicine"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fmed.2026.1851512\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,3]],"date-time":"2026-08-03T12:58:38Z","timestamp":1785761918000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fmed.2026.1851512\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,8,3]]},"references-count":26,"alternative-id":["10.3389\/fmed.2026.1851512"],"URL":"https:\/\/doi.org\/10.3389\/fmed.2026.1851512","relation":{},"ISSN":["2296-858X"],"issn-type":[{"value":"2296-858X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,8,3]]},"article-number":"1851512"}}