BCLA CLEAR Presbyopia: Management with contact lenses and spectacles.

This paper seeks to outline the history, market situation, clinical management and product performance related to the correction of presbyopia with both contact lenses and spectacles. The history of the development of various optical forms of presbyopic correction are reviewed, and an overview is presented of the current market status of contact lenses and spectacles. Clinical considerations in the fitting and aftercare of presbyopic contact lens and spectacle lens wearers are presented, with general recommendations for best practice. Current options for contact lens correction of presbyopia include soft simultaneous, rigid translating and rigid simultaneous designs, in addition to monovision. Spectacle options include single vision lenses, bifocal lenses and a range of progressive addition lenses. The comparative performance of both contact lens and spectacle lens options is presented. With a significant proportion of the global population now being presbyopic, this overview is particularly timely and is designed to act as a guide for researchers, industry and eyecare practitioners alike.

TFOS Lifestyle: Impact of contact lenses on the ocular surface.

Several lifestyle choices made by contact lens wearers can have adverse consequences on ocular health. These include being non-adherent to contact lens care, sleeping in lenses, ill-advised purchasing options, not seeing an eyecare professional for regular aftercare visits, wearing lenses when feeling unwell, wearing lenses too soon after various forms of ophthalmic surgery, and wearing lenses when engaged in risky behaviors (e.g., when using tobacco, alcohol or recreational drugs). Those with a pre-existing compromised ocular surface may find that contact lens wear exacerbates ocular disease morbidity. Conversely, contact lenses may have various therapeutic benefits. The coronavirus disease-2019 (COVID-19) pandemic impinged upon the lifestyle of contact lens wearers, introducing challenges such as mask-associated dry eye, contact lens discomfort with increased use of digital devices, inadvertent exposure to hand sanitizers, and reduced use of lenses. Wearing contact lenses in challenging environments, such as in the presence of dust and noxious chemicals, or where there is the possibility of ocular trauma (e.g., sport or working with tools) can be problematic, although in some instances lenses can be protective. Contact lenses can be worn for sport, theatre, at high altitude, driving at night, in the military and in space, and special considerations are required when prescribing in such situations to ensure successful outcomes. A systematic review and meta-analysis, incorporated within the review, identified that the influence of lifestyle factors on soft contact lens dropout remains poorly understood, and is an area in need of further research. Overall, this report investigated lifestyle-related choices made by clinicians and contact lens wearers and discovered that when appropriate lifestyle choices are made, contact lens wear can enhance the quality of life of wearers.

Blinking and upper eyelid morphology.

PURPOSE: To explore blinking patterns and sagittal eyelid misalignment in the East Asian eye. METHODS: Forty-four participants (22 females; age 26 ± 5 years; 52% of East Asian ethnicity) were enrolled in this pilot study and subdivided, based on upper eyelid crease presence and extent, into single (n = 10), partial (n = 11) or double (n = 23) eyelid crease groups. Blinking was filmed surreptitiously with high-speed video simultaneously from an inferior temporal and frontal view. Spontaneous blink rate and type (incomplete, almost complete, or complete) were assessed over a 30 s period. Sagittal misalignment of the lids on closure was graded during complete spontaneous blinks, voluntary lid closure and voluntary maximal lid contraction (squeezing). A 0.15 µL drop of lissamine green was placed on the central lower lid margin and the number and type of blinks required to eliminate the drop informed complete palpebral apposition during blinking. RESULTS: Mean ± SD blink rates averaged 16.9 ± 10.5 blinks/minute. The proportion of incomplete blinks was 83 ± 22% in single, 58 ± 35% in partial and 59 ± 30% in double eyelid crease groups. The sagittal misalignment of the lid margins during blinking was limited to approximately one-third of the lid margin width; this was similar for all lid morphologies and blink types. The lissamine green drop was eliminated only by voluntary maximal lid contraction, and was similar in all groups (p = 0.97). CONCLUSIONS: Incomplete blinking and sagittal lid misalignment of the central eyelid margin predominate in habitual blinking, irrespective of lid morphology.

