Palfi's Sign

[Michael I. Davis]

A colleague of ours in the UK has come up with what I think is a simple
elegant test for diagnosing dry eye

Palfi's Sign: if the eyes are dry - you will get chronic mild inflammation
of the conjunctivae, and this causes slightly swollen palpebral conjunctiva.
This causes the lower lid to stand away from the globe, and this stand off
drops the tear prism at the lid margin.
So here is how you do it. Sit patient at slit lamp and observe tear prism -
note it - then get them to look up : if the tear prism DROPS it is because
of lower lid stand off and you can feel confident of patient having dry eye.
You may also spot a smile stain.
Also - no drop on upgaze means no dry eye. Try it! See a drop - ask if they
get dry eye!

Palfi likes to divide the tear prism in to 4 - high, medium, low, gone! On
an upgaze it will either rise slightly , or stay the same height if they
have no dry eye - but drop two points in mild dry eye and three points in
established dry eye. Whether the lower lid stands away from the globe (pouts
slightly) because the mildly inflamed conjunctiva surface wrinkles, or
simply because it is thickened - I don't know. The test is easiest to see
with fluorescen.

Comments welcome.


Michael I. Davis, O.D.
PCO '82
Eldersburg, MD

[Arun Kaistha]

How do you use this test in any patient older than 60 as lower lid position will have poor apposition to the globe from just age appropriate changes in the lid/tyalosis/ectropion/blepharitis/any other cause of "swollen conjunctiva"?

Also, how about a lipid-deficiency dry eye due to meibomitis? I wouldn't expect Palfi's sign to diagnose the dry eye in that case...I find a quick tear break-up test, observation of the tear lake after fluorescein and, if necessary, a Shirmer tear-strip are usually sufficient for dry eye diagnosis, but they ALL take the back to seat to a good history, which is usually the give away. Then again, doesn't everyone these days have dry eyes??? It seems so sometimes, maybe it's just Jersey or all the elderly pts I see.

I'm not questioning the validity of Palfi's sign, I'm intrigued by it and anxious to try it..I just think it may not work clinically as well is it sounds in theory.

A colleague of ours in the UK has come up with what I think is a simple
elegant test for diagnosing dry eye

Palfi's Sign: if the eyes are dry - you will get chronic mild inflammation
of the conjunctivae, and this causes slightly swollen palpebral conjunctiva.
This causes the lower lid to stand away from the globe, and this stand off
drops the tear prism at the lid margin.
So here is how you do it. Sit patient at slit lamp and observe tear prism -
note it - then get them to look up : if the tear prism DROPS it is because
of lower lid stand off and you can feel confident of patient having dry eye.
You may also spot a smile stain.
Also - no drop on upgaze means no dry eye. Try it! See a drop - ask if they
get dry eye!

Palfi likes to divide the tear prism in to 4 - high, medium, low, gone! On
an upgaze it will either rise slightly , or stay the same height if they
have no dry eye - but drop two points in mild dry eye and three points in
established dry eye. Whether the lower lid stands away from the globe (pouts
slightly) because the mildly inflamed conjunctiva surface wrinkles, or
simply because it is thickened - I don't know. The test is easiest to see
with fluorescen.

Comments welcome.


Michael I. Davis, O.D.
PCO '82
Eldersburg, MD

[Michael I. Davis]

A reply from Palfi:


here is the reply to Arun
Thank for keeping me in touch!

Palfi's sign has been clinically found to be a measure of how inflamed of the eyelids are due to dry eye. It is known that dry eye is caused and also causes mild but chronic inflammation of the eye lids.
As Arun says - classically dry eye can have different causes - evaporative and tear deficient, for example. And these would present in different ways.
Often symptomology will give a clue to this as shown by McMonies et Al. However, as researchers have shown — even questionnaires, etc. have their limitations.
Palfi's sign would not give any clue to how to manage the condition, it simply reports some degree of dry eye — which on asking the patient is found to be true! It opens up an avenue to diagnosis of dry eye — independent of other signs. i am glad you find it as interesting as we do over here — and I hope you find it as useful.
A point can be furthered by noting at which part of the lid the tears are dropping (on upgaze). Early dry eye tend to cause a drop on the nasal side of the lower lid — and as it progresses it becomes total. So the degree can be determined.
As a further point, we have found that Palfi's sign is independent of age — but that is no surprise — as dry eye occurs at any age.
Thank you for raising several interesting points, Arun.

All the best: Palfi