5  Tears and Contact Lenses
JENNIFER P. CRAIG and LAURA E. DOWNIE
CHAPTER CONTENTS The Tear Film,  97
The Tear Film in the Contact Lens–Wearing
Eye, 98
Tear Film and Ocular Surface Assessment,
Relevant to Contact Lens Wear,  99
The quality of the tear film covering the anterior surface of
the eye is critically important when considering the chal-
lenges of contact lens wear. Contact lens discomfort and
dryness are the most common reasons for reduced lens
wearing times and lens discontinuation (Nichols et al. 2013*).
Careful assessment of the tear film and ocular surface before
contact lens wear can enable optimisation of the environ-
ment to support contact lens wear, and ongoing evaluation
will highlight aspects requiring attention to maintain optimal
wearing conditions.
Several supportive videos on aspects of tear assessment
and treatment are available at: https://expertconsult.inkling.
com/ and are referenced in the text.
The Tear Film
TEAR FILM STRUCTURE, ORIGIN AND
FUNCTIONS
The tear film (Fig. 5.1) is a carefully ordered structure with
a thin layer of lipid on the surface and a thicker aqueous-
mucin phase beneath which increases in mucin concentration
towards the epithelial cell layer of the cornea. Conferring
hydrophilicity to the naturally hydrophobic corneal surface
is the thin, innermost layer of membrane-bound mucins
described as glycocalyx (Dilly, 1994).
The tear lipid layer (or meibum) is in the order of
50–100 nm thick. It arises mainly from the meibomian
glands embedded within the eyelid, with a smaller contri-
bution from the eyelid glands of Moll and Zeis (Wolff 1946,
Norn 1979). Meibum contains both polar and nonpolar com-
ponents that align to form the duplex structure of the lipid
layer: a thin polar layer interfacing with the aqueous layer
and a thicker, nonpolar layer blanketing the upper surface
*The Tear Film and Ocular Surface Society (TFOS) organised an International
Workshop on Contact Lens Discomfort (CLD) involving 79 experts and
culminating in the TFOS reports Invest. Ophthalmol. Vis. Sci.. 2013; 54(11)
History and Symptoms,  100
Objective Clinical Assessments,  101
Creating and Maintaining a Robust Tear
Film, 110
Conclusions, 115
exposed to the air. The primary function of the lipid layer is
to retard evaporation of the underlying tear fluid, but it also
has a role in lowering the surface tension of the tears and
in preventing tear spillage over the lid margins (Bron et al.
2004).
The lacrimal gland is the main source of the aqueous fluid,
with minor contributions from the accessory lacrimal glands
of Krause and Wolfring and from epithelial cell secretions
(Dartt 2004). The aqueous component forms the bulk of
the tear film (Wolff 1946) and helps to nurture the avascular
cornea by transferring oxygen and nutrients as well as con-
veying chemical signals between envelop (Rolando & Zierhut
2001). The electrolytes contained within the aqueous fluid
determine its osmolarity as well as help to stabilise tear pH
and maintain epithelial integrity. The aqueous tears further
defend the ocular surface through their antimicrobial and
antioxidant constituents, and they contain growth factors
that are critical to ocular surface maintenance and repair
(Chen et al. 2009b).
Soluble, gel-forming mucins, produced by the goblet cells
of the conjunctiva, increase in concentration towards the
base of the aqueous tear layer (Argueso 2013). These mucins
help lubricate the ocular surface, promoting a smooth and
intact surface to facilitate the blinking action of the eyelids.
They further protect the corneal cells by encasing debris
on the ocular surface for safe removal at the caruncle,
via blinking (Rolando & Zierhut 2001). Supporting this
aqueous-mucin gel matrix are transmembrane mucins,
which are anchored to the epithelial cells of the cornea
and conjunctiva and contribute to the glycocalyx. As well
as promoting hydrophilicity, these mucins further protect the
ocular surface.
Blinking spreads the tear film, replenishes its components
and reforms its structure. After a blink, the compressed lipid
layer is stretched across the exposed interpalpebral area as
the eye opens, drawing beneath it the replenished aqueous
layer (Doane 1981). Between blinks, the tear film thins and
destabilises. Altered interfacial tensions cause contamination
between the layers and the formation of dry spots within the
film, evaluated clinically as tear film breakup. Regular and
complete blinks are required to avoid such destabilisation.
97
98 SECTION 2  •  Anatomy, Physiology and Patient Suitability
Superficial corneal
epithelial cells with microvilli
Fig. 5.1  Schematic representation of tear film structure (not to scale).
For the ocular surface to be protected, the period of tear film
stability must exceed the interblink interval (Ousler et al.
2008).
THE TEAR FILM IN THE NON–CONTACT
LENS–WEARING EYE
The ocular surface and tear film are closely interdependent,
and an imbalance in one or the other can result in tear film
instability and trigger the cycle of hyperosmolarity, inflamma-
tion and further loss of tear film integrity observed in dry eye.
Normal tear film thickness over the central cornea is
approximately 3 µm, and the rate of tear turnover, corre-
sponding primarily to replenishment of the aqueous tear
component, is approximately 15.5% per minute (van Best
et al. 1995, Webber et al. 1987).
LIPID LAYER GRADE AND TEAR FILM STABILITY
Lipid layer thickness can be graded on a six-point scale (see
Fig. 5.8), according to the pattern visible with interferometry
(Guillon & Guillon 1993). A normal tear film exhibits at
least a closed-meshwork lipid layer pattern. Thinner lipid
layers are associated with poor tear film stability (Craig &
Tomlinson 1997). Tear film instability is a core feature of
dry eye that occurs not only in the presence of a poor lipid
layer, but also from dysfunction of any one of the tear com-
ponents or the ocular surface itself. Aqueous deficiency, mucin
abnormality or excessive evaporation, or any combination
of these, can contribute to an unstable tear film.
TEAR FILM EVAPORATION AND
HYPEROSMOLARITY
Disruption of the tear film structure, reflected in a loss of
tear film stability, leads to increased evaporation of the tears,
triggering tear film hyperosmolarity. Aqueous deficiency and
excessive evaporation often coexist and are the major aetio-
logical classes of dry eye identified by the TFOS (Tear Film
and Ocular Surface Society) Dry Eye Workshop (DEWS Report,
2007 and 2017) (see also Section 9, Addendum, available
at: https://expertconsult.inkling.com/).
Superficial
lipid layer
Aqueous-mucin
phase
Glycocalyx layer
(with secretory and
transmembrane
mucins)
Hyperosmolarity reflecting a high tear solute concentra-
tion is an indicator of tear film homeostatic imbalance. It is
considered a core feature in the pathophysiology of dry eye
(Lemp 1995, TFOS, 2017). The electrolytes sodium, chloride,
potassium and bicarbonate are the predominant contributors
to tear film osmolarity, while tear film proteins and sugars
have little influence (Craig & Tomlinson 1995).
TEAR FILM BIOCHEMICAL COMPOSITION
This can be described according to its proteome (proteins
and peptides), lipidome (lipids), mucins and glycocalyx, and
other components (see also Section 9, Addendum, available
at: https://expertconsult.inkling.com/).
The Tear Film in the Contact
Lens–Wearing Eye
CLINICAL CHANGES
■ Placing a contact lens within the preocular tear film
induces both biophysical and biochemical alterations to
the tear film (Craig et al. 2013). A contact lens is in the
order of 30 times thicker than the tear film and divides the
naturally ordered preocular film into the anterior, prelens
tear film and the posterior, post-lens tear film, sandwiched
between the posterior lens surface and the anterior ocular
surface.
■ Wearing a lens can result in incomplete blinks where the
eyelids cover less than two-thirds of the cornea during a
blink especially in rigid lens wearers. In soft lens wearers,
incomplete blinking causes symptoms of dryness and dis-
comfort, lens deposits and increased corneal fluorescein
staining.
■ The lipid layer of the prelens tear film is adversely affected by
contact lens wear. This is attributed to the reduced prelens
aqueous layer, which impedes tear film lipid layer spread
after a blink (Guillon & Guillon 1993, Lorentz & Jones
2007, Chen et al. 2011). The lens may also exhibit areas
with poor wettability, which predisposes the lens surface
to deposition-impaired optical quality.
 5  •  Tears and Contact Lenses 99

Table 5.1  Summary of the Key Clinical Tests for Assessing the Tear Film and Ocular Surface
Fundamental Components
1. Clinical history and symptom ■ General medical and ophthalmic histories
assessment ■ Identification of risk factors for dry eye
■ Qualitative symptom assessment
Additional Components
■ Standardised symptom questionnaires
■ Contact lens–associated (e.g. CLDEQ-8)
■ Dry eye disease (e.g. OSDI)