Effect of Eye Spray Phospholipid Concentration on the Tear Film and Ocular Comfort.

OBJECTIVES: To evaluate the effect of eye spray phospholipid concentration on symptoms and tear film stability. METHODS: High-concentration (Tears Again, Optima Pharma GmbH, Hallbergmoos, Germany) and low-concentration (Ocuvers, Innomedis AG, Germany) phospholipid eye sprays were sprayed onto the closed eyelids of 30 subjects (33.2±1.8 years; 20 women) in a multicentered, prospective, crossover study. Ocular comfort (visual analog scale) and noninvasive tear film stability (NIBUT) of each eye were evaluated before application (along with the Ocular Surface Disease Index), 10 min after application, and 30 min after application. RESULTS: Comfort (high concentration: 68.5±16.4 vs. low concentration: 70.7±14.5 phospholipid) and NIBUT (high concentration: 11.5±4.6 sec vs. low concentration: 11.2±6.0 sec phospholipid) were not different (P>0.3) between sprays before application, but comfort (by 12 points, P=0.001) and NIBUT (by 5 sec, P=0.016) were significantly better with a high-concentration phospholipid spray at both 10 min and 30 min time points than those with the low-concentration phospholipid spray. CONCLUSIONS: The liposomal eye spray with higher concentration of phospholipids significantly improved ocular comfort and tear film stability in contrast to the eye spray with lower concentration of phospholipids, hence practitioners need to choose an appropriate eye spray to maximize the patient benefit.

Evaluation of tear meniscus height using different clinical methods.

Clinical relevance: The height of the tear meniscus (TMH) is a generally accepted method to evaluate tear film volume, especially in dry eye diagnoses and management.Background: The purpose of this study was to evaluate the ability of different methods to measure tear meniscus height accurately and repeatably.Methods: Lower TMH of 20 volunteers (26.8 ± 5.6 years) was measured by two observers (OI and OII) using optical coherence tomography (OCT), slitlamp microscope image analysis, and with a reticule at low (8x) and high (32x) magnification. TMH was also evaluated by both observers by comparing TMH to thickness of the lid margin (lid-ratio; grade 0: TMH 1/2 lid margin thickness; grade 1: 1/3; grade 2: 1/4; grade 3: 1/5; grade 4: 1/6) and to the number of eyelashes fitting in the tear meniscus. Differences between observers were analysed by paired-t-test. Differences between OCT-TMH and other methods were analysed by ANOVA, and inter-observer repeatability by intra-class-correlation-coefficient (ICC). The ability to predict OCT-TMH was calculated by receiver operative characteristic (ROC) curve analysis.Results: There was no significant difference between OI and OII in all methods except of the eyelash-count-method (p = 0.008). For OI, TMH measured using a reticule at 8x (0.20 ± 0.05 mm) was significantly lower than OCT-TMH (0.24 ± 0.07 mm) (p = 0.032) but not at 32x (0.22 ± 0.01 mm; p = 0.435). TMH evaluated by the image software of the slitlamp (0.20 ± 0.05 mm) was significantly lower than OCT-TMH (p = 0.022). The lid-ratio-method and eyelash-count-method resulted in grades of 2.35 ± 1.22 and 2.85 ± 0.81, respectively. ROC analyses showed that only the 8x and the 32x magnification method could discriminate between normal and abnormal OCT-TMH. OCT had the best repeatability (ICC = 0.88; p < 0.001) followed by reticule using 32x magnification (ICC = 0.70; p = 0.004).Conclusion: The most reliable method to measure TMH was OCT followed by slitlamp using a reticule. TMH cannot be reliably evaluated by comparing it against lid margin thickness or number of eyelashes.

CLEAR - Evidence-based contact lens practice.

