ARTICLE

Lid-Parallel Conjunctival Folds and Their Ability to Predict Dry Eye

Heiko Pult, Ph.D. and Stefan Bandlitz, Ph.D.

evidence suggests that practitioners are incorporating LIPCOF as

Purpose: The observation of lid-parallel conjunctival folds (LIPCOF) is
reported to be useful in dry eye diagnoses. Around 70% of the European
clinicians use this test in a dry eye clinic. This study investigated the
sensitivity and specificity of LIPCOF to predict dry eye.
Methods: Ocular Surface Disease Index (OSDI) outcome, noninvasive
break-up time (NIKBUT) using the Keratograph (Oculus, Wetzlar,
Germany), and LIPCOF of 148 randomized selected patient reports (88
females; mean age¼37.0612.9 years) from 3 different sites were analyzed.
Subjects were divided into dry eye and non-dry eye groups by OSDI only,
named symptomatic dry eye (OSDI scores $15) and by a composite score
(OSDI scores $15 and NIKBUTaverage of #9 sec).
Results: Lid-parallel conjunctival folds (temporal, nasal, Sum [¼temporal
+nasal]) were significantly correlated to OSDI and to NIKBUTaverage
(Spearman; r.20.185, P,0.013). NIKBUTaverage (r¼20.322; P,0.001)
was significantly correlated to OSDI scores. Based on the OSDI question-
naire, 37.2% of the subjects were symptomatic and 14.7% were positive for
dry eye based on the composite score. Lid-parallel conjunctival folds were
a significant discriminator between healthy and dry eye subjects (P#0.001).
The areas under the receiver operating characteristic curve for temporal
LIPCOF, nasal LIPCOF, and LIPCOF Sum were 0.716, 0.737, and
0.771, respectively, for the symptomatic dry eye group and 0.771, 0.719,
and 0.798, respectively, for the composite dry eye group.
Conclusions: As LIPCOF demonstrated high predictive ability of dry eye;
it appears to be a promising test in the diagnoses of dry eye.
Key Words: Dry eye—Lid-parallel conjunctival folds—LIPCOF—
Conjunctivochalasis—Tear film—NIBUT—NIKBUT—OSDI.
(Eye & Contact Lens 2017;0: 1–7)
part of their dry eye evaluation. For example, around 70% of
practitioners in Germany, Switzerland, and Austria use this test,14
although only 40% do so in Australia.15
Lid-parallel conjunctival folds (Fig. 1) are folds in the lateral,
lower quadrant of the bulbar conjunctiva, parallel to the lower lid
margin. Lid-parallel conjunctival folds are significantly related to
dry eye.11,13,16–18 Bulbar conjunctival folds may have been first
described by Middlemore in 1835,19 having used the term “con-
junctival fold” to describe bulbar conjunctival folds visible with the
naked eye. It was Hughes20 in 1942 who named these severe
bulbar conjunctival folds, which are treatable by surgery, “conjunc-
tivochalasis” (Fig. 2); however, the term “chalasis” may implicate
a potential relationship between age and these conjunctival folds.
For small conjunctival folds, age does not seem to be correlated
with the degree of their formation.13 Consequently, Höh et al.13
described this latter type as LIPCOF. This group published the first
LIPCOF grading scale in which these folds were compared with
normal tear meniscus height. Pult et al.12,21 then introduced an
optimized, and for the first time validated, a LIPCOF grading scale
with which the number of folds are counted instead of comparing
fold height to tear meniscus height. In addition, Pult et al.12,17,22
reported the importance of observing not only temporal but also
nasal LIPCOF.
Lid-parallel conjunctival folds occurs behind the temporal and
nasal tear meniscus. Consequently, two-third of the total length of
the inferior tear meniscus is influenced by LIPCOF.23 Interestingly,
although LIPCOF does not occur centrally, it causes central tear
meniscus height measurements to be underestimated24 and disrupts

M illions of patients have ocular-related symptoms, such as

stinging, burning, itching, light sensitivity, and blurry vi-
sion1–4 that limit the quality of life, as well as occupational pro-
ductivity.5,6 Correlations between these symptoms and individual
clinical dry eye tests are frequently poor.7–10
However, other tests such as lid-parallel conjunctival folds
(LIPCOF) have been reported to be promising tests in dry eye
patients.11–13 A multiple regression analysis including common dry
eye tests showed that noninvasive tear film stability and LIPCOF
were the most effective tests in dry eye diagnoses.12 Recent

