{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,28]],"date-time":"2026-08-28T15:11:42Z","timestamp":1787929902527,"version":"build-2784847793"},"reference-count":55,"publisher":"MDPI AG","issue":"1","license":[{"start":{"date-parts":[[2026,1,1]],"date-time":"2026-01-01T00:00:00Z","timestamp":1767225600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Diagnostics"],"abstract":"<jats:p>Dry eye disease (DED) is a multifactorial disorder of the ocular surface, characterised by tear film instability, hyperosmolarity, inflammation, and neurosensory abnormalities. Its clinical heterogeneity and the weak correlation between symptoms and signs complicate both diagnosis and management. Conventional assessments, such as patient-reported symptom questionnaires and basic clinical tests like the Schirmer test, are useful; however, their variability and limited sensitivity highlight the need for more reliable and objective diagnostic tools. This narrative review summarises and analyses current imaging approaches used for the diagnosis of DED. A comprehensive literature search was performed in the PubMed and Google Scholar databases to identify relevant studies published up to October 2025. In recent years, imaging technologies have revolutionised the approach to DED. Modalities such as in vivo confocal microscopy (IVCM), meibography, anterior segment optical coherence tomography (AS-OCT), interferometry, thermography, tear fluorescein clearance, impression cytology, and multifunctional imaging systems allow for non-invasive, high-resolution, and reproducible assessment of ocular surface structures and tear film dynamics. The integration of these techniques into clinical practice supports a more personalised management of DED. Future directions include further technological refinements and the application of artificial intelligence (AI) to imaging analysis, with the potential to enhance diagnostic precision and facilitate earlier intervention. While imaging cannot replace a thorough clinical examination, it has become an essential adjunct that significantly enriches the evaluation and management of patients with DED.<\/jats:p>","DOI":"10.3390\/diagnostics16010126","type":"journal-article","created":{"date-parts":[[2026,1,2]],"date-time":"2026-01-02T09:18:56Z","timestamp":1767345536000},"page":"126","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":5,"title":["Imaging Approaches for the Diagnosis of Dry Eye: A Review"],"prefix":"10.3390","volume":"16","author":[{"given":"Angelo","family":"Macri","sequence":"first","affiliation":[{"name":"IRCCS Ospedale Policlinico San Martino, 16132 Genoa, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Margherita","family":"Tarallo","sequence":"additional","affiliation":[{"name":"Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, 16132 Genoa, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0524-2637","authenticated-orcid":false,"given":"Michele","family":"Iester","sequence":"additional","affiliation":[{"name":"Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, 16132 Genoa, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,1,1]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"312","DOI":"10.1097\/ICL.0000000000001171","article-title":"Exploring New and Global Therapeutic Options for Dry Eye Disease: What You Need to Know","volume":"51","author":"Koh","year":"2025","journal-title":"Eye Contact Lens"},{"key":"ref_2","unstructured":"Golden, M.I., Meyer, J.J., Zeppieri, M., and Patel, B.C. (2025, June 16). Dry Eye Syndrome, StatPearls, Available online: http:\/\/www.ncbi.nlm.nih.gov\/books\/NBK470411\/."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"820","DOI":"10.18240\/ijo.2022.05.20","article-title":"Inflammation and dry eye disease\u2014Where are we?","volume":"15","author":"Rao","year":"2022","journal-title":"Int. J. Ophthalmol."},{"key":"ref_4","doi-asserted-by":"crossref","unstructured":"Rolando, M., and Barabino, S. (2023). Dry Eye Disease: What Is the Role of Vitamin D?. Int. J. Mol. Sci., 24.","DOI":"10.3390\/ijms24021458"},{"key":"ref_5","doi-asserted-by":"crossref","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":"ref_6","doi-asserted-by":"crossref","first-page":"1719","DOI":"10.2147\/OPTH.S89700","article-title":"Associations between signs and symptoms of dry eye disease: A systematic review","volume":"9","author":"Bartlett","year":"2015","journal-title":"Clin. Ophthalmol. Auckl. N.Z."},{"key":"ref_7","doi-asserted-by":"crossref","unstructured":"Villani, E., Barabino, S., Giannaccare, G., Di Zazzo, A., Aragona, P., and Rolando, M. (2025). From Symptoms to Satisfaction: Optimizing Patient-Centered Care in Dry Eye Disease. J. Clin. Med., 14.","DOI":"10.3390\/jcm14010196"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"815","DOI":"10.1007\/s40123-025-01129-8","article-title":"Optimizing Diagnosis and Management of Dry Eye Disease: A Practical Framework for Hong Kong","volume":"14","author":"Lam","year":"2025","journal-title":"Ophthalmol. Ther."},{"key":"ref_9","doi-asserted-by":"crossref","unstructured":"Guarnieri, A., Carnero, E., Bleau, A.-M., L\u00f3pez de Aguileta Casta\u00f1o, N., Llorente Ortega, M., and Moreno-Monta\u00f1\u00e9s, J. (2020). Ocular surface analysis and automatic non-invasive assessment of tear film breakup location, extension and progression in patients with glaucoma. BMC Ophthalmol., 20.","DOI":"10.1186\/s12886-019-1279-7"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"857","DOI":"10.1007\/s00417-014-2618-2","article-title":"Image-guided evaluation and monitoring of treatment response in patients with dry eye disease","volume":"252","author":"Qazi","year":"2014","journal-title":"Graefes Arch. Clin. Exp. Ophthalmol."},{"key":"ref_11","doi-asserted-by":"crossref","unstructured":"Di Cello, L., Pellegrini, M., Vagge, A., Borselli, M., Ferro Desideri, L., Scorcia, V., Traverso, C.E., and Giannaccare, G. (2021). Advances in the Noninvasive Diagnosis of Dry Eye Disease. Appl. Sci., 11.","DOI":"10.3390\/app112110384"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"219","DOI":"10.1080\/17434440.2018.1435271","article-title":"The tear turnover and tear clearance tests\u2014A review","volume":"15","author":"Garaszczuk","year":"2018","journal-title":"Expert Rev. Med. Devices"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"54","DOI":"10.1016\/j.clae.2017.08.004","article-title":"Evaluating tear clearance rate with optical coherence tomography","volume":"41","author":"Garaszczuk","year":"2018","journal-title":"Contact Lens Anterior Eye"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"531","DOI":"10.1097\/ICO.0000000000000786","article-title":"Impact of Eyelid Laxity on Symptoms and Signs of Dry Eye Disease","volume":"35","author":"Chhadva","year":"2016","journal-title":"Cornea"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"1338","DOI":"10.1016\/S0161-6420(00)00101-9","article-title":"A standardized visual scale for evaluation of tear fluorescein clearance","volume":"107","author":"Macri","year":"2000","journal-title":"Ophthalmology"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"81","DOI":"10.1111\/j.1442-9071.2008.01823.x","article-title":"Clinical and research applications of anterior segment optical coherence tomography\u2014A review","volume":"37","author":"Ramos","year":"2009","journal-title":"Clin. Exp. Ophthalmol."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"583","DOI":"10.1080\/08164622.2021.1878854","article-title":"Evaluation of tear meniscus height using different clinical methods","volume":"104","author":"Niedernolte","year":"2021","journal-title":"Clin. Exp. Optom."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"2524","DOI":"10.1167\/iovs.02-0731","article-title":"Precorneal and pre- and postlens tear film thickness measured indirectly with optical coherence tomography","volume":"44","author":"Wang","year":"2003","journal-title":"Investig. Ophthalmol. Vis. Sci."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"261","DOI":"10.1007\/s10792-021-02022-6","article-title":"The relationship of tear osmolarity with tear meniscus curvature and contact angles in healthy subjects: Anterior segment optical coherence tomography study","volume":"42","author":"Yeter","year":"2022","journal-title":"Int. Ophthalmol."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"101540","DOI":"10.1016\/j.clae.2021.101540","article-title":"OCT applications in contact lens fitting","volume":"45","author":"Valdes","year":"2022","journal-title":"Contact Lens Anterior Eye"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"25","DOI":"10.22336\/rjo.2021.6","article-title":"Tear evaluation by anterior segment OCT in dry eye disease","volume":"65","author":"Diana","year":"2021","journal-title":"Rom. J. Ophthalmol."},{"key":"ref_22","doi-asserted-by":"crossref","unstructured":"Bucsan, R., Coroleuc\u0103, R., Garh\u00f6fer, G., Popa-Cherecheanu, A., Schmetterer, L., and Iancu, R. (2024). Confocal Microscopy of the Cornea in Aqueous-Deficient Dry Eye Disease\u2014A Literature Review. Diagnostics, 14.","DOI":"10.3390\/diagnostics14151613"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"652","DOI":"10.1038\/s42003-023-05005-8","article-title":"In-vivo corneal confocal microscopy: Imaging analysis, biological insights and future directions","volume":"6","author":"Chiang","year":"2023","journal-title":"Commun. Biol."