Evidence-based contact lens -->practice involves finding, appraising and applying research findings as the basis for patient management decisions. These decisions should be informed by the strength of the research study designs that address the question, as well as by the experience of the practitioner and the preferences and environment of the patient. This reports reviews and summarises the published research evidence that is available to inform soft and rigid contact lens history and symptoms taking, anterior eye health examination (including the optimised use of ophthalmic dyes, grading scales, imaging techniques and lid eversion), considerations for contact lens selection (including the ocular surface measurements required to select the most appropriate lens parameter, lens modality and material selection), evaluation of lens fit, prescribing (teaching self-application and removal, adaptation, care regimen and cleaning instructions, as well as -->minimising risks of lens wear through encouraging compliance) and an aftercare routine.

Clinical significance of contact lens related changes of ocular surface tissue observed on optical coherence images.

PURPOSE: To investigate the relationship between the real contact lens imprint into the conjunctival tissue, observed by optical coherence tomography (OCT) and conjunctival staining and contact lens wearing comfort. METHODS: 17 participants (mean age = 26.6 SD ± 3.6 years; 7 females) were fitted with three different contact lenses base curves of the same silicone hydrogel custom lens type (Visell 50; Hecht Contactlinsen, Au, Germany) in a randomised order. One lens was optimally fitted according to the manufacturer's recommendation, one fitted 0.4 mm flatter and one fitted 0.4 mm steeper. After 4 h of lens wear the contact lens edge in the area of the conjunctiva was imaged nasally and temporally using OCT (Optovue iVue SD-OCT). To correct the artefact due to optical distortion with OCT, the imprint of all worn lenses was measured on a glass plate afterwards. Conjunctival staining in the limbal region after 4 h of lens wear was classified using the CCLRU Grading Scale. Comfort scoring was based on visual analog scales from 0 (very poor) to 100 (excellent). RESULTS: The mean conjunctival imprint of all contact lens edges was 32.0 ± 8.1 µm before and 7.3 ± 6.5 µm after distortion correction of the OCT images. The distortion corrected conjunctival imprint with the 0.4 mm steeper lens (11.5 ± 6.2 µm) was statistically significantly greater compared to the optimally fitted lens (6.5 ± 5.9 µm) (One-way ANOVA followed Tukey-test; p = 0.017) and greater compared to the 0.4 mm flatter lens (3.9 ± 5.3 µm) (p < 0.001). There was no statistically significant difference between the optimally fitted lens and the 0.4 mm flatter lens (p = 0.209). The nasally measured imprint (11.4 ± 9.0 µm) was significantly greater than the temporally measured (3.3 ± 7.6 µm) (p < 0.001). There was no statistically significant correlation between the amount of conjunctival imprint and the graded conjunctival staining (p = 0.346) or the wearer's comfort (p = 0.735). CONCLUSIONS: Contact lens edges imaged by OCT exhibited displacement artefacts. The observed conjunctival imprints are a combination of real conjunctival compression and artefacts. A deeper imprint of the contact lens into the conjunctiva caused by a steeper base curve was not related to clinically significant staining or changes in comfort after 4 h of lens wear. The observed differences between nasal and temporal imprint are likely to be caused by variations of conjunctival thickness and the shape of the underlying sclera.

TFOS European Ambassador meeting: Unmet needs and future scientific and clinical solutions for ocular surface diseases.

The mission of the Tear Film & Ocular Surface Society (TFOS) is to advance the research, literacy, and educational aspects of the scientific field of the tear film and ocular surface. Fundamental to fulfilling this mission is the TFOS Global Ambassador program. TFOS Ambassadors are dynamic and proactive experts, who help promote TFOS initiatives, such as presenting the conclusions and recommendations of the recent TFOS DEWS II™, throughout the world. They also identify unmet needs, and propose future clinical and scientific solutions, for management of ocular surface diseases in their countries. This meeting report addresses such needs and solutions for 25 European countries, as detailed in the TFOS European Ambassador meeting in Rome, Italy, in September 2019.