From the Optometry and Vision Research (H.P.), Weinheim, Germany;

School of Optometry and Vision Sciences (H.P.), Cardiff University, Cardiff,
United Kingdom; Ophthalmic Research Group (H.P., S.B.), Life and Health
Sciences, Aston University, Birmingham, United Kingdom; and Höhere
Fachschule für Augenoptik Köln (HFAK) (S.B.), Cologne, Germany.
The authors have no funding or conflicts of interest to disclose.
Address correspondence to Heiko Pult, Ph.D., Optometry and Vision
Research, Steingasse 15, 69469 Weinheim, Germany; e-mail: ovr@
heiko-pult.de
Accepted August 14, 2017. FIG. 1. Lid-parallel conjunctival folds (LIPCOF degree 2) at the
DOI: 10.1097/ICL.0000000000000435 temporal area of observation.

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 H. Pult and S. Bandlitz Eye & Contact Lens  Volume 0, Number 0, Month 2017

only.12 It may be of interest to investigate predictive ability of nasal

and temporal LIPCOF in a larger cohort of patients and using
a combination of symptoms and objective signs as outcome
measurements.
The aim of this study was to evaluate the predictive ability of dry
eye (defined by symptoms and objective signs) of nasal LIPCOF,
temporal LIPCOF, and LIPCOF Sum (nasal+temporal LIPCOF) in
a multicenter study.

FIG. 2. Conjunctivochalasis.
the tear film along the peripheral portions of the lower lid.23,24
Decreased mucin production is associated with the severity of
LIPCOF,22 and LIPCOF are significantly correlated with lid-
wiper epitheliopathy.12,17,22 Furthermore, LIPCOF are related to
blinking (complete and incomplete),25,26 blink speed, and tear film
viscosity.27
Lid-parallel conjunctival folds are reversible. They can, for
example, be treated using a liposomal eye spray28 or a carbomer
eye gel (Bausch and Lomb, Berlin, Germany).29 Experienced con-
tact lens wearers with an increased LIPCOF score showed signif-
icantly lower LIPCOF degrees after 3 months, having been re-fitted
with senofilcon A contact lenses (Johnson & Johnson, Vision Care,
Jacksonville, FL).30
Nemeth et al. evaluated a medium predictive ability of dry eye
(outcome measurement: symptoms plus signs; sensitivity: 0.52,
specificity: 0.64) of temporal LIPCOF. However, this group used
the former nonvalidated LIPCOF scale of Höh et al.13 and only
observed temporal LIPCOF.
By contrast, Pult et al.12,16,17,22 demonstrated that the evaluation
of both nasal and temporal LIPCOF improves the predictive ability
of dry eye. However, the outcome measurement in the study of
a small group of noncontact lens wearers (n¼47) was symptoms
METHODS
Ocular Surface Disease Index (OSDI) outcome, noninvasive
break-up time (NIBUT), and LIPCOF of 148 patient reports (88
females; mean age¼37.0612.9 years) were analyzed in this pro-
spective study (Table 1). Volunteers (irrespective of dry eye status,
but meeting the observation and inclusion and exclusion criteria) of
three different sites (Höhere Fachschule für Augenoptik Köln
[HFAK], Cologne, Germany and Horst Riede GmbH, Weinheim,
Germany and Augenoptik/Optometrie Etzler Arnsberg, Germany)
were observed. All procedures were conducted in accordance with
the Declaration of Helsinki (1983) and approval for the study was
given by the Cardiff School of Optometry and Vision Sciences
Human Ethics Committee. All subjects provided written informed
consent before participating in the study, and patient data were
anonymized.
Lid-parallel conjunctival folds were evaluated, without fluores-
cein, on the bulbar conjunctiva in the area perpendicular to the
temporal and nasal limbus, above the lower lid (temporal and nasal
LIPCOF, respectively). Observations were performed with a slit-
lamp microscope using ·25 magnification.16,17,22
Lid-parallel conjunctival folds were classified by counting the
number of folds according the Pult scale (Table 2).16,17,22 Care was
taken to differentiate between parallel, permanent, conjunctival
folds, (LIPCOF) and disrupted microfolds.16,17,22,31–33 This was
done based on the height of the fold; the height of a single LIPCOF
is approximately 0.08 mm, whereas that of a microfold is
0.01 mm.21
NIKBUT was observed using Keratograph 4 (Oculus, Wetzlar,
Germany), and the median of three consecutive measurements was
noted. The Keratograph measurement results in two outcomes, the
very first break-up (NIKBUTfirst) and the average time of all break-
up incidents (NIKBUTaverage).34 The latter seems to be closer to the