2. General anterior eye
assessment
3. Tear volume assessment
(noninvasive)
4. Tear stability assessment and
lipid layer evaluation
(noninvasive)
■ Slit-lamp biomicroscopy: ocular bulbar redness,
eyelid evaluation, ocular surface examination,
tear film assessment, evaluation for lid parallel
conjunctival folds (LIPCOF)
■ Tear meniscus height (TMH, slit-lamp)
■ Noninvasive tear break-up time NIBUT (e.g.
Oculus Keratograph 5M, Medmont E300 corneal
topographer)
■ Tear film composition (tear osmolarity), e.g.
TearLabTM Osmolarity System (see Fig. 5.6)
■ TMH (OCT)
■ Interferometry (e.g. Tearscope™, Polaris™,
EasyTearView+™, Oculus Keratograph 5M, Kowa
DR-1)
■ Lipid layer thickness (e.g. LipiView II™)

5. Conjunctival surface integrity ■ Conjunctival impression cytology (goblet cell

density and squamous cell metaplasia)
■ In vivo confocal microscopy

6. Tear stability (invasive) ■ TBUT with sodium fluorescein (NaFl)

7. Ocular surface staining
8. Tear volume assessment
(invasive)
9. Blinking evaluation
10. Eyelid assessment
■ Assessment of corneal and conjunctival sodium
fluorescein and lissamine green staining
■ Schirmer test or phenol red thread test
■ Blink rate (clinician observation)
■ Blink completeness (clinician observation)
■ Ocular Protection Index (OPI)
■ Other eyelid abnormalities (e.g. lagophthalmos)
■ Meiboscopy (clinician observation).
(transillumination, EasyTearView+™)
■ Lid eversion
■ Assessment and grading of LWE
■ Evaluating position of Marx’s line
■ Manual meibomian gland expression
■ Adoption of standardised grading scales for
assessing staining severity (e.g. BHVI* Oxford,
Efron, van Bijsterveld)
■ Korb-Blackie transillumination test for
lagophthalmos (Blackie and Korb, 2015)
■ Blink rate and completeness (LipiView II)
■ Meibography (imaging). (Oculus Keratograph 5M,
Topcon)
■ Korb Meibomian Gland Evaluator (TearScience) for
meibomian gland expression

*For further information, see https://expertconsult.inkling.com/.

A summary of the major clinical diagnostic techniques for assessing the tear film and ocular surface, as relevant to contact lens fitting, categorised as
‘Fundamental’ or ‘Additional’. Fundamental techniques are more commonly used in clinical practice and provide key clinical information to inform patient
care. Additional techniques are less frequently adopted assessments that can potentially provide enhanced disease resolution but often require more
advanced clinical instrumentation . A recommended order for clinical testing is indicated in the left-most column.
CLDEQ-8, 8-item contact lens dry eye questionnaire; LWE, lid wiper epitheliopathy; NITBUT, noninvasive tear break-up time; OCT, optical coherence
tomography; OSDI, Ocular Surface Disease Index; TBUT, tear break-up time; BHVI, Brien Holden Vision Institute.

■ Tear film stability, measured noninvasively, has been reported

to be useful as a predictor of symptoms (Situ et al. 2008).
■ Tear evaporation rate increases with all lens wear, sug-
gesting that physical disruption to the tear film in the
presence of a lens is the primary driver of excessive evapo-
ration, rather than the lens material or fit.
■ At approximately 2 µm, the prelens tear film is thinner than
the preocular tear film by approximately 1 µm (Nichols &
King-Smith 2003, Chen et al. 2010), possibly predisposing
the fluid to the more rapid destabilisation described previ-
ously. Instilling artificial tears can increase the prelens tear
film thickness, but the effect is transient and the post-lens
tear film shows minimal fluctuation (Chen et al. 2010).
■ Asymptomatic contact lens wearers have a greater basal
tear flow rate than symptomatic wearers, perhaps helping
to counteract the loss of tear fluid from the higher tear
evaporation rate in contact lens wear (Craig et al. 2013).
BIOCHEMICAL CHANGES (see Section 9,
Addendum, available at: https://expertconsult.
inkling.com/)
Tear Film and Ocular Surface
Assessment, Relevant to Contact
Lens Wear
Anterior eye health needs to be carefully evaluated both
before the commencement of contact lens wear and at regular
review intervals in established wearers. In Table 5.1, the
authors propose a systematic approach to assessing relevant
tear film and ocular surface parameters, including details
of the key clinical tests.
100 SECTION 2  •  Anatomy, Physiology and Patient Suitability
History and Symptoms
Initial clinical examination invariably begins with a thor-
ough history and exploration of any presenting symptoms.
Symptoms frequently reported in dry eye disease (e.g. eye
scratchiness, grittiness, foreign body sensation, burning) are
also common in contact lens wearers. Several patient-related
factors have been associated with lens discomfort, including:
■ female sex
■ younger age
■ poor tear film quantity and quality
■ seasonal allergy
■ certain systemic medications (Dumbleton et al. 2013).
Fig. 5.2  The Contact Lens Dry Eye Questionnaire-8 (CLDEQ-8) is a validated questionnaire for establishing dryness symptoms related to contact lens
wear. © Indiana University (permission granted)
Cigarette smoking also is a risk factor for tear instability and
ocular surface damage (Ward et al. 2010).
The frequency and/or severity of discomfort symptoms
can be measured using standardised questionnaires. The
eight-item Contact Lens Dry Eye Questionnaire (CLDEQ-8)
(Chalmers et al. 2012) is a good quantitative tool for mea-
suring lens discomfort (Fig. 5.2). This validated survey cap-
tures information over the preceding 2 weeks relating to eye
discomfort, eye dryness and changeable/blurry vision, as
well as the effects of eye closure and contact lens removal.
Changes to CLDEQ-8 score are considered to be reflective of
a wearer’s global opinion of his or her lens comfort.
 5  •  Tears and Contact Lenses 101

KEY POINTS
For subjective evaluation of ocular comfort in contact lens
wearers
• A thorough clinical history is essential to assess for symp-
toms, the influence of exacerbating conditions and/or any
potential risk factors for lens discomfort.
Objective Clinical Assessments
Consider the test order of objective assessments to ensure
test results are not affected by preceding tests. The order
should progress from least invasive (e.g. noncontact tests)
to most invasive (e.g. Schirmer test).
ANTERIOR EYE (see Chapters 6, 8 and 15)
Carry out a general slit-lamp examination and assess param-
eters using standardised clinical grading scales (e.g. Brien
Holden Vision Institute (BHVI) (for further information see
https://expertconsult.inkling.com/), Efron), including:
■ The lashes for signs commonly associated with meibomian
gland dysfunction (MGD):
■ madarosis (Fig. 5.4a)
■ poliosis
■ trichiasis
Blepharitis
Any anterior blepharitis (crusting as shown in Fig. 5.4d).
MGD or anterior blepharitis should preferably be managed
before contact lens fitting is attempted. The presence of notch-
ing of the inferior eyelid (Fig. 5.4c) may be a sign of long-
standing meibomian gland disease, with associated gland
atrophy. Evert the superior eyelid to check for a conjunctival
papillary response (see Chapters 12 & 16).
■ Examine the corneal and conjunctival integrity before
instilling diagnostic dyes, and note anomalies such as
pingueculae or pterygia. Folds in the bulbar conjunctiva
(LIPCOF – see page 110) are likely to prevent the

■ Ocular bulbar redness is a common and nonspecific clinical

sign that can be associated with several factors, includ-
ing dryness, exposure, inflammation and infection (Fig.
5.3). The location, pattern and depth of the response can
assist with guiding the diagnosis. For example, vasodi-
lation of the blood vessels adjacent to the limbus may
be associated with a hypoxic-driven response to contact
lens wear or may indicate inflammation within the uveal
tissues.
■ Evaluation of the eyelids with regard to:
■ hyperaemia (Fig. 5.4a)
■ oedema (Fig. 5.4a)
■ thickening (Fig. 5.4a)
■ telangiectasia (Fig. 5.4a)
Fig. 5.3  Ocular bulbar redness. An anterior eye photograph showing
■ concretions generalised ocular bulbar redness in a patient with dry eye disease.
■ keratinsation (Fig. 5.4b) Note the incomplete rings reflected from the corneal topographer also
■ irregularity (Fig. 5.4c). a sign of dry eye.

C D
Fig. 5.4  Common eyelid margin features of meibomian gland dysfunction (MGD). (a) Lid rounding and thickening with madarosis and lid margin
telangiectasia in severe MGD. (b) Lower lid margin hyperkeratinisation highlighted with lissamine green. (c) Lid margin irregularity with marked notch-
ing of the lower eyelid margin in severe MGD. Lid margin telangiectasia and bulbar hyperaemia can also be seen. (d) Marked crusting of the lashes on
the upper lid, a hallmark feature of anterior blepharitis.
102 SECTION 2  •  Anatomy, Physiology and Patient Suitability
Fig. 5.5  Tear film frothing at the lateral canthus arises as a result of
bacterial esterases breaking down tear lipids in a saponification process.
Fig. 5.6  TearLab™ osmometer measures tear film osmolarity, via imped-
ance spectroscopy, in the clinical setting.
formation of a normal tear reservoir and are an indicator
of conjunctival dryness.
■ Assess the overall tear film quality, in particular looking
for the presence of frothing or foaming which may be
indicative of MGD (Fig. 5.5).
Tear compositional integrity can be quantified by measuring
tear osmolarity (Fig. 5.6). A value greater than or equal to
316 mOsmol/L provides high predictive accuracy for diag-
nosing dry eye (Tomlinson et al. 2006).
TEAR LIPID LAYER
Tear Film Stability
The most common method for assessing tear film stability
is tear film break-up time (TBUT). This technique involves
instilling a small volume of sodium fluorescein into the eye
and observing the integrity of the precorneal tear film by
slit-lamp biomicroscopy using cobalt blue illumination, which
can be enhanced with a Wratten-12 yellow barrier filter.
TBUT is the time, in seconds, between a complete blink and
the first dark patch (break) appearing in the film (Norn 1969).
TBUT is:
■ shorter in females than males
■ shorter in Asians than Caucasians. In Caucasians, a TBUT
of less than 10 seconds is considered a marker of tear film
instability (Mengher et al. 1985) but for Asians 7 seconds
is adequate (Yeh et al. 2015).
Measuring TBUT with sodium fluorescein has several
limitations:
■ The method is poorly reproducible.
■ Instilling fluid into the eye affects tear stability (Mooi
et al. 2017).
■ Measurement accuracy can be influenced by factors such
as the volume and pH of instilled fluid, slit-lamp illumina-
tion level and clinician expertise (Sweeney et al. 2013).
These limitations provide rationale for utilising less invasive
tear stability measures (see Table 5.1). Several techniques for
measuring noninvasive tear break-up time NIBUT are avail-
able, most of which involve the observation and/or quantifica-
tion of the integrity of a reflected-grid or videokeratographic
mire pattern from the precorneal film (Fig. 5.7) (see Video
5.1). Normative values depend on the instrumentation and
will not necessarily correlate well with traditional TBUT mea-
sures derived using sodium fluorescein (Cho & Douthwaite
1995, Downie 2015).
Tear stability can be quantified for the prelens tear film
to assess lens wettability. Contact lens wear thins the tear
lipid layer, leading to a relatively reduced prelens NIBUT
(Faber et al. 1991, Young & Efron 1991), more rapid tear
evaporation (Guillon & Maissa 2008) and accelerated tear
thinning (Nichols et al. 2005) compared with no lens wear.
The gradual accumulation of surface deposits in rigid lens
wear exacerbates the effects of poor prelens wetting and
emphasises the need for appropriate lens maintenance and
regular lens replacement with this modality.
Impaired tear stability is associated with higher levels of
ocular discomfort during contact lens wear, and symptomatic
soft lens wearers show significant differences in their prelens
tear film kinetics. In a retrospective analysis, symptomatic
soft lens wearers were found to have reduced surface cover-
age of the lens by the tear film during the interblink period
and a greater proportion of surface exposure at the time of
blink than asymptomatic lens wearers (Guillon et al. 2016).
Evaluating prelens tear film kinetics may be valuable, there-
fore, for monitoring the efficacy of management strategies
(e.g. changes to lens materials and/or contact lens solutions)
aimed at supporting the prelens tear film to enhance lens
comfort.
KEY POINT
Evaluating tear stability, as relevant to contact lens wear:
• The level of tear film stability relates to the degree of
comfort during contact lens wear.
• Noninvasive measures of tear stability are preferable for
examining the tear film in its natural state compared with
traditional measures requiring the instillation of sodium
fluorescein.
• Automated measurement systems are clinically useful for
determining NIBUT; however, diagnostic criteria for tear
instability are instrument-specific.
• The wettability of a contact lens in situ can be quanti-
fied dynamically using similar techniques to measuring
precorneal NIBUT.
Lipid Layer Evaluation
The nature of the tear film’s thin layer of lipid adjacent to
the different refractive index of the aqueous phase allows
 5  •  Tears and Contact Lenses 103

A C

B
Fig. 5.7  Noninvasive tear break-up time NIBUT measurement. (a) Grid attachment inserted within the Tearscope Plus™ reflects mires from the tear
film surface and facilitates NIBUT measurement. (b) The Oculus Keratograph 5M reflects Placido disc rings from the tear film surface, and the automated
software allows evaluation of the noninvasive Keratograph break-up time (NIKBUT) and the break-up profile between blinks. Tear film breakup can be
seen inferiorly in the infrared image (left) as distortions in the reflected mire pattern. Analysis of the breakup over time is plotted and enables the
pattern of breakup with time to be mapped (right). (c) Placido disc rings reflected onto the corneal surface, as captured by the Medmont E300 corneal
topographer. The yellow arrows identify points of ring distortion, indicating localised areas of tear film instability, from which a value for the tear film
surface quality (TFSQ) is derived.

visualisation of the oil layer by thin film interferometry for
estimation of quality and thickness. Specular reflection of
white light from the lipid layer of the tears generates first order
coloured interference fringes when the lipid thickness exceeds
one-quarter of the wavelength of light. These coloured fringes
can sometimes be seen on standard slit-lamp biomicroscopy.
However, lipid layer thicknesses in the normal tear film are
often less than 100 nm, and so colours are not visible. A
meaningful assessment of the lipid layer by interferometry
thus requires a wide-field, cold, broad-spectrum light source
to allow observation of thinner layers.
Although precise quantification of lipid thickness is most
accurately achieved with the use of single-wavelength
interferometers (Doane 1989), white-light interferometry
reveals patterns characteristic of a particular lipid thick-
ness range, which can be classified according to published
grading scales (Fig. 5.8) (Guillon & Guillon 1993). The fol-
lowing numbered lipid pattern grading scale, based on the
ordinal Guillon scale (Ruben & Guillon 1994, Guillon &
Guillon 1993), is helpful in the clinical setting for assessment
and review:
Open Meshwork (Grade 1). This describes an extremely
thin lipid layer. By virtue of the lipid thickening when it is
compressed between the eyelid margins during a blink, this
pattern tends to be visible only by the postblink movement.
When the eye is fully open and the lipid is maximally stretched
over the tear film surface, it is often no longer visible.
Closed Meshwork (Grade 2). In clinical appearance, this
pattern has been likened to marble, fish scales or loosely
stretched knitting (Fig. 5.8a). It is similar in appearance
to the open meshwork pattern, except that because of its
greater thickness, the closed meshwork pattern remains
stable and clearly visible between blinks when the eye is
fully open.
Wave (Grade 3). This is the most commonly observed pattern
in the non–lens-wearing eye (Fig. 5.8b) (see Video 5.2). It is
visible as parallel streaks or waves flowing across the tear
film surface signifying increasing thickness of the lipid layer.
The waves can flow either horizontally or vertically (i.e. par-
allel or perpendicular to the lid margins).
104 SECTION 2  •  Anatomy, Physiology and Patient Suitability
A B
D E
Fig. 5.8  Range of lipid layer patterns visible by interferometry with the Tearscope Plus™. (a) Lipid layer meshwork pattern. (b) Lipid layer wave or flow
pattern. (c) Lipid layer amorphous pattern. (d) Lipid layer normal coloured fringe pattern. (e) Lipid layer abnormal coloured fringe patterns. (f) Lipid
layer contaminated by face cream previously applied to the periocular skin.
Amorphous (Grade 4). This highly reflective layer has a
stable, whitish, even appearance indicating a good-quality,
thick lipid layer, which is considered ideal for contact lens
wear (Fig. 5.8c). A tip to help avoid confusion when differ-
entiating between an amorphous or absent lipid pattern,
since both lack discernible features, is to ask the patient to
partially close his or her eyes. Compression of the lipid layer
between the lid margins will induce a coloured fringe appear-
ance in the case of a thicker amorphous lipid pattern but
not in the case of a thin or absent pattern.
Coloured Fringes (Grade 5). With further thickening of
the lipid layer, first order coloured fringes (blues and browns)
are visible on the tear film surface when the eye is fully open
(Fig. 5.8d) (see Video 5.3). This stable pattern, where the
position of the fringes remains relatively fixed between blinks,
also indicates a good-quality, thick lipid layer. This pattern
is also is ideal for prospective contact lens wearers.
The following patterns are both highly abnormal and
graded as zero.
Abnormal Colours (Grade 0). This globular appearance
indicates highly variable lipid thickness across the surface
and is commonly observed in MGD (Fig. 5.8e). It signifies an
unstable lipid layer with a poor ability to inhibit tear film evapo-
ration (Craig & Tomlinson 1997). This association with poor
stability and a fourfold increase in evaporation rate highlights
the importance of treating underlying lid disease, indicated by
a pattern such as this, before fitting contact lenses.
Absent (Grade 0). The lipid is described as clinically absent
when no pattern is visible. This appearance is similarly
C
F
associated with a fourfold increase in tear evaporation rate
and shows rapid, often instantaneous tear film breakup (Craig
& Tomlinson 1997). A clinically absent lipid layer is a common
feature of advanced obstructive MGD.
Contaminated. Face creams and eye makeup can often
migrate over the eyelid margins into the tear film (Fig. 5.8f).
The contamination precludes maintenance of a continuous
or stable lipid layer.
A number of slit-lamp mounted devices exist to facilitate
interferometric lipid layer analysis; these include the Tear-
scope™ or Tearscope Plus™,* EasyTearView+™ (EASYTEAR
s.r.l., Rovereto, Italy) and Polaris™ (C.S.O. s.r.l., Florence,
Italy). Videokeratographic instruments, such as the Oculus
Keratograph 5M, also provide some ability to evaluate the
lipid layer from interferometric patterns created by the
illumination arising from the white rings of their Placido
devices. Commercial interferometers such as the LipiView
II (TearScience Inc., USA) provide objective quantification
of lipid layer thickness.
Meibum Quality and Ease of Expression
The expressibility of the meibomian glands is shown in Fig.
5.9. Contact lenses can affect the morphological integrity of
these glands, particularly in the superior eyelid (Arita et al.
2009), although whether meibum composition is related to
the degree of contact lens comfort is uncertain.
A key recommendation of the TFOS International Workshop
on Meibomian Gland Dysfunction (2011) was for diagnostic
*The Keeler Tearscope™ and Tearscope Plus™ are currently unavailable
commercially.