COVID-19 Pandemic: Survey of future use of personal protective equipment in optometric practice.

PURPOSE: The aim of this project was to evaluate which personal protective equipment (PPE) eye care practitioners (ECP) will use during the next months and also what they will ask the patient to use in clinical practice. METHODS: A social-media survey was carried out, asking 257 optometrists and opticians in Germany, Austria and Switzerland (i) which PPE they intended to use in the future (after lockdown and before herd immunity and / or vaccine availability) and (ii) what they would ask the patient to do in terms of this. RESULTS: 75 % of the ECPs planned on wearing masks during refractions and 69 % when fitting contact lens. 62 % of the ECPs also expected their patients to wear masks in these tasks. This number is higher than for distance tasks such as fitting frames. Around 90 % of the ECPs would, in addition to hand washing, disinfect their hands and around 80 % expected their patients to do so too. Less than one third of ECPs favoured wearing safety spectacles, gloves and / or protective facial shields. 73 % planed on disinfecting frames after they would have been tried on by customers. CONCLUSIONS: In summary, most ECPs planed on continuing to use higher standards of PPE. Those, who intended to wear masks themselves, would ask their patients to also do so, combined with hand disinfection.

Global trends in myopia management attitudes and strategies in clinical practice - 2019 Update.

PURPOSE: A survey in 2015 identified a high level of eye care practitioner concern about myopia with a reported moderately high level of activity, but the vast majority still prescribed single vision interventions to young myopes. This research aimed to update these findings 4 years later. METHODS: A self-administrated, internet-based questionnaire was distributed in eight languages, through professional bodies to eye care practitioners globally. The questions examined: awareness of increasing myopia prevalence, perceived efficacy of available strategies and adoption levels of such strategies, and reasons for not adopting specific strategies. RESULTS: Of the 1336 respondents, concern was highest (9.0 ±â€¯1.6; p < 0.001) in Asia and lowest (7.6 ±â€¯2.2; p < 0.001) in Australasia. Practitioners from Asia also considered their clinical practice of myopia control to be the most active (7.7 ±â€¯2.3; p < 0.001), the North American practitioners being the least active (6.3 ±â€¯2.9; p < 0.001). Orthokeratology was perceived to be the most effective method of myopia control, followed by pharmaceutical approaches and approved myopia control soft contact lenses (p < 0.001). Although significant intra-regional differences existed, overall, most practitioners did not consider single-vision distance under-correction to be an effective strategy for attenuating myopia progression (79.6 %), but prescribed single vision spectacles or contact lenses as the primary mode of correction for myopic patients (63.6 ±â€¯21.8 %). The main justifications for their reluctance to prescribe alternatives to single vision refractive corrections were increased cost (20.6 %) and inadequate information (17.6 %). CONCLUSIONS: While practitioner concern about myopia and the reported level of activity have increased over the last 4 years, the vast majority of eye care clinicians still prescribe single vision interventions to young myopes. With recent global consensus evidence-based guidelines having been published, it is hoped that this will inform the practice of myopia management in future.

The development and evaluation of the new Ocular Surface Disease Index-6.