TABLE 1. Mean and Standard Deviation (SD) of Sex, Age OSDI Scores, and NIKBUT Average Grouped by the Different Sites and Median and
Interquartile of Lid-Parallel Conjunctival Folds (LIPCOF) Values of the Different Sites
Site 1 Site 2 Site 3

Female Male Female Male Female Male

Sex 29 21 32 17 27 22
Mean SD Mean SD Mean SD
Age 38.69 13.23 38.41 12.43 33.98 12.69
OSDI 15.29 13.02 14.83 12.57 12.43 12.62
NIKBUTaverage 17.69 24.01 15.78 14.25 16.08 14.88

Site 1 Site 2 Site 3

25% Median 75% 25% Median 75% 25% Median 75%

LIPCOF temp 0 1 2 0 1 2 0 1 2
LIPCOF nasal 0 0 1 0 0.5 1 0 0 1
LIPCOF Sum 0 2 3 0 2 3 0 2 3

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 Eye & Contact Lens  Volume 0, Number 0, Month 2017
TABLE 2. Optimized Lid-Parallel Conjunctival Folds Grading Scale12
Grade
No conjunctival folds 0 used any medication or eye drops known to affect the ocular
One permanent and clear parallel fold 1
Two permanent and clear parallel folds (normally ,0.2 mm) 2 surface, wore contact lenses, were pregnant, had conjunctivo-
More than two permanent and clear parallel folds 3 chalasis (defined as conjunctival folds increased by forceful
(normally .0.2 mm)
NIBUT measurements when using the Tearscopeplus (Keeler Ltd,
Windsor, United Kingdom).35
Subjects were categorized as dry-eyed in two ways. First, on the
basis of the OSDI only, those with a score of greater than 142 were
assigned to the symptomatic dry eye group. The second method
involved a composite score in which those having an OSDI score
of $15 and NIKBUTaverage of #9 sec36 were assigned to the dry
eye group. The reported cutoff value of noninvasive break-up time
is reported to be 10 sec,36 when using a tearscope. However, the
cut-off value for NIKBUTaverage is reported to be 9 sec,35 and was
the value used for this study.
There are many different tear film tests and ocular signs in dry
eye diagnosis. However, some of the tests are useful to detect dry
eye generally, known as global tests. Those are, for example,
ocular surface staining, tear film stability, LIPCOF, lid-wiper
epitheliopathy, and osmolarity. Other tests are subset tests as, for
example, the evaluation of the meibomian glands or the evaluation
of the tear volume.37,38
Of the listed global tests, only those that are suitable and easily
available should be considered. For example, conjunctival staining
is criticized being rather a test of dry eye severity and limited in the
diagnoses of mild to moderate dry eye.39 Lid-wiper epitheliopathy
is likely to be a frictional sign as LIPCOF is too.27 Therefore, lid-
wiper epitheliopathy and staining were not considered as potential
objective tests in this study analyzing predictive ability of LIPCOF.
The evaluation of tear film osmolarity is reported to be an
effective dry eye test.39–41 However, this test was not available at
all sites. As NIBUT was found to be one of the most valuable dry
eye test,12,42–44 this study used NIKBUT as the objective dry eye
test.
Statistical Analyzes
Data were analyzed for normal distribution by
Kolmogorov–Smirnov test, and correlations between variables
were analyzed by Pearson correlation for parametric data or
Spearman rank for nonparametric variables. Differences
between eyes were analyzed by paired t test or Wilcoxon test.
The ability of LIPCOF to predict subjective dry eye and the
composite dry eye was evaluated using the receiver operative
characteristic curve. Sensitivity and specificity values were
calculated based on published cutoff values.12 For any analyzes,
SPSS version 20 (SPSS, Inc., Chicago, IL) was applied. The
sample size was evaluated before the study by power calcula-
tion45 based on a power of 1-b¼0.80 (symptomatic dry eye:
OSDI differences of 7,46 standard deviation [SD] non-dry eye
group: 6.90 and dry eye group: 15.1134; NIKBUTaverage: dif-
ferences of 2.3 sec, SD non-dry eye group: 4.22 sec and dry eye
group: 4.08 sec34). To our knowledge, indicative values for the
composite score are unknown; hence, power calculation was
based on OSDI and NIKBUTaverage.