meibomian gland expression to be routinely performed, even
in asymptomatic adults (Nichols et al. 2011). The procedure
should involve the application of moderate digital pressure
(Fig. 5.9) or a standardised technique. A gland expression
device developed by Korb and Blackie (Meibomian Gland
Evaluator, TearScience Inc., USA) applies a force (0.8–1.2 g/
mm2) that approximates the force applied by the eyelids to
the globe during natural blinking (Korb & Blackie 2008).
Gland expressibility is scored according to the number of
glands producing fluid secretions (Meadows et al. 2012).
For manual digital expression, a semiquantitative scale for
meibomian gland expressibility has been proposed, which
considers:
1. the amount of pressure required to express the glands
(ranging from 1–3, where 1 = light, 2 = moderate and 3
= heavy)
2. the quality of the expressed meibum (ranging from
0–3, where 0 = clear, 1 = cloudy, 2 = granular and 3 =
toothpaste)
3. the volume of secreted meibum (where the diameter of
the largest pool expressed is measured in millimetres)
(Foulks and Bron 2003, Tomlinson et al. 2011).
Fig. 5.9  Meibomian gland expressibility evaluated with digital pressure.
Expressed meibum is graded according to the number of glands express-
ible, and by quality of meibum.
A B
D
C
Fig. 5.10  Infrared meibography images of the upper everted eyelid with the Oculus Keratograph. The meibomian glands appear white against a darker
background of the tarsus, and in the healthy eyelid would be expected to be evenly spaced and parallel to one another, perpendicular to the lid margin
and covering the tarsal area. (a) Minimal meibomian gland dropout. (b) Partial meibomian gland dropout. (c) Marked meibomian gland dropout. (d)
Almost complete meibomian gland dropout.
5  •  Tears and Contact Lenses 105
Lipid deposition occurs on the surface of contact lenses,
particularly with silicone hydrogel materials, and differs in
terms of the amount and distribution depending on meibo-
mian gland health (Hagedorn et al. 2015). Lipids extracted
from people with MGD tend to deposit irregularly on the
contact lens surface, whereas lipids from patients with
healthy glands deposit relatively uniformly. Further research
is required to understand the relative significance of these
findings.
Meibography
Morphological assessment of the inferior and superior mei-
bomian glands is performed by transilluminating the eyelid
(meibography under infrared illumination (Tomlinson et al.
2011). Several devices for noncontact meibography are com-
mercially available, including the Oculus Keratograph 5M
(Oculus Inc., Wetzlar, Germany), EASYTEARview (EasyTear,
Trento, Italy), LipiView II (TearScience Inc., USA) and the
Topcon BG-4M system, which can be mounted on certain
Topcon slit-lamps (Topcon, USA).
The extent of gland dropout, which defines the degree
of partial or total loss of the acinar tissues (Fig. 5.10), can
be quantified using photographic-based grading scales for
assessing meibomian gland dropout (Arita et al. 2009, Pult &
Riede-Pult 2013). Currently there are no commercial devices
that provide an automated, quantitative assessment of mei-
bomian gland morphology relative to a normative database,
but photographic documentation of the extent of meibomian
gland dropout is valuable for qualitatively monitoring pro-
gressive changes to gland morphology.
KEY POINT
Meibomian gland evaluation, as relevant to contact lens
wear:
• Evaluation of eyelid health should be performed both before
the initiation of contact lens wear and at regular intervals
in established wearers to guide appropriate therapy for
MGD.
106 SECTION 2  •  Anatomy, Physiology and Patient Suitability

Fig. 5.12  Schirmer test: Lacrimal gland function is tested by hooking

sterile filter paper strips over the lateral third of the lower eyelids for 5
minutes. The wetted length is then measured.
Fig. 5.11  Tear meniscus height. Image of the inferior tear meniscus,
taken under infrared illumination, showing a central tear meniscus height
of 0.24 mm.

• Meibomian glands should be thoroughly examined, ideally

using a standardised grading scheme (Tomlinson et al.
2011) to quantify both expressibility and morphology.

TEAR AQUEOUS LAYER

Meniscometry
The height and/or volume of the tear meniscus, the reservoir
adjacent to the lid margin (see Fig. 5.11) for tear distribu-
tion into the precorneal film, is measured by meniscometry.
Tear meniscus height (TMH) is the height of the tear film
at the junction of the bulbar conjunctiva and the eyelid; it
is a surrogate measure of tear volume. It is typically taken
at the central aspect of the inferior eyelid immediately after
a blink. Techniques are noninvasive and can be performed
in real time using a slit-lamp, slit-lamp photography (Fig.
5.11), tear interference imaging or optical coherence tomog-
raphy. For assessment of the tear reservoir using fluorescein,
see Fig. 5.16.
An inferior TMH of less than 0.30 mm is generally consid-
ered consistent with dry eye, although a range of normative
values have been suggested in the literature. Contact lens
wear has been established to reduce the volume of the tear
meniscus by approximately one-third (Craig et al. 2013).
Total tear volume also decreases from lens application to
end-of-day removal, which appears related to the degree of
lens discomfort. Instilling topical lubricants, with the intent
of improving lens comfort, has been shown to enhance tear
meniscus volume transiently (i.e. for less than 30 minutes)
(Chen et al. 2011), supporting subjective clinical reports from
symptomatic lens wearers that improvements in comfort with
topical lubricants are often short-lived.
Schirmer Test
The Schirmer test (Fig. 5.12) is used to evaluate aqueous
tear production and is carried out as follows:
■ Sterile paper strips are applied into the inferior-temporal
aspect of the conjunctival sac of both eyes.
■ The room is dimly lit, and the patient asked to close
their eyes.
■ The wetted length, in millimetres, is measured after 5
minutes.
Fig. 5.13  Phenol read thread test. The preimpregnated cotton thread
is hooked over the lateral third of the lower eyelid, and the wetted
length, as indicated by the red colour, is measured after 15 seconds.
There are two variations of the test:
■ Without topical anaesthesia – this measures the total tear
secretion and is the sum of reflex and basal tear flow
■ With topical anaesthesia for patient comfort – This aims
to quantify basal tear secretion, but the ability of topical
anaesthetic application to eliminate the reflex component
of tearing has been questioned (Jordan & Baum 1980).
Although the Schirmer test has poor discriminability for
milder forms of dry eye disease, a Schirmer test score below
5 mm without anaesthetic is abnormal.
There has been limited research to investigate tear produc-
tion during contact lens wear, with studies suggesting that tear
production and turnover per se are not significantly altered.
Phenol Red Thread Test
The phenol red thread test (Fig. 5.13) also quantifies tear
secretion and causes less conjunctival and eyelid irritation
than the Schirmer test. It comprises a 70 mm thin cotton
thread preimpregnated with phenol red (phenolsulfonphtha-
lein), a pH indicator. When wet slightly alkaline by tears (pH
range 7.0–8.0), the colour changes from yellow to red. The
test is carried out as follows:
■ Hook the folded end of the thread at a point one-third of
the distance from the lateral canthus of the lower eyelid,
in each eye.
 5  •  Tears and Contact Lenses 107

■ Ask the patient to maintain primary gaze and blink nor-

mally for 15 seconds.
■ Measure the length of the red (wet) portion of the thread.