AIM: To evaluate if the OSDI can be shortened and the score calculation simplified without significantly impacting the outcome of the questionnaire. METHODOLOGY: Study#1: 264 participants completed the OSDI questionnaire (174 females; mean age: 34.4 ±â€¯12.3yrs) and the results were analyzed to detect those questions of each subscale that are the most discriminative by multiple regression and RASCH analyses, resulting in the OSDI-6. Study#2: OSDI-6 was compared to the OSDI and the 5-item Dry Eye Questionnaire (DEQ-5) in 120 patients (73 females; mean age: 51 ±â€¯20.2yrs) to evaluate predictive ability of the OSDI-6. Repeatability was analyzed in 50 participants. RESULTS: Study#1: The mean OSDI score was 13.1 ±â€¯11.5. The most discriminant questions were questions 1, 4, 7, 9, 10 and 11. Infits and outfits of the OSDI-6 were between 1.26 and 0.78 (STRATA = 3). The OSDI-6 was significantly correlated to the OSDI (r = 0.898, p < 0.001). Area under the curve (AUC) of the OSDI-6 to predict OSDI was 0.967 p < 0.001. Study#2: The mean OSDI score was 20.3 ±â€¯16.6, the mean DEQ-5 score 7.9 ±â€¯4.6 and the mean OSDI-6 score 10.3 ±â€¯8.6. AUC of the OSDI-6 to predict OSDI was 0.901 (p < 0.001) and 0.803 (p < 0.001) to predict DEQ-5. The OSDI-6-V2 was significantly correlated to the OSDI and its sub-scales (r > 0.842, p < 0.001). Repeatability of the OSDI was 0.72 ±â€¯0.11 (Kappa; p < 0.001), the DEQ-5 was 0.75 ±â€¯0.06 (p < 0.001) and the OSDI-6 was 0.80 ±â€¯0.05 (p < 0.001). CONCLUSIONS: The OSDI-6 seems to be a repeatable questionnaire and a good alternative to the full original OSDI for use in clinical practice as well as research.

Lid-parallel conjunctival fold (LIPCOF) morphology imaged by optical coherence tomography and its relationship to LIPCOF grade.

PURPOSE: Lid-parallel conjunctival folds (LIPCOF) are a well-accepted clinical sign in dry eye diagnosis. Commonly, LIPCOF is classified by grading the number of folds observed by slit-lamp microscope. This study investigated the relationship between subjective grading scale and LIPCOF morphology imaged by optical coherence tomography (OCT). METHODS: Temporal and nasal LIPCOF of 42 subjects (mean age 27.3 ± 8.4 (SD) years; 13 M, 29 F) were observed and classified by an experienced optometrist using the Pult LIPCOF grading scale (0: no permanent, lid-parallel conjunctival fold; 1: one fold; 2: two folds, 3: three or more folds). Additionally, LIPCOF cross-sectional area (LIPCOF-A) and fold count (LIPCOF-C), as imaged by OCT (Cirrus HD; Carl Zeiss Meditec, Jena, Germany), were analysed with ImageJ 1.50 (http://rsbweb.nih.gov/ij). Correlations between subjective grading and LIPCOF-A and LIPCOF-C were analysed by Spearman correlation, differences between subjective grading and LIPCOF-C were analysed by Wilcoxon test. RESULTS: For temporal and nasal sectors, mean subjective LIPCOF grade was 1.43 ± 0.86 grade units and 0.57 ± 0.80 grade units, mean LIPCOF-C was 1.67 ± 0.82 folds and 0.69 ± 0.78 folds, and mean LIPCOF-A was 0.0676 ± 0.0236mm2 and 0.0389 ± 0.0352 mm2, respectively. Subjective temporal and nasal LIPCOF grade was significantly correlated to LIPCOF-C (r = 0.610, p < 0.001 and r = 0.645, p < 0.001, respectively), and to LIPCOF-A (r = 0.612, p < 0.001 and r = 0.583, p < 0.001, respectively). LIPCOF-C was not statistical different to subjective LIPCOF grade (p = 0.07 and p = 0.239; temporal and nasal sectors, respectively). CONCLUSIONS: OCT allows for better imaging of finer details of LIPCOF morphology, and especially of LIPCOF area. OCT evaluation of LIPCOF area correlated well with subjective grading and appears to be a promising objective method for LIPCOF classification.

Impact of soft contact lenses on lid- parallel conjunctival folds.