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LIPCOF and Dry Eye
Inclusion and Exclusion Criteria
Subjects were excluded if they had abnormal lid margins,
were younger than 18 years, had any history of ocular surgery,
blinks or digital pressure toward the lid margin, or at least one
central conjunctival fold47,48). Furthermore, only those reports
in which OSDI and NIKBUT evaluation was masked against
LIPCOF evaluation; simply having used two different observers
were considered to be included in this study.
RESULTS
Lid-parallel conjunctival folds scores and NIKBUT measure-
ments were not significantly different between right and left
eyes (Wilcoxon test, P.0.229). In the further analyzes, LIPCOF
and NIKBUT were either taken from the right or left eye (ran-
domized by lottery). Lid-parallel conjunctival folds were not
different between females and males (U test, P¼0.848,
P¼0.113, and P¼0.220, temporal, nasal, and LIPCOF Sum,
respectively). Temporal LIPCOF were significantly negatively
correlated with age, while nasal LIPCOF and LIPCOF Sum
were not. Lid-parallel conjunctival folds were significantly
correlated with OSDI and to NIKBUTaverage (Table 3).
NIKBUTaverage (r¼20.322; P,0.001) was significantly corre-
lated to OSDI scores.
Based on the OSDI questionnaire, 37.2% of the subjects were
symptomatic and 31.1% showed a NIKBUTfirst #6 sec,35 39.9%
showed a NIKBUTaverage #9 sec.35 Based on the composite score,
14.7% were positive for dry eye.
Lid-parallel conjunctival folds score was a significant discrim-
inator between healthy and dry dye subjects (Tables 4 and 5, Figs.
3 and 4) using the published12 cutoff values (temporal LIPCOF 2,
nasal LIPCOF 1, LIPCOF Sum 2).
Based on the published cutoff values, the sensitivity and
specificity of LIPCOF Sum was 83.6% and 54.8%, respectively,
in symptomatic dry eye, and 85.7% and 46.7%, respectively, in the
composite dry eye score. However, a different cutoff value of
LIPCOF Sum 3 was derived from this study. This was done by
a trade-off between the detection rate and false positive rate
depending on the distribution of test values between these two
groups.49 The new cutoff value resulted in a better true-negative
rate (but a worse true-positive rate) with a sensitivity and specific-
ity of 61.8% and 82.8%, respectively, in the symptomatic dry eye
group and 61.9% and 75.9%, respectively (Table 6), in the com-
posite dry eye group.
TABLE 3. Correlations Between Lid-Parallel Conjunctival Folds
(LIPCOF) and Age, OSDI Scores and NIKBUTaverage (Spearman’s Rho)
Temporal LIPCOF Nasal LIPCOF LIPCOF Sum
Age
r 20.193 20.053 20.146
P 0.019 0.525 0.078
OSDI score
r 0.569 0.584 0.654
P ,0.001 ,0.001 ,0.001
NIKBUTaverage
r 20.400 20.185 20.362
P ,0.001 0.013 ,0.001
3
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TABLE 4. Area Under the Receiver Operating Characteristic (ROC) similar to the current study, but the specificity figures of the current
Curve of the Different Lid-Parallel Conjunctival Folds (LIPCOF) Scores to study were 10% less than those observed in our previous study. In
Discriminate Between Healthy and Dry Eye in the Symptomatic Dry Eye
our previous study12 the number of subjects was smaller, with 64%
Score (OSDI Only)
being women, a median age of 35 years, and a median OSDI score
Asymptomatic 95% of 8.33 (median OSDI scores of the non-dry eye and dry eye
Confidence Interval
groups were 4.2 and 18.8, respectively; only median values and
Area P Lower Bound Upper Bound not mean values are stated in that article). In the current study, 59%
Temporal LIPCOF 0.716 ,0.001 0.632 0.801
of the subjects were women, the median age was 37, and median
Nasal LIPCOF 0.737 ,0.001 0.651 0.822 OSDI scores were 12.0 (OSDI scores of the non-dry eye and dry
LIPCOF Sum 0.771 ,0.001 0.690 0.851 eye groups were 6.25 and 22.9, respectively [symptomatic score]),
and are, therefore, a very similar population to the previous one.
Consequently, those differences may be an effect of the multicenter
DISCUSSION study design. However, using a cutoff value of three for LIPCOF
This was a multicenter retrospective analysis of data to Sum may result in more balanced outcomes of sensitivity and
determine sensitivity and specificity values of LIPCOF in dry specificity and are remarkably closer to those of the previous study.
eye diagnoses. This study confirmed LIPCOF as being a potential However, it is valuable to discuss whether true negatives are more
diagnostic dry eye test. Lid-parallel conjunctival folds values were important than true positives. It may likely be the other way around
significantly correlated to dry eye symptoms. Furthermore, LIP- such that the former cutoff value may be the preferable one. On the
COF Sum seemed to be a good discriminator between dry eye and other hand, the evaluation of the new cutoff value was according to