A wetted length of 10 mm or less has a relatively high speci-

ficity (93%), albeit low sensitivity (25%), for identifying dry
eye disease (Pult et al. 2011).

KEY POINT

Evaluating the tear aqueous layer, as relevant to contact

lens wear:
• Assessment of the tear aqueous layer and/or tear produc-
tion using at least one clinical method (TMH, Schirmer
test or phenol red thread test) before contact lens fitting is
essential for identifying any potential aqueous deficiency,
to allow appropriate management strategies to be insti-
tuted and to guide the lens fitting approach in suitable
candidates. Fig. 5.14  Mucin balls: Spherical mucin balls observed by slit-lamp bio-
• The Schirmer test has limited discriminative capacity for microscopy after overnight wear of silicone hydrogel contact lenses.
milder states of tear insufficiency.
• TMH has the advantage of being a noninvasive measure
of tear volume that is useful in dry eye assessment and
2002) with a reduction in density of about 20 percent in
can also be quantified with the contact lenses in situ.
dry eye disease (Nelson & Wright 1984).
Mucin Balls (see also Chapter 12)
CLINICAL ASSESSMENTS TO EVALUATE THE
TEAR MUCIN LAYER Secreted mucins at the ocular surface are decreased in contact
lens wearers (Craig et al. 2013). A phenomenon specific to
Diagnosis of mucin deficiency can inform the clinician contact lens wear, thought to result from the shear forces
whether to adopt treatment strategies that aim to increase created between the epithelial surface and the contact lens
goblet cell density and/or whether to use mucomimetics with blinking, is the formation of ‘mucin balls’. Mucin balls
to improve the hydrophilicity of the ocular or contact lens (Figs 5.14 and 12.27) consist predominantly of glycoproteins,
surface. rather than lipids or bacteria, and are considered an innocu-
Examples of conditions that predispose patients to mucin ous finding that results in transient spherical indentations
deficiency include Sjögren’s syndrome, thermal and alkali in the corneal epithelium (Millar et al. 2003).
burns, vitamin A deficiency, Stevens-Johnson syndrome
and cicatricial ocular pemphigoid (Ramamoorthy & Nichols KEY POINT
2008). Excessive production of mucin may occur in atopic
Evaluation of the tear mucin layer, as relevant to contact
conditions including giant papillary conjunctivitis and vernal
lens wear:
conjunctivitis (Hu et al. 2007). Tear mucin levels are also
• The extent of conjunctival staining with lissamine green
decreased in dry eye disease in response to a reduction in
provides an indirect measure of the degree of mucin cov-
conjunctival goblet cell density.
erage on the ocular surface.
Clinical dyes rose bengal and lissamine green (see ‘Ocular
• Impression cytology can be used to assess goblet cell density
Surface Staining’, p. 108) highlight dead and devitalised cells,
and squamous cell metaplasia.
as well as cells lacking mucin cover. These dyes provide an
indirect means of assessing conjunctival mucin coverage
(see Fig. 5.16c). CLINICAL ASSESSMENTS TO EVALUATE OCULAR
Impression Cytology SURFACE INTEGRITY
An indirect measure of the amount of secreted mucin can Blinking Characteristics
be obtained by quantifying the goblet cell density and the
extent of squamous cell metaplasia as follows: Clinical evaluation for potential eyelid and/or blinking anoma-
lies in contact lens wearers should consider:
■ applying a small cellulose-acetate disc onto the conjunctival
surface
■ gently removing it to extract a superficial layer of con-
Blink Rate/Frequency. Most people blink every 4–6
seconds. Blink rate can be reduced by systemic conditions
junctival and goblet cells, along with the tear film and
(e.g. Parkinson’s disease) or by states of concentration (e.g.
conjunctival mucin layer.
■ processing the sample histologically to highlight the cells
driving and computer use) and can be a risk factor for ocular
exposure. Knowledge of a potential contact lens wearer’s
and enable assessment by light microscopy
visual tasks is important for assessing whether the blink
In healthy eyes, conjunctival goblet cell density is in the range rate may be a predisposing factor for dry eye and/or ocular
of 380–430 cells/mm2 (Nelson & Wright 1984, Kunert et al. discomfort.
108 SECTION 2  •  Anatomy, Physiology and Patient Suitability
Blink Completeness. Incomplete blinking refers to partial
coverage of the ocular surface with natural blinking and is
frequently observed in people with dry eye disease. Blink
characteristics can be qualitatively observed at the slit-lamp
biomicroscope. For more advanced analysis, the LipiView II
system (TearScience, Inc., USA) incorporates a quantitative
evaluation of both blink rate and the frequency of partial
versus complete blinks. Incomplete blinking may affect on-eye
lens movement and/or tear film distribution, resulting in
vision fluctuation and poor tear exchange with contact lenses,
and has been implicated in longer-term meibomian gland
health (Craig et al. 2016). Some practitioners advocate blink-
ing training regimes, for which computer-based programs
are available (see page 113 and fig. 5.24).
The Ocular Protection Index (OPI). This index is the
ratio of the TBUT (in seconds) to the interblink interval (in
seconds) and can be quantified to assess the potential risk
of exposure-type ocular surface injury. Ousler et al. (2008)
considered an OPI of 1.0 or greater to be indicative of ade-
quate ocular surface protection. Based on the OPI, a reduction
in tear film stability (TBUT) can potentially be compensated
for by an increase in blink rate and still provide adequate
ocular surface protection. In dry eye disease and in contact
lens wearers experiencing dry eye symptoms, blinking fre-
quency tends to increase, presumably as a compensatory
mechanism to offset the relative tear instability.
Other Eyelid Abnormalities. Abnormalities including
lagophthalmos, proptosis and eyelid positional defects should
also be considered.
Lagophthalmos (Fig. 5.15) (see Video 5.4). Lagophthalmos,
the inability to completely close the eyelids, can be grossly
examined by assessing a patient’s attempt to fully shut his
or her eyes. Blackie and Korb (2015) described a method to
evaluate the presence of a compromised overnight eyelid
moisture seal which involves a transilluminating device being
placed against the closed, relaxed outer eyelid with the patient
in a semireclined position. The amount of light emanating
from between the eyelashes is then quantified on a four-step
scale. Greater degrees of emerging light have been shown
to be associated with higher levels of discomfort symptoms
on waking.
KEY POINT
Blinking and eyelid characteristics, as relevant to contact
lens wear:
Fig. 5.15  Closed eye in a patient with lagophthalmos. Forced eye closure
fails to juxtapose the upper and lower eyelids, leaving 2 mm exposure.
• Given the importance of complete and regular blinking
in promoting meibum excretion, distributing the lipid layer
and promoting tear film stability, a thorough prelens fitting
examination of blinking dynamics and eyelid mechanics
is warranted.
• The Ocular Protection Index, describing the ratio of the
tear break-up time to interblink interval, can provide an
overall measure of the level of ocular surface protection
in vivo.
Ocular Surface Staining
Ocular surface damage can be assessed clinically using bio-
logical stains; in contemporary practice, the most common
vital dyes are sodium fluorescein (Fig. 5.16a) and lissamine
green (Fig. 5.16b and c). ‘Staining’ is the general term
used to describe the punctate uptake of the dye by ocular
surface cells.
Ocular surface staining is a nonspecific sign, which can
result from multiple aetiologies, including dry eye disease,
contact lens wear and trauma. In dry eye disease, staining
is classically interpalpebrally located. This is considered to
reflect the distribution of tear hyperosmolarity, a major con-
tributory factor to epithelial cell injury (Gaffney et al. 2010).
Grading scales can again be useful in quantifying the severity
of ocular surface staining.
Sodium Fluorescein. This is an orange water-soluble dye
that fluoresces green when excited by short-wavelength
(typically blue) light (see also Chapter 9). Maximum fluores-
cence occurs at a concentration of approximately 0.08 g/L,
with ocular surface staining optimally visualised about 1–2
minutes after instillation. Appropriate clinical interpretation
of ocular surface staining with sodium fluorescein has evolved
in recent years. In a comprehensive review, Bron et al. (2015)
described the presence of sparse punctate corneal staining
in the healthy cornea, historically considered an indicator of
pathology, as being due to the regional absence of a protective
glycocalyx barrier. As corneal epithelial cells are shed and
underlying new cells replace these, the new cells are yet to
be sufficiently covered by glycocalyx and so will absorb the
sodium fluorescein stain. Pathological corneal staining is
considered to represent an exaggeration of this process in
which abnormalities in the tight-junctions between adjacent
corneal epithelial cells are combined.
Conjunctival sodium fluorescein staining is often less appar-
ent than corneal staining.
Rose Bengal or Lissamine Green (Figs 5.16b and c). Rose
bengal is a water-soluble dye that stains primarily devitalised
cells, mucous fibrils, plaques and epithelial cells devoid of
surface glycocalyx (mucin) (Khan-Lim & Berry 2004).
Instillation of the dye results in a prominent stinging sen-
sation and may induce cell surface toxicity, although paper
strips impregnated with the dye cause less discomfort. Lis-
samine green, which demonstrates a similar staining profile
to rose bengal, is now more commonly used. It is useful for
detecting eyelid anomalies, including lid wiper epitheliopathy
(LWE) and positional changes to Marx’s line (see below and
Figs 5.17a and b).
Contact lens wearers frequently exhibit ocular surface
staining, which is covered in Chapters 9 and 16.
 5  •  Tears and Contact Lenses 109