PURPOSE: Lid-parallel conjunctival folds (LIPCOF) are related to dry eye symptoms and appear to be related to mechanical forces in blinks. The primary aim of this longitudinal, parallel group study was to investigate impact of contact lens wear (CLW) on LIPCOF and secondly the impact of contact lens wear on lid-wiper epitheliopathy (LWE) and dry eye symptoms. METHODS: After a 2-week wash-out phase with a hydrogen peroxide care regimen, 30 experienced contact lens wearers (female: 25, male: 5; median age: 34.5 years) with at least LIPCOF Sum grade 1 (nasal + temporal LIPCOF, either eye) were randomised into three groups: one which discontinued CLW (SPEC), one which were refitted with senofilcon A two-weekly replacement daily wear silicone hydrogel (OAS) and one which continued to wear their habitual lenses (HCL). LIPCOF Sum and LWE were evaluated at the enrolment visit and over a period of 12 weeks. LIPCOF were classified by fold number using a four-grade scale. LWE was classified using a five-point scale after staining with lissamine green and fluorescein. Symptoms were evaluated with the Ocular Surface Disease Index (OSDI). RESULTS: On enrolment, there were no differences between groups for LIPCOF Sum (median 2.0), LWE (1.0) and OSDI scores (12.5) (Kruskal-Wallis, p > 0.718). Median changes at 12-weeks follow-up compared to the enrolment visit were (HCL-group: 0.5, 0.0, 0.0; OAS-group: -1.0, -0.5, -10.42; SPEC-group: -0.5, -0.5, -5.21; LIPCOF, LWE and OSDI, respectively). LIPCOF (Friedman-Test, p = 0.178), LWE (p = 0.791) and OSDI (p = 0.874) were unaltered over the period of observation in the HCL group. LWE (p = 0.120) was unaltered in OAS group but LIPCOF (p = 0.001) and OSDI (p = 0.003) significantly improved. In the SPEC group LIPCOF (p = 0.031), LWE (p = 0.002) and OSDI (ANOVA repeated measurements, p = 0.034) changed significantly. CONCLUSIONS: Refitting experienced CLW with senofilcon A daily wear, 2-week reusable contact lenses, or ceasing lens wear, improved LIPCOF, LWE and dryness symptoms.

Relationships Between Meibomian Gland Loss and Age, Sex, and Dry Eye.

PURPOSE: This study evaluated relationships between meibomian gland loss (MGL) and age, sex, and dry eye. METHODS: Dry eye and MGL of the lower eyelid was evaluated from 112 randomly selected subjects (66 women; mean age 62.8; SD ±15.7; and age range: 19-89 years) from Horst Riede GmbH, Weinheim, Germany. In addition, subjects were grouped into dry eye and non-dry eye by the Ocular Surface Disease Index (OSDI) score, lid-parallel conjunctival folds and non-invasive break-up time. Symptoms were evaluated by the OSDI. Meibography of the lower eyelid was performed using a Cobra camera (bon Optic, Lübeck, Germany), and images were analyzed by its digital grading tool. Data were analyzed by backward, multiple regression analyses and Pearson correlation. RESULTS: Analyzing all subjects, multiple regression analyses detected that age and dry eye status (dry eye diagnosis or OSDI) but not sex were significantly related to MGL. In both, non-dry eye (n=66) and dry eye subjects (n=46), dry eye status (OSDI) but not age or sex was significantly related to MGL. Ocular Surface Disease Index scores were significantly correlated with MGL, but this correlation was stronger among all subjects (Pearson correlation; r=0.536, P<0.001) and dry eye group subjects (r=0.520, P<0.001) than in non-dry eye group subjects (r=0.275, P=0.014). CONCLUSIONS: Dry eye group subjects showed significantly increased MGL of the lower eyelid. Age and dry eye status were related to MGL of the lower eyelid, but sex was not; dry eye status was the dominant factor.

Does air gas aesthesiometry generate a true mechanical stimulus for corneal sensitivity measurement?