healthy subjects. The poor correlation between LIPCOF and age, the recommendations of the Dry Eye Workshop Report 2007.49
albeit being negative, may highlight the difference of conjuncti- Another group11 also evaluated predictive ability of LIPCOF
vochalasis, confirming the observations of Höh et al.13 using a composite score. In that multicenter study, the subjects
Previous investigation evaluated predictive ability of dry eye of were grouped based on a self-composed questionnaire, corneal
different common dry eye tests (LIPCOF, tear meniscus height, and conjunctival fluorescein staining, and break-up time measure-
noninvasive break-up time, phenol red thread test, bulbar and limbal ment using fluorescein and Schirmer I. Only sensitivity and spec-
hyperaemia, corneal and conjunctival staining, and lid-wiper epitheli- ificity values of temporal LIPCOF were analyzed in this study
opathy). LIPCOF and NIBUT showed promising predictive ability (sensitivity of 52% and specificity of 64%, cutoff value 2), and
values of dry eye. Furthermore, based on a multiple regression they were remarkably lower than those of the current study. This
analyzes, this study reported that NIBUT and nasal LIPCOF is best can be for many reasons, as we may have observed this in a youn-
test combination to diagnose dry eye symptoms.12 In addition to that ger patient cohort (mean age in this study was 37.0612.9 years
study, our work aimed to analyze sensitivity and specificity values of compared to 52.7616.211) and sex distribution being relatively
LIPCOF to predict symptomatic dry eye and dry eye defined by balanced, while Németh et al.11 analyzed LIPCOF in females
objective evaluation (NIKBUT) and symptoms (OSDI). mainly (75 male, 197 female). Another reason may be the different
However, sensitivity and specificity values in this study were approach of grouping subjects, using a self-composed question-
different from previous published values.11,12 In a previous inves- naire and invasive tests (corneal and bulbar conjunctival fluores-
tigation by our group,12 LIPCOF were evaluated in symptomatic cein staining followed by fluorescein tear film break-up time and
and asymptomatic groups, based on OSDI scores only. Such direct Schirmer I). Furthermore, the only global dry eye tests are the
comparison to the composite dry eye score’s outcome cannot be corneal and bulbar conjunctival fluorescein staining and fluorescein
drawn; however, even the symptomatic grouping showed some tear film break-up time, while Schirmer I is a subset test to detect
differences here. aqueous deficient dry eye.36 Conjunctival staining is criticized
In our previous study, the sensitivity and specificity of LIPCOF when being used in the diagnoses of mild to moderate dry eye.39
Sum (nasal+temporal LIPCOF; cutoff value 2) to discriminate Finally, although fluorescein break-up time is widely used instead
between asymptomatics and symptomatics was 70% and 91%, of the noninvasive measurement of the tear film stability,14 limi-
respectively. The sensitivity and specificity of temporal LIPCOF tations of this test without controlling volume and concentration
were 60% (cutoff value 2) and 81%, respectively, and those of are known.50,51 Therefore, we observed the tear film stability non-
nasal LIPCOF were 70% and 81%, respectively (cutoff value 1). invasively and objectively using the Keratograph. In this study,
Such sensitivity values for temporal and nasal LIPCOF were grouping criteria of subjects in terms of dry eye were based on
symptoms or combined by symptoms and tear–film instability.
This approach meets the dry eye definition of the DEWs Report
TABLE 5. Area Under Receiver Operating Characteristic (ROC) Curve 200736: “Dry eye is a multifactorial disease of the tears and ocular
of the Different Lid-Parallel Conjunctival Folds (LIPCOF) Scores to
Discriminate Between Healthy and Dry Eye in the Composite Dry Eye surface that results in symptoms of discomfort, visual disturbance,
Score (OSDI and NIKBUT Combination) and tear film instability with potential damage to the ocular sur-
face.” It is accompanied by increased osmolarity of the tear film
Asymptomatic 95%
Confidence Interval and inflammation of the ocular surface.52 Although the DEWs
Report 200736 does not state a recommended algorithm for diag-
Area P Lower Bound Upper Bound
nosing dry eye, the three factors symptoms, visual disturbance, and
Temporal LIPCOF 0.771 ,0.001 0.665 0.877 tear film instability are highlighted in the definition of this report.
Nasal LIPCOF 0.719 0.001 0.578 0.859 The other factors are potential factors or accompanying factors.
LIPCOF Sum 0.798 ,0.001 0.682 0.914
Symptoms and visual disturbance were evaluated in this study