C
Fig. 5.16  Diagnostic dyes used to aid visualising ocular surface health: Images show (a) corneal staining with sodium fluorescein, (b) lissamine green
staining of the cornea, and (c) staining of the conjunctiva with lissamine green.

lissamine green staining will occur in earlier stages of

ocular surface disease.

Lid Margin Evaluation

Eyelid margin assessment is enhanced by applying vital dyes
(Fig. 5.17) to assist with detecting the following changes to
lid integrity:

Position of Marx’s Line. Marx’s line consists of a zone of

cells located at the surface of the mucocutaneous junction
and marks the transition point between the palpebral con-
A junctiva and keratinised lid margin (Fig. 5.17a). It consists
of stratified squamous epithelium, contains goblet cells and
stains prominently with lissamine green. Keratinisation is
a key feature of MGD that can contribute to gland block-
age and restrict meibum egress from the gland orifices (Fig.
5.4b). It leads to changes to the eyelid architecture, reflected
in anteroposterior migration and irregularity in the position
of Marx’s line. A functional consequence of this alteration
is a tendency for meibum secretion to be blocked, or misdi-
B rected into the aqueous component of the tears, which has
a destabilising effect on the tear film. The effects of excess
Fig. 5.17  (a) Lid margin evaluation: position of Marx’s line and lid wiper keratinisation can be reduced with lid margin debridement
epitheliopathy (LWE). (b) Upper LWE observed with lissamine green
staining. Inset shows detail of LWE in higher magnification. (described on p. 111 and Fig. 5.20).

The Lid Wiper. This is a narrow portion of the eyelid mar-

KEY POINT
Evaluating ocular surface staining, as relevant to contact
lens wear:
• The pattern and location of ocular surface staining
can provide important diagnostic information about its
aetiology.
• Corneal sodium fluorescein staining generally occurs
with more severe tear dysfunction, whereas conjunctival
ginal conjunctiva that makes direct contact with the ocular
surface during blinking. Assessment of the superior zone
is traditionally undertaken by instilling sodium fluorescein
and lissamine green dyes, in combination, and by gently
everting the eyelid(s) to observe the staining. The extent of
eyelid margin staining can be graded using a four-step scale
which factors in the horizontal length and sagittal width
of the staining (Korb et al. 2005). Staining of the lid wiper
is indicative of trauma to this region, and LWE is highly
110 SECTION 2  •  Anatomy, Physiology and Patient Suitability
prevalent in people symptomatic of dry eye. LWE may exist in
the absence of other classical clinical signs of dry eye and can
therefore provide a useful sign for diagnosing tear film dys-
function. LWE is observable in the majority (67–80 percent)
of symptomatic soft lens wearers, with significantly lower
prevalence in asymptomatic lens wearers (13–32 percent)
(Korb et al. 2005, Yeniad et al. 2010).
KEY POINT
Evaluating the eyelid margins, as relevant to contact lens
wear:
• Eyelid eversion should be routinely performed.
• Ensure the entire eyelid is examined, including the tarsal
conjunctiva and the margin, and assess for LWE as it is
strongly associated with ocular dryness symptoms.
• LWE is frequently observed in the absence of more tradi-
tional signs of dry eye as a relatively early indicator of
ocular surface disease.
Lid Parallel Conjunctival Folds (LIPCOF). These are
considered predictive of symptoms of dryness. LIPCOF (Fig.
5.18), generally considered a subtle manifestation of con-
junctivochalasis, consists of folds in the temporal and nasal
aspects of the bulbar conjunctiva. It has been suggested that
they are markers of mechanical conjunctival injury that
Fig. 5.18  Lid parallel conjunctival folds (LIPCOF) adjacent to the inferior
lid margin.
Table 5.3  Strategies for Improving Tear Film and Ocular Surface Integrity
Lipid
(1). Optimise eyelid margins:
■ lid cleansing (minimise bacterial and/or
Demodex load)
■ lid margin debridement
(2). Promote meibum outflow:
■ controlled application of heat to lid
margins (e.g. warm compresses, intense
pulse light (IPL), Blephasteam, LipiFlow)
■ therapeutic meibomian gland expression
■ blinking exercises
(3). Improve quality of lipid secretions:
■ omega-3 essential fatty acid
supplementation
■ oral antibiotics (e.g. tetracyclines/
macrolides)
■ lipid-based artificial tears
occur as a consequence of friction between the lid wiper and
bulbar conjunctiva. Pult et al. (2011) proposed a four-step
grading scale for nasal and temporal conjunctival areas,
shown in Table 5.2.
Table 5.2 
Grade Number of Folds
0 No conjunctival folds
1 One permanent and clear parallel fold
2 Two permanent and clear parallel folds (normally 0.2 mm)
3 More than two permanent and clear parallel folds
(normally >0.2 mm)
Creating and Maintaining a
Robust Tear Film
A robust tear film provides essential support for a contact
lens and increases the likelihood of successful wear.
Table 5.3 summarises the range of management strategies
relating to the relevant tear layers in order to improve the
tear film and ocular surface.
LIPID (see Section 9, Addendum, available at:
https://expertconsult.inkling.com/)
A three-step approach is recommended for improving the
tear film lipid layer.
STEP 1
Promote a high-quality lipid layer by confirming optimal
health of the lid margins and ensuring gland orifices are
conducive to meibum release. This may involve a combina-
tion of eyelid cleansing to reduce bacterial and Demodex load
and debridement to remove excess lid margin keratinisation.
■ Removing crusting from around the eyelashes reduces the
bacterial load and improves clinical signs and patient-
reported symptoms.
Aqueous Mucin
(1). Promote tear retention: (1). Promote tear stabilisation:
■ environmental adaptation (e.g. ■ muco-mimetic artificial tears
humidifier, moisture-retention goggles) (2). Minimise potential impact upon
■ punctal occlusion goblet cell density:
(2). Supplement the tear film: ■ consider fitting with silicone
■ aqueous-based artificial tears hydrogel lenses in preference to
(3). Reduce ocular surface inflammation: hydrogel lenses
■ topical anti-inflammatory agents
■ omega-3 essential fatty acid
supplementation

