The clinical and experimental significance of blinking behavior

The effect of incomplete blinking rate on corneal epithelial remodeling after trans-PRK surgery: a six-month study

Purpose

To evaluate the impact of incomplete blink rate on corneal epithelial thickness after transepithelial photorefractive keratectomy (Trans-PRK) surgery.

Methods

Trans-PRK patients were divided into two groups based on preoperative incomplete blinking rates, namely rates ≤0.5 (41 right eyes, group A) and rates >0.5 (65 right eyes, group B). We used anterior segment optical coherence tomography to measure the corneal epithelial thickness (CET) and lipiview to measure the number of blinks, incomplete blinking rate, and lipid layer thickness (LLT).

Results

In both groups, CET decreased at 1 week and 1 month, and the thicknesses in the IT, T, and ST regions exceeded the preoperative levels. Three months after Trans-PRK, the thickness exceeded the preoperative levels and continued to increase during subsequent follow-ups. The blinking times and LLT in both groups decreased at 1 week and gradually increased but did not return to preoperative levels. Group A maintained an incomplete blinking rate of over 0.5 at all postoperative periods. The incomplete blinking rate of group B remained above 0.5 postoperatively, although there was an improvement compared with preoperative rates. Both groups showed a correlation between changes in CET and incomplete blinking rate. There was a correlation between changes in LLT and the incomplete blinking rate after surgery.

Conclusion

Both groups showed uneven corneal epithelia thickening, which became more pronounced approaching the peripheral areas. In addition, changes in CET after surgery were positively correlated with the incomplete blinking rate in both patient groups. There was a negative correlation between postoperative LLT and incomplete blinking rate.

Dry eye disease in astronauts: a narrative review

Long-duration spaceflight can have adverse effects on human health. One of the most common ocular conditions experienced by astronauts is dry eye disease (DED). Symptoms of DED include feelings of eye irritation, eye strain, foreign body sensation and blurred vision. Over 30% of International Space Station expedition crew members reported irritation and foreign body sensation. We reviewed the current literature on the prevalence and mechanisms of DED in astronauts and its potential implications for long-duration spaceflight, including the influence of environmental factors, such as microgravity and fluid shift on tear film physiology in space. DED has negative effects on astronaut performance, which is why there is a need for further research into the pathophysiology and countermeasures. As an in-flight countermeasure, neurostimulation seems to be among the most promising options.

Design and Usability Study of a Point of Care mHealth App for Early Dry Eye Screening and Detection

Significantly increased eye blink rate and partial blinks have been well documented in patients with dry eye disease (DED), a multifactorial eye disorder with few effective methods for clinical diagnosis. In this study, a point of care mHealth App named "EyeScore" was developed, utilizing blink rate and patterns as early clinical biomarkers for DED. EyeScore utilizes an iPhone for a 1-min in-app recording of eyelid movements. The use of facial landmarks, eye aspect ratio (EAR) and derivatives enabled a comprehensive analysis of video frames for the determination of eye blink rate and partial blink counts. Smartphone videos from ten DED patients and ten non-DED controls were analyzed to optimize EAR-based thresholds, with eye blink and partial blink results in excellent agreement with manual counts. Importantly, a clinically relevant algorithm for the calculation of "eye healthiness score" was created, which took into consideration eye blink rate, partial blink counts as well as other demographic and clinical risk factors for DED. This 10-point score can be conveniently measured anytime with non-invasive manners and successfully led to the identification of three individuals with DED conditions from ten non-DED controls. Thus, EyeScore can be validated as a valuable mHealth App for early DED screening, detection and treatment monitoring.

Profiling tear film enzymes reveals major metabolic pathways involved in the homeostasis of the ocular surface

The ocular surface (OS) enzymes are of great interest due to their potential for novel ocular drug development. We aimed first to profile and classify the enzymes of the OS to describe major biological processes and pathways that are involved in the maintenance of homeostasis. Second, we aimed to compare the enzymatic profiles between the two most common tear collection methods, capillary tubes (CT) and Schirmer strips (ScS). A comprehensive tear proteomic dataset was generated by pooling all enzymes identified from nine tear proteomic analyses of healthy subjects using mass spectrometry. In these studies, tear fluid was collected using CT (n = 4), ScS (n = 4) or both collection methods (n = 1). Classification and functional analysis of the enzymes was performed using a combination of bioinformatic tools. The dataset generated identified 1010 enzymes. The most representative classes were hydrolases (EC 3) and transferases (EC 2). Phosphotransferases, esterases and peptidases were the most represented subclasses. A large portion of the identified enzymes was common to both collection methods (n = 499). More enzymes were specifically detected in the ScS-extracted proteome. The major pathways in which the identified enzymes participate are related to the immune system and protein, carbohydrate and lipid metabolism. Metabolic processes for nucleosides, cellular amides, sugars and sulfur compounds constituted the most enriched biological processes. Knowledge of these molecules highly susceptible to pharmacological manipulation might help to predict the metabolism of ophthalmic medications and develop novel prodrug strategies as well as new drug delivery systems. Combining such extensive knowledge of the OS enzymes with new analytical approaches and techniques might create new prospects for understanding, predicting and manipulating the metabolism of ocular pharmaceuticals. Our study reports new, essential data on OS enzymes while also comparing the enzyme profiles obtained via the two most popular methods of tear collection, capillary tubes and Schirmer strips.

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.