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"1099","DOI":"10.4103\/IJO.IJO_3013_22","article-title":"Role of in vivo confocal microscopy in dry eye disease and eye pain","volume":"71","author":"Shetty","year":"2023","journal-title":"Indian J. Ophthalmol."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"5144","DOI":"10.1167\/iovs.13-12370","article-title":"Corneal nerve structure and function in patients with non-sjogren dry eye: Clinical correlations","volume":"54","author":"Liang","year":"2013","journal-title":"Investig. Ophthalmol. Vis. Sci."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"183","DOI":"10.1016\/j.jtos.2020.05.012","article-title":"Correlation of corneal immune cell changes with clinical severity in dry eye disease: An in vivo confocal microscopy study","volume":"19","author":"Aggarwal","year":"2021","journal-title":"Ocul. Surf."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"3509064","DOI":"10.1155\/2020\/3509064","article-title":"Objective Imaging Diagnostics for Dry Eye Disease","volume":"2020","author":"Han","year":"2020","journal-title":"J. Ophthalmol."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"576","DOI":"10.1097\/OPX.0b013e318294c184","article-title":"In vivo confocal evaluation of the ocular surface morpho-functional unit in dry eye","volume":"90","author":"Villani","year":"2013","journal-title":"Optom. Vis. Sci. Off. Publ. Am. Acad. Optom."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"911","DOI":"10.1016\/j.ophtha.2007.06.031","article-title":"Noncontact infrared meibography to document age-related changes of the meibomian glands in a normal population","volume":"115","author":"Arita","year":"2008","journal-title":"Ophthalmology"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"119","DOI":"10.1016\/j.jtos.2022.06.002","article-title":"Latest developments in meibography: A review","volume":"25","author":"Swiderska","year":"2022","journal-title":"Ocul. Surf."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"349","DOI":"10.1016\/j.sjopt.2012.08.007","article-title":"Meibography: A review of techniques and technologies","volume":"26","author":"Wise","year":"2012","journal-title":"Saudi J. Ophthalmol."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"040508","DOI":"10.1117\/1.3475957","article-title":"In vivo volumetric imaging of the human upper eyelid with ultrahigh-resolution optical coherence tomography","volume":"15","author":"Bizheva","year":"2010","journal-title":"J. Biomed. Opt."},{"key":"ref_33","doi-asserted-by":"crossref","unstructured":"Ha, M., Oh, S.-E., Whang, W.-J., Na, K.-S., Kim, E.C., Kim, H.-S., Kim, J.S., and Hwang, H.S. (2022). Relationship between meibomian gland loss in infrared meibography and meibum quality in dry eye patients. BMC Ophthalmol., 22.","DOI":"10.1186\/s12886-022-02509-5"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"945","DOI":"10.1016\/j.survophthal.2024.07.005","article-title":"Advances in artificial intelligence for meibomian gland evaluation: A comprehensive review","volume":"69","author":"Li","year":"2024","journal-title":"Surv. Ophthalmol."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"5804123","DOI":"10.1155\/2020\/5804123","article-title":"Diagnostic Performance of a Novel Noninvasive Workup in the Setting of Dry Eye Disease","volume":"2020","author":"Vigo","year":"2020","journal-title":"J. Ophthalmol."},{"key":"ref_36","doi-asserted-by":"crossref","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":"ref_37","doi-asserted-by":"crossref","unstructured":"Wu, L., Huang, Y., Lv, T., Xiao, C., Wang, Y., and Zhao, S. (2025). Advances in AI-assisted quantification of dry eye indicators. Front. Med., 12.","DOI":"10.3389\/fmed.2025.1628311"},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"105269","DOI":"10.1016\/j.cmpb.2019.105269","article-title":"Interferometer eye image classification for dry eye categorization using phylogenetic diversity indexes for texture analysis","volume":"188","author":"Souza","year":"2020","journal-title":"Comput. Methods Programs Biomed."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"18","DOI":"10.1016\/j.ajo.2010.07.019","article-title":"Interferometry in the Evaluation of Precorneal Tear Film Thickness in Dry Eye","volume":"151","author":"Hosaka","year":"2011","journal-title":"Am. J. Ophthalmol."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"356","DOI":"10.1016\/j.jtos.2018.12.003","article-title":"Characterization of the thickness of the tear film lipid layer using high resolution microscopy","volume":"17","author":"Bai","year":"2019","journal-title":"Ocul. Surf."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"3491","DOI":"10.1109\/JBHI.2020.3026940","article-title":"Tear Film Classification in Interferometry Eye Images Using Phylogenetic Diversity Indexes and Ripley\u2019s K Function","volume":"24","author":"Souza","year":"2020","journal-title":"IEEE J. Biomed. Health Inform."},{"key":"ref_42","doi-asserted-by":"crossref","unstructured":"Paik, J.-S., Kwon, M.J., Nam, G.H., Han, K., Whang, W.-J., Hwang, H.S., Yang, S.-W., Kim, H.-S., Na, K.S., and Cho, W.-K. (2025). Tear film lipid layer thickness and blink dynamics in patients with blepharospasm. BMC Ophthalmol., 25.","DOI":"10.1186\/s12886-025-03852-z"},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"5319","DOI":"10.1167\/iovs.07-1407","article-title":"Rheology of tear film lipid layer spread in normal and aqueous tear-deficient dry eyes","volume":"49","author":"Yokoi","year":"2008","journal-title":"Investig. Ophthalmol. Vis. Sci."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"164","DOI":"10.1186\/s12938-018-0597-y","article-title":"An imaging system integrating optical coherence tomography and interferometry for in vivo measurement of the thickness and dynamics of the tear film","volume":"17","author":"Bai","year":"2018","journal-title":"Biomed. Eng. Online"},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"78","DOI":"10.1016\/j.cbpa.2016.02.022","article-title":"Infrared thermography: A non-invasive window into thermal physiology","volume":"202","author":"Tattersall","year":"2016","journal-title":"Comp. Biochem. Physiol. A Mol. Integr. Physiol."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"117","DOI":"10.1097\/01.ICL.0000141921.80061.17","article-title":"Ocular Surface Temperature: A Review","volume":"31","author":"Purslow","year":"2005","journal-title":"Eye Contact Lens"},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"1079","DOI":"10.1097\/ICO.0000000000000512","article-title":"Subjective Discomfort Symptoms Are Related to Low Corneal Temperature in Patients with Evaporative Dry Eye","volume":"34","author":"Versura","year":"2015","journal-title":"Cornea"},{"key":"ref_48","doi-asserted-by":"crossref","unstructured":"Gulias-Ca\u00f1izo, R., Rodr\u00edguez-Malag\u00f3n, M.E., Botello-Gonz\u00e1lez, L., Belden-Reyes, V., Amparo, F., and Garza-Leon, M. (2023). Applications of Infrared Thermography in Ophthalmology. Life, 13.","DOI":"10.3390\/life13030723"},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"615","DOI":"10.1038\/eye.1995.149","article-title":"Infrared thermography of the tear film in dry eye","volume":"9","author":"Morgan","year":"1995","journal-title":"Eye"},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"635","DOI":"10.1038\/eye.2000.156","article-title":"The role of tear physiology in ocular surface temperature","volume":"14","author":"Craig","year":"2020","journal-title":"Eye"},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"782","DOI":"10.1016\/j.ajo.2010.10.033","article-title":"Screening for dry eye with newly developed ocular surface thermographer","volume":"151","author":"Kamao","year":"2011","journal-title":"Am. J. Ophthalmol."},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"943","DOI":"10.1177\/1120672120932093","article-title":"Impression cytology for detection of clinically suspected ocular surface disorders: A cross-sectional study","volume":"31","author":"Moshtaghion","year":"2021","journal-title":"Eur. J. Ophthalmol."},{"key":"ref_53","doi-asserted-by":"crossref","first-page":"576","DOI":"10.1111\/ceo.14379","article-title":"Imaging assessment of conjunctival goblet cells in dry eye disease","volume":"52","author":"Liu","year":"2024","journal-title":"Clin. Exp. Ophthalmol."},{"key":"ref_54","doi-asserted-by":"crossref","first-page":"927","DOI":"10.1038\/sj.eye.6702058","article-title":"Evaluating an impression cytology grading system (IC score) in patients with dry eye syndrome","volume":"20","author":"Schwantzer","year":"2006","journal-title":"Eye"},{"key":"ref_55","doi-asserted-by":"crossref","first-page":"71","DOI":"10.1097\/00003226-198801000-00012","article-title":"Impression cytology","volume":"7","author":"Nelson","year":"1988","journal-title":"Cornea"}],"container-title":["Diagnostics"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2075-4418\/16\/1\/126\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,1,9]],"date-time":"2026-01-09T08:17:21Z","timestamp":1767946641000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2075-4418\/16\/1\/126"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,1,1]]},"references-count":55,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2026,1]]}},"alternative-id":["diagnostics16010126"],"URL":"https:\/\/doi.org\/10.3390\/diagnostics16010126","relation":{},"ISSN":["2075-4418"],"issn-type":[{"value":"2075-4418","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,1,1]]}}}