Fig. 5.19  BlephEx™. The foam-tipped applicator rotates at high speed
to permit thorough lid and lash cleansing.
■ Eyelid margin cleansing is most often performed with lid
wipes or with a cotton-tipped application soaked in lid
cleanser. It can be performed more thoroughly in-office
with custom-designed devices such as the BlephEx (Scope
ophthalmics) (Fig. 5.19) (see Video 5.5). This device com-
prises a spinning foam sponge–tipped applicator, which
the clinician premoistens with an eyelid cleansing solution
and then gently works along the lid margin to clear the
crusting from on and around the lashes.
■ Intractable cases of blepharitis, which do not respond to
conventional lid hygiene measures, may be caused or exac-
erbated by Demodex. These ectoparasites live within the
eyelash follicles (Demodex folliculorum) and deep within the
meibomian and eyelash sebaceous glands (Demodex brevis).
Ocular demodicosis and blepharitis are associated with
each other, although there lacks clarity over cause and
effect. Treatments that successfully reduce Demodex counts
have been shown to effect improvements in lid signs and
symptoms (Gao et al. 2005). Treatment of Demodex with
conventional therapies shows little benefit. Better outcomes
are achieved with topical application of tea tree oil and,
potentially, oral ivermectin (Holzchuh et al. 2011). Clinical
treatment involves weekly application by the practitioner
of a 50% tea tree oil solution to the external eyelid and
eyelash bases, with conventional daily lid hygiene per-
formed at home in between. With the Demodex life cycle
being approximately 2–3 weeks, weekly treatments are
recommended over at least 3 consecutive weeks to ensure
elimination of Demodex at different life stages.
■ Hyperkeratinisation is a key pathophysiological feature of
MGD and contributes to gland obstruction at the orifice
(Knop et al. 2011). Removal of excess keratinised mate-
rial from the lid margin, by debridement with a golf club
spud (Fig. 5.20), can improve meibomian gland function,
reduce ocular surface staining and decrease symptoms
5  •  Tears and Contact Lenses 111
C
Fig. 5.20  Removal of keratinised tissue, with lissamine green staining
as a guide, from the lid margin surface by debridement with a ‘golf club
spud’ epithelial debridement tool. (a) Prelid margin debridement. (b)
Lid margin debridement with a golf club spud. (c) After lid margin
debridement.
(Korb & Blackie 2013, Ngo et al. 2015). Application of
topical anaesthetic and lissamine green before treatment
will respectively aid in loosening and highlighting the kera-
tinised tissue (see Video 5.6).
STEP 2
Encourage meibum flow from the glands (see Section 9,
Addendum, available at: https://expertconsult.inkling.com/).
The melting point of meibum increases in MGD (Borchman
et al. 2011) contributing to the obstruction. Heat encourages
melting of the gland contents so it should be applied together
with some form of assisted gland expression.
■ Using a hot flannel as a compress for the eyes has lost
favour due to rapid cooling and concerns over potential
contamination and inconvenience.
■ Other methods of periocular heating are more controlled,
including microwave-heated seed or hydrating bead
pouches which are applied to the closed eyelids for a period
of 5–10 minutes depending on the manufacturer’s instruc-
tions. A range of products exists, such as MGDRx EyeBag®
(Fig. 5.21), which is approved by the FDA as a class 1
medical device. It has efficacy in improving signs and
symptoms of MGD (Bilkhu et al. 2014, Wang et al. 2015).
■ Therapeutic gland expression describes the forced expres-
sion of meibum by compressing the eyelid between two
rigid implements (Fig. 5.22) (see Video 5.7), usually a com-
bination of cotton buds, fingertips or proprietary devices
such as a flattened stainless steel paddle (e.g. Mastrota
paddle) or flattened stainless steel forceps (e.g. Collins
112 SECTION 2  •  Anatomy, Physiology and Patient Suitability
Fig. 5.21  Warm compress therapy for meibomian gland dysfunction
in the form of the MGDRx Eyebag® (Halifax, UK).
Fig. 5.22  Therapeutic expression of the meibomian glands. A cotton
bud is used to exert pressure against a flattened metal paddle (Mastrota
paddle) to encourage expression of the meibum from the meibomian
glands of the lower eyelid.
Expressor Forceps). Therapeutic expression is performed
more effectively after gland warming but is a painful tech-
nique (Korb & Blackie 2011). In children, this may need
to be carried out under general anaesthesia. To reduce
the risk of traumatic damage to the eyelid tissues, it is
usual to perform the procedure only as deemed clinically
necessary and usually no more frequently than monthly
(McPherson et al. 2016).
■ The Blephasteam® is a proprietary latent heat device
in which moist heat is delivered within a sealed goggle
system. Improvements in symptoms and signs of MGD,
visual quality, conjunctival hyperaemia and tear evapora-
tion rate have been noted after treatment.
■ Intense pulsed light (IPL) therapy (Fig. 5.23) is an approach
to MGD treatment that has gained popularity since the
serendipitous discovery of improvement in MGD symptoms
after IPL was performed to reduce the appearance of facial
flushing secondary to rosacea. Craig et al. (2015) reported
cumulative improvements in lipid layer grade, noninva-
sive tear film stability and symptoms 6 weeks after three
treatments performed on Day 1, Day 15 and Day 45 with
the E-Eye device (E-Swin, France), but the mechanism of
Fig. 5.23  Intense pulsed light therapy is applied to the upper cheek
area while metal goggles protect the globe. The light intensity (fluence)
relates inversely to the level of skin pigmentation. Conducting gel helps
distribute the light evenly and protects the skin from excessive heat.
action of IPL in treating MGD is poorly understood. In the
clinical setting, therapeutic gland expression is typically
performed immediately after IPL treatment.
■ Thermal pulsation therapy describes treatment with the
LipiFlow® device, during which heat is applied to the palpe-
bral conjunctival surfaces of the inner eyelids while pulsing
pressure is applied externally to the eyelids to express the
warmed glands of the upper and lower lids simultaneously.
Greiner (2012) suggested that after a single treatment,
some patients can achieve between 9 and 12 months of
relief from dry eye symptoms, together with improved tear
film stability and an increased number of functional mei-
bomian glands. Finis et al. (2014) found superior results in
patients with less meibomian gland atrophy at the outset.
McPherson et al. (2016) reported similar outcomes to those
of daily traditional warm compress therapy combined with
regular therapeutic expression of the glands, but the less
costly traditional approach requires a much higher level
of compliance for success, lending appeal to the concept
of a single 12-minute LipiFlow® treatment.
Incomplete blinking (Fig. 5.24) is associated with higher levels
of ocular surface staining and symptoms of dryness and dis-
comfort in contact lens wearers (Craig et al. 2013). Full and
regular blinking is therefore important. Increasing blink rate
can improve tear film stability and symptoms, and blinking
exercises (Fig. 5.25) can improve meibomian gland function
and reduce the frequency of partial blinks (Murakami et al.
2014). Blink reminders are available for download from the
internet or as an app for smartphones (IOS: https://itunes.apple.
com/gb/app/donald-korb-blink-training/id941412795?mt=8;
Android: https://play.google.com/store/apps/details?id=com.
tearscience.drkorbblinktraining&hl=en).
STEP 3
Improve the quality of the tear lipids.
Drug Treatment
Tetracyclines are broad-spectrum, bacteriostatic antibiotics
that impart anti-inflammatory effects at the lower doses typi-
cally prescribed for managing MGD. These agents reduce the