Extended screen time and dry eye in youth

PURPOSE

Extended screen time amongst youth is a pervasive global phenomenon, with wide-ranging implications for health and quality of life. Dry eye disease is increasingly reported as emerging in paediatric populations and is associated with modified blinking behaviour during extended screen time. This study sought to evaluate spontaneous blink rates, dry eye symptomology and screen use habits of young extended screen time users.

METHODS

Attendees of a gaming convention in Auckland, NZ, completed a self-directed iPad-based survey on personal screen use habits and ocular symptoms using the 5-item Dry Eye Questionnaire (DEQ-5) and the Symptom Assessment in Dry Eye (SANDE) questionnaire. Blink rate was covertly and concomitantly recorded using the front-facing iPad camera and quantified by automated software. A validated, self-assessment blink test was administered as a proxy for tear film stability measurements.

RESULTS

A total of 456 respondents (mean age ± SD: 24 ± 10 years, range: 13 - 75, 38% female) reported an average weekly screen time of 43.7 ± 24.4 h. DEQ-5 and SANDE scores were 10 ± 3 and 34 ± 19; 90% of respondents qualified as symptomatic for dry eye disease (DEQ-5 ≥ 6). Blink test results suggested a tear film stability < 10 s in 24% of cases. Poorer symptomology correlated with increased screen use, elevated blink rates and reduced proxy tear film stability (r = 0.15 to 0.22, all p < 0.01).

CONCLUSION

Extended screen time in a young population was associated with blinking behaviour and symptomology consistent with patients with dry eye. Implementing routine clinical screening, educational interventions, and developing official guidance on safe screen use may help prevent an accelerated degradation of ocular surface health and quality of life in young people.

The Relationship Between Dry Eye Disease and Digital Screen Use

Dry eye disease is characterized by tear film instability that can result in ocular surface damage. Patients with dry eye disease may experience ocular pain/discomfort and visual disturbances that may negatively impact quality of life. Increased use of digital screens for work, communication, and entertainment, especially during times of pandemic, may contribute to dry eye. Extensive cross-sectional studies have shown that digital screen use duration is associated with an increased risk of severe symptoms and clinical diagnosis of dry eye disease in adults. Smartphone use duration has also been found to be greater in school-age children with dry eye disease than in those without dry eye disease. A commonly accepted hypothesis for the relationship between digital screen use and dry eye disease is that digital screen use changes blinking dynamics, leading to ocular dryness. This review describes evidence that digital screen use is associated with dry eye disease, that digital device use alters blinking dynamics, and that dry eye affects mental health and work productivity in digital screen users. Helpful prevention and management strategies for dry eye disease exist for those who use digital screens.

CLEAR - Effect of contact lens materials and designs on the anatomy and physiology of the eye

This paper outlines changes to the ocular surface caused by contact lenses and their degree of clinical significance. Substantial research and development to improve oxygen permeability of rigid and soft contact lenses has meant that in many countries the issues caused by hypoxia to the ocular surface have largely been negated. The ability of contact lenses to change the axial growth characteristics of the globe is being utilised to help reduce the myopia pandemic and several studies and meta-analyses have shown that wearing orthokeratology lenses or soft multifocal contact lenses can reduce axial length growth (and hence myopia). However, effects on blinking, ptosis, the function of Meibomian glands, fluorescein and lissamine green staining of the conjunctiva and cornea, production of lid-parallel conjunctival folds and lid wiper epitheliopathy have received less research attention. Contact lens wear produces a subclinical inflammatory response manifested by increases in the number of dendritiform cells in the conjunctiva, cornea and limbus. Papillary conjunctivitis is also a complication of all types of contact lenses. Changes to wear schedule (daily disposable from overnight wear) or lens materials (hydrogel from SiHy) can reduce papillary conjunctivitis, but the effect of such changes on dendritic cell migration needs further study. These changes may be associated with decreased comfort but confirmatory studies are needed. Contact lenses can affect the sensitivity of the ocular surface to mechanical stimulation, but whether these changes affect comfort requires further investigation. In conclusion, there have been changes to lens materials, design and wear schedules over the past 20+ years that have improved their safety and seen the development of lenses that can reduce the myopia development. However, several changes to the ocular surface still occur and warrant further research effort in order to optimise the lens wearing experience.

Diagnosis and remediation of blink inefficiency

To examine the role of incomplete blinking in contributing to blink inefficiency, symptoms of dry eye and ocular surface disease. To review methods for diagnosing blink inefficiency (including both reduced overall blink rate and increased incomplete blink rate) and the role of remediation for efficient complete blinking as an essential part of the lacrimal functional unit in maintaining tear homeostasis. Diagnosis and remediation of blink inefficiency appear to have been somewhat misunderstood in the management of dry eye disease. To the extent that a high incomplete blink rate ranks in significance with low blink frequency in contributing to blink inefficiency, measures and remediation of only total blink rate are of reduced usefulness in the diagnosis and treatment of blink inefficiency-related ocular surface exposure, dry eye symptoms and ocular surface disease. In addition, a patient's blink performance during a biomicroscopy or any other clinical assessment of blink efficiency, is unlikely to be characteristic of or relevant to the blink inefficiency that develops and causes symptoms during their various day-to-day activities. There appears to be a strong case for prescribing blink efficiency exercises in the management of many cases of dry eye symptoms and ocular surface disease. Remediation of spontaneous blink inefficiency may require that a motor memory of voluntary complete, rapid, relaxed and natural looking blink formation is established and maintained as the basis for efficient spontaneous blinking. Voluntary forceful blinking may undermine the motor memory of efficient blinking and risk the depletion of any reserves of lipid.