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 Eye & Contact Lens  Volume 0, Number 0, Month 2017
using the OSDI questionnaire, tear film instability was observed
fully objectively using a video topographer.
Nevertheless, differences between both studies may be due to
Nemeth et al.11 having observed more severe dry eyes than that
observed in this study. In addition, there may be a higher num-
ber of aqueous deficient dry eye patients in their study due to the

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LIPCOF and Dry Eye
FIG. 3. Discrimination of symptomatic
dry eye by lid-parallel conjunctival folds
(LIPCOF) (temporal, nasal, and Sum).
use of the Schirmer I test as a dry eye criterion. However, in
future, it may be interesting to investigate whether the predic-
tive ability of LIPCOF differs between aqueous deficient dry
eye or evaporation dry eye. This could be done by additionally
grouping patients into groups using appropriate subset tests as
the evaluation of the tear film volume, lipid layer, meibomian
FIG. 4. Discrimination of composite dry
eye by lid-parallel conjunctival folds
(LIPCOF) (temporal, nasal, and Sum).
5
 H. Pult and S. Bandlitz
TABLE 6. Sensitivity and Specificity (%) Values of Nasal and Temporal Lid-Parallel Conjunctival Folds (LIPCOF) and LIPCOF Sum
Symptomatic Dry Eye
Cutoff Sensitivity
Temporal LIPCOF 2 60.0
Nasal LIPCOF 1 72.7
LIPCOF Sum 2 83.6
LIPCOF Sum 3a 61.8
Symptomatic dry eye derived from OSDI outcome only, composite dry eye is based on OSDI and NIKBUTaverage.
a
New cutoff value.
glands, etc.53 Nevertheless, this was not the approach of the
current study.
Németh et al.11 applied the grading scale developed by Höh
et al.13 This is the original grading scale with the limitations,
comparing folds height with the tear meniscus height, whereas
the latter is different between subjects and impacted by LIPCOF
themselves.24,54 Furthermore, area of observation is not as exactly
defined in this grading scale as in the grading scale in the current
study.
In the current study, the area of observation of LIPCOF was
clearly defined by the applied grading scale and grading was
independent of the tear meniscus height. The Pult LIPCOF grading
scale12 may have resulted in an improved discrimination between
dry and healthy eyes.
Correlations between LIPCOF and NIKBUT and NIKBUT and
OSDI were significant albeit not strong. Because correlation
between these parameters were found to be better when using
a Tearscope (Keeler Ltd, Windsor, United Kingdom),12 this might
indicate that the Keratograph measurement (NIKBUT) cannot be
used interchangeably with the established method of tear film sta-
bility measurement (NIBUT). Interestingly, almost the same pro-
portion of subjects were dry eye positive based on the OSDI and
NIKBUTaverage. However, many of those who were symptomatic
did not show an instable tear film and those with instable tear film
did not report remarkable dry eye symptoms. Although this seems
to be surprising, this is what clinical practice tells us. Symptoms
and signs are not always well correlated.9 However, the tear film
examination using the Keratograph is still under debate.34,55–57
CONCLUSIONS
In this multicenter study, the optimized, validated LIPCOF
grading scale was applied to diagnose dry eye, defined by tear film
stability and symptoms. It was shown, that LIPCOF were
a significant discriminator of dry eye. Predictive ability values
seem to be promising.
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