activity of collagenases, phospholipase-A2 and several matrix
metalloproteinases, which degrade connective tissue. A 5-day
pulsed dose* of oral azithromycin imparts a similar degree
of improvement in symptoms for MGD when compared with
a 1-month low dose of oral doxycycline (Kashkouli et al.
2015). However, it is possible that the mechanism of action
of doxycycline and azithromycin for treating MGD is distinct
(Foulks et al. 2013). Topical 1% azithromycin, available com-
mercially in some countries, has also been shown to signifi-
cantly improve the lipid characteristics of meibum in
individuals with MGD (Foulks et al. 2010), as well as to reduce
meibomian gland blockage, lid redness and palpebral con-
junctival hyperaemia (Haque et al. 2010).
Diet
Diet can also influence the quality of meibum secretions.
The level of consumption of omega-3 (ω-3) essential fatty
*Pulse dosing is the administration of a drug that produces high and low
concentrations of the drug.
Fig. 5.24  Incomplete blinking highlighted by horizontal bands in a
fluorescein-stained tear film.
BLINKING EXERCISES
(based on the recommendations of Donald Korb, O.D.)
Close Pause 2 seconds
Close Pause 2 seconds
Fig. 5.25  Recommendations to encourage complete and regular blinking.
5  •  Tears and Contact Lenses 113
acids (EFAs) affects meibum composition and modulates
systemic inflammatory pathways.
Lipid-Containing Artificial Tear Products
Certain artificial tear products contain lipids, including
mineral oils and phospholipids, designed to improve tear
stability and reduce tear evaporation by supplementing defi-
ciencies in the natural tear lipids. Products are formulated
as emulsions and include Retaine MGD (OcuSoft), Optrex
liposomal spray (Reckitt Benckiser), Systane Balance (Alcon),
Refresh Optive Advanced (Allergan) and Soothe XP-Xtra
Protection (Bausch & Lomb).
KEY POINT
To improve the tear lipid layer:
• Optimise lid margin health through controlling anterior
blepharitis, lid margin keratinisation, bacterial load and
Demodex infestation.
• Promote meibum outflow through the application of heat
(e.g. warm compresses, Blephasteam, LipiFlow) combined
with therapeutic meibomian gland expression and blinking
exercises.
• Improve tear film lipid quality by managing MGD with
topical and/or oral therapeutics as appropriate and using
lipid-based artificial tear supplements.
AQUEOUS
Deficiencies in the tear aqueous layer occur primarily as a
consequence of lacrimal gland hyposecretion. Although lac-
rimal tear insufficiency is not necessarily a contraindication
for contact lens wear, practitioners are encouraged to adopt
an individual approach to determining patient suitability.
Improving Aqueous Deficiency
Drugs. Anti-inflammatory strategies can be of value for
controlling ocular inflammation in aqueous-deficient forms
of tear dysfunction. Cyclosporine-A is an immunomodulator
that selectively inhibits the activation of T-lymphocytes via
Open Relax
Squeeze Open Relax
114 SECTION 2  •  Anatomy, Physiology and Patient Suitability
Fig. 5.26  Moisture retention spectacles with silicone inserts held in place by micromagnets.
Fig. 5.27  Silicone punctal plug insertion.
interleukin-2. In treating dry eye disease, cyclosporine-A can
increase aqueous production and improve conjunctival goblet
cell density. The potential application of cyclosporine-A in
improving contact lens comfort is unclear.
Anti-inflammatory drugs which could potentially be used
in the management of ocular surface diseases include
corticosteroids and nonsteroidal anti-inflammatory drugs,
but the risk of side effects makes them controversial and
therefore unlikely candidates for treating contact lens–related
tear film dysfunction or lens discomfort.
Humidifying Devices. Beneficial effects, from utilising a
desktop humidifier during computer use, have been reported
(Wang et al. 2017). Moisture-chamber spectacles may help
to reduce aqueous tear loss. They are designed to reduce
tear evaporation by providing a local humid environment
that decreases airflow on the surface of the eye (Fig. 5.26).
Improving Tear Retention. Tear aqueous volume may be
enhanced by methods to improve tear retention, such as
punctal occlusion or by blocking the lacrimal puncta (Fig.
5.27) (see Video 5.8). Reversible punctal occlusion is more
commonly used and can be useful for increasing wearing times
and reducing symptoms in patients experiencing discomfort
from dry eyes both with and without contact lenses. Usually,
occlusion of only the lower puncta is adequate, but occlu-
sion of both the upper and lower puncta may be of greater
value Murgatroyd et al. (2004) found that the about 60% of
the tears drain through the lower puncta whilst 40% drains
through the upper ones.
Management of any underlying lid disease or ocular inflam-
mation should precede punctal occlusion, and the potential
risks and complications, such as infection and migration of
the plug into the canalicular apparatus, need to be discussed
with the patient before the procedure.
Artificial Tear Products. Ocular lubricants are a common
option for aqueous tear film enhancement. They consist of
hypotonic or isotonic buffered solutions and contain various
components, including viscosity-enhancing agents, surfac-
tants, electrolytes and/or lipids. Their primary mode of action
is palliative and can improve the following:
■ replacement of absent tear constituents
■ reduced friction between the palpebral conjunctiva and
cornea
■ reduced tear hyperosmolarity
■ increased tear retention time
■ dilution of inflammatory cytokines.
Nonpreserved preparations minimise the potential for toxic
and/or hypersensitivity reactions.
Lubricant eye drops may be formulated to resolve different
aspects of tear dysfunction; for example, ‘electrolyte balanc-
ing’ attempts to mimic the electrolyte composition of the
natural tears to compensate for osmolar imbalances. Potas-
sium and bicarbonate are considered the most critical tear
electrolytes, with potassium being important for maintaining
corneal thickness (Green et al. 1992) and bicarbonate for
promoting the recovery of epithelial barrier function in a
compromised corneal epithelium (Bernal Lopez & Ubels,
1993). Examples of electrolyte-balancing lubricant eye drops
include Thera Tears (Akorn) and Bion Tears (Alcon).
Some artificial tears are hypo-osmotic to help counteract
hyperosmolarity in dry eye disease. Others contain constitu-
ents described as compatible solutes which protect the ocular
surface against the adverse effects of elevated tear osmolarity
(Lanzini et al. 2015), including components such as glycerine,
erythritol and levocarnitine. Optive (Allergan) is an example
of an osmoprotective eye drop.
KEY POINT
To improve aqueous-deficient forms of tear film dysfunction:
• Control ocular inflammation with the judicious use of
anti-inflammatory agents.
• Enhance tear retention by environmental adaptation (e.g.
humidifiers, moisture-chamber spectacles).
• Apply other more invasive strategies (e.g. punctal plugs)
with caution.
• Supplement the tear film with artificial tears to assist, at
least in the short term, with improving tear volume and
ocular comfort.

MUCIN
Although there are evolving therapeutics designed to target
mucin insufficiency, a common therapeutic approach involves
the application of artificial tears containing ‘mucomimetic’
components. These products have a low risk of side effects
and offer the potential for significant clinical benefits. An
example of a mucomimetic agent is hydroxypropyl (HP) guar,
found in the Systane range of products (Alcon). This is a
pH-dependent gelling agent that is designed to assist with
improving tear retention at the ocular surface.
The effect of contact lenses on conjunctival cytology
remains equivocal, but consensus suggests that silicone
hydrogel lenses might have a lesser impact on goblet cell
density than hydrogel lenses, a feature which is attributed
to maintenance of more physiological ocular surface condi-
tions (Sapkota et al. 2016).
KEY POINT
To improve mucous deficient tears, promote stabilisation of
the tear film with the use of arti­ficial tears containing muco-
mimetic components.
Conclusions
The tear film is a vitally important ocular component that
continuously interacts with a contact lens in situ. This chapter
has considered the structure, origin, function and importance
of the tear film for contact lens wear. In addition, we have
described a systematic approach to the clinical evaluation of
the tear film, including the application of a wide variety of
clinical tools. Thorough and accurate clinical assessment is
necessary to guide the appropriate management of any tear
film abnormalities to maximise contact lens fitting success.
Further information and videos are available at: https://
expertconsult.inkling.com/
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In addition to the videos cited within the chapter, there
are also Tear Film & Ocular Surface Society (TFOS) diagnostic/
management strategy videos that would be of value to anyone
reading this chapter. These videos (listed below) have been
designed as an educational tool for practitioners, with voice
over and step-by-step instructions on how to perform the
diagnostic tests and how best to apply certain therapeutic
strategies.
The TFOS diagnostic videos are as follows:
■ Impression Cytology https://www.youtube.com/watch?v=
Nk3Vjj2iPSc
■ Lid evaluation and DGE (diagnostic gland expression)
https://www.youtube.com/watch?v=yIwUxRlSuto
■ Lid eversion https://www.youtube.com/watch?v=3FEl0rUntss
■ Lipid evaluation https://www.youtube.com/watch?v=
Jpi9ULjwXzQ
■ Ocular surface damage assessment https://www.youtube.
com/watch?v=wOd1T7quu2o
■ Osmometry (with the TearLab) https://www.youtube.com/
watch?v=7OyYl8S9ijQ
■ Inflammation assessment (with an MMP-9 point of care
test (InflammaDry)) https://www.youtube.com/watch?v=
2Q_cr2H-ddg
5  •  Tears and Contact Lenses 115.e1
■ Tear stability assessment (covers automated and non-
automated non-invasive break up time assessment as well
as how best to measure a fluorescein (invasive) break up
time) https://www.youtube.com/watch?v=f1f0hOiyhZc
■ Tear volume assessment (covers tear meniscus height,
phenol red thread and Schirmer) https://www.youtube.
com/watch?v=3a8JO45j9wI
The management strategies are as follows:
■ Debridement https://www.youtube.com/watch?v=U-a40Lak
DvA
■ Lid hygiene https://www.youtube.com/watch?v=7G1uX
SPSbhA
■ Lid warming https://www.youtube.com/watch?v=Pmp
n9_ovo0Q
■ Punctal plugging https://www.youtube.com/watch?v=3t
0QF38Uvcs
■ Therapeutic meibomian gland expression https://www.
youtube.com/watch?time_continue=7&v=bxB18sY7d9Y
116 SECTION 2  •  Anatomy, Physiology and Patient Suitability
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