BACKGROUND: Belmonte Ocular Pain Meter (OPM) air jet aesthesiometry overcomes some of the limitations of the Cochet-Bonnet aesthesiometer. However, for true mechanical corneal sensitivity measurement, the airflow stimulus temperature of the aesthesiometer must equal ocular surface temperature (OST), to avoid additional response from temperature-sensitive nerves. The aim of this study was to determine: (A) the stimulus temperature inducing no or least change in OST; and (B) to evaluate if OST remains unchanged with different stimulus durations and airflow rates. METHODS: A total of 14 subjects (mean age 25.14 ± 2.18 years; seven women) participated in this clinical cohort study: (A) OST was recorded using an infrared camera (FLIR A310) during the presentation of airflow stimuli, at five temperatures, ambient temperature (AT) +5°C, +10°C, +15°C, +20°C and +30°C, using the OPM aesthesiometer (duration three seconds; over a four millimetre distance; airflow rate 60 ml/min); and (B) OST measurements were repeated with two stimulus temperatures (AT +10°C and +15°C) while varying stimulus durations (three seconds and five seconds) and airflow rates (30, 60, 80 and 100 ml/min). Inclusion criteria were age <40 years, no contact lens wear, absence of ocular disease including dry eye, and no use of artificial tears. Repeated measures (analysis of variance) and appropriate post-hoc t-tests were applied. RESULTS: (A) Stimulus temperatures of AT +10°C and +15°C induced the least changes in OST (-0.20 ± 0.13°C and 0.08 ± 0.05°C). (B) OST changes were statistically significant with both stimulus temperatures and increased with increasing airflow rates (p < 0.001), and were more marked with stimulus temperature AT +10°C. CONCLUSION: A true mechanical threshold for corneal sensitivity cannot be established with the air stimulus of the Belmonte OPM because its air jet stimulus with mechanical setting is likely to have a thermal component. Appropriate stimulus selection for an air jet aesthesiometer must incorporate stimulus temperature control that can vary with stimulus duration and airflow rate.

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

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 age=37.0±12.9 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 [=temporal+nasal]) were significantly correlated to OSDI and to NIKBUTaverage (Spearman; r>-0.185, P<0.013). NIKBUTaverage (r=-0.322; P<0.001) was significantly correlated to OSDI scores. Based on the OSDI questionnaire, 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.

TFOS DEWS II Diagnostic Methodology report.

The role of the Tear Film and Ocular Surface Society (TFOS) Dry Eye Workshop (DEWS) II Diagnostic Methodology Subcommittee was 1) to identify tests used to diagnose and monitor dry eye disease (DED), 2) to identify those most appropriate to fulfil the definition of DED and its sub-classifications, 3) to propose the most appropriate order and technique to conduct these tests in a clinical setting, and 4) to provide a differential diagnosis for DED and distinguish conditions where DED is a comorbidity. Prior to diagnosis, it is important to exclude conditions that can mimic DED with the aid of triaging questions. Symptom screening with the DEQ-5 or OSDI confirms that a patient might have DED and triggers the conduct of diagnostic tests of (ideally non-invasive) breakup time, osmolarity and ocular surface staining with fluorescein and lissamine green (observing the cornea, conjunctiva and eyelid margin). Meibomian gland dysfunction, lipid thickness/dynamics and tear volume assessment and their severity allow sub-classification of DED (as predominantly evaporative or aqueous deficient) which informs the management of DED. Videos of these diagnostic and sub-classification techniques are available on the TFOS website. It is envisaged that the identification of the key tests to diagnose and monitor DED and its sub-classifications will inform future epidemiological studies and management clinical trials, improving comparability, and enabling identification of the sub-classification of DED in which different management strategies are most efficacious.

Investigating the Short-term Effect of Eyelid Massage on Corneal Topography.

PURPOSE: The aim of this study was to evaluate the short-term effect of eyelid massage, after the use of warm compresses, on corneal topography. METHODS: Corneal topography was evaluated on 20 subjects (mean age, 47.0 [SD ±17.3] years) using the Oculus Keratograph (Oculus, Wetzlar, Germany). Corneal eccentricity (Epsilon) was compared between topography measurements before eyelid warming (using warm compresses) (T1), after eyelid warming (T2), directly after eyelid massage (T3), and 30 minutes after eyelid massage (T4). Differences in corneal eccentricity between the enrolment measurement (T1) and consecutive measurements (T1-4) were analyzed. The contralateral eye-treated by warm compresses, but not by eyelid massage-was the control. Visual acuity (decimal), bulbar conjunctival hyperemia, and corneal staining (Cornea and Contact Lens Research Unit grading scale) were evaluated at T1 and T4 to assess clinical safety. RESULTS: No significant differences were found between consecutive eccentricity measurements overall and with the central radii (repeated-measures analysis of variance, P > .238 (massaged eyelid: Epsilon T1: 0.48 [95% confidence interval, ±0.07], T2: 0.49 [±0.05], T3: 0.49 [±0.06], T4: 0.48 [±0.06]; horizontal radii T1: 7.76 [±0.13] mm, T2: 7.74 [±0.13] mm, T3: 7.75 [±0.13] mm, T4: 7.76 [±0.13] mm; vertical radii T1: 7.56 [±0.12] mm, T2: 7.55 [±0.10] mm, T3: 7.54 [±0.10] mm, T4: 7.58 [±0.11] mm). Decimal visual acuity significantly improved at the end of the study (massaged eyelid: T1: 1.1 [±0.1]; T4: 1.3 [±0.1]; P < .032). No significant differences were detected between the consecutive evaluation of corneal staining (Wilcoxon test; P > .285). Redness was not significantly different between time points (repeated-measures analysis of variance; P = .187) in the colateral eyes. Hyperemia was significantly reduced in the massaged eyes (T1: 2.0 grade units [±0.3]; T4: 1.9 [±0.3]; P = .021). CONCLUSIONS: Eyelid warming followed by eyelid massage appears to be a safe procedure, without any clinically relevant short-term effects on the cornea.

Influence of Conjunctival Folds on Calculated Tear Meniscus Volume Along the Lower Eyelid.

PURPOSE: In calculating tear meniscus volume (TMV), tear meniscus height (TMH), radius (TMR) and cross-sectional area (TMA) are usually measured at the center of the lower lid margin, but lid-parallel conjunctival folds (LIPCOFs) are known to influence the tear meniscus regularity. The aim of this study was to analyze the influence of LIPCOFs on TMA measured by optical coherence tomography (OCT) and consequently, the calculated tear meniscus volume (TMV). METHODS: Using OCT (Cirrus-HD; Carl Zeiss Meditec, Jena, Germany), the TMH, TMR and TMA in 42 subjects (13M, 29F; mean age 27.3 SD±8.4 years) were measured directly below the pupil center, plus at temporal and nasal locations perpendicularly below the limbus, where LIPCOFs were also evaluated and graded. TMV for the different locations was calculated. Correlations between LIPCOFs and the tear meniscus parameters were analyzed using the Spearman Rank-Order coefficients. Differences between tear meniscus parameters at the different locations were evaluated by the paired t-test. RESULTS: Central TMV (5.30±1.42 x10(-2)µl/mm) was significantly positively correlated to LIPCOF sum (grade 2.4±1.2) (r=0.422; P<.05). The calculated temporal TMV was greater by 0.53x10(-2)µl/mm compared to the central TMV (P=.037), while there was no significant difference in tear volume between the other locations. CONCLUSIONS: Using OCT it was possible to investigate the influence of LIPCOFs on TMH, TMR, and for the first time on TMA, at central and paracentral positions along the lower lid margin. The presence of LICPOF results in an irregularity of tear meniscus with a difference in the amount of predicted tear volume while measuring TMH or TMR at the different locations.