Lid Wiper Epitheliopathy & Dry Eye Symptoms

Content written by: Osuagwu Levi RO, RCLP

Content originally published in the Winter 2011 edition of The Eighth Line

Table of Contents
• Introduction
• Schirmer Test
• Tear Break Up Time (TBUT)
o FBUT
o NIBUT
• Lid Wiper Epitheliopathy (LWE)
o Etiology of LWE
o Differential Diagnosis
o Causes of LWE
o Treatment of LWE
• References
• Post Test

Introduction
Symptoms of dry eye states are universally recognized as frequent principal complaints of the adult population
presenting for eye examination. Dry eye symptoms are readily understood if accompanied by marked vital staining of
the cornea or other frank signs associated with dry eye states. When clinical signs correlating with these symptoms are
absent, however, a clinical confusion exists.

Dry eye or keratoconjunctivitis sicca is a rubric for a number of clinical disease states, accounting for a high percentage
of patient visits to ophthalmologists and optometrists alike. In a large sample of the general population, 33% reported
dry eye problems. This included those whose conditions were provoked by exposure to air conditioning, central heating,
cigarette smoke, smog, and the use of certain medications1. In addition to dry eye problems in the wider community,
tear function is further challenged by contact lens wear which has become the mainstay of refractive correction and
fashion in this techno era. Even marginal tear deficiency may significantly reduce contact lens performance. For
example, symptoms of contact lens dryness are a very common source of discomfort and are associated with reduced or
abandonment of lens wear2-5. Dryness symptoms are most common in the evening5 and, anecdotally, patients report
that dryness symptoms increase toward the end of their lens replacement cycle as well. When recommended
replacement schedules are not followed, dryness symptoms appear to be one of the triggers for both early and late lens
replacement.

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Diagnosis of dry eye is generally based on assessing the quantity of tear (Schirmer test) and quality of tears (tear break
up time test and fluorescein staining). Assessing the tear volume through Schirmer test has remained a problematic
approach with many authorities describing it as variable, inexact, fraught with errors, and lacking standardization. These
has also led to the conclusion that it might be the least reliable of all dry eye test, but if the findings are less than 5mm,
there is reason to suspect aqueous deficiency6.

Schirmer’s Test
A Schirmer test measures the quantity of tears that are produced by the
eye. A 35 mm x 5 mm size filter paper strip is used to measure the
amount of tears that are produced over a period of 5 minutes. The strip is
placed at the junction of the middle and lateral thirds of the lower eye lid.
The test is done under ambient light. The patient is instructed to look
forward and to blink normally during the course of the test.

A negative test (more than 10 mm wetting of the filter paper in 5

minutes) means the patient produced a normal quantity of tears. Patients
with dry eyes have wetting values of less than 5mm in 5 mins.

An important limitation of the Schirmer test is that there may be considerable variability in the results of tests done at
different times and by different doctors. So whereas this is perhaps the most common dry eye test performed, its main
utility may really be in diagnosing patients with severe dry eyes. Sequential tests to follow the course of patient with
mild dry eye may not be of value. There is one point of some debate in the Schirmer test. When an anesthetic eye drop
is NOT used this test is thought to measure the basal + reflex tear secretion. When an anesthetic eye drop IS used this
test is thought to measure only the basic tear secretion. There is compelling reason to believe that the tears measured
by these two different methods may not sufficiently differentiate between basic and reflex tear production. Most
clinicians perform this test after using anesthetic eye drops to numb the eye. However, The National Eye Institute
workshop on dry eyes recommended not using anesthetic eye drops before performing this test. The cut off value is
similar whether or not anesthetic is used. To measure the reflex tear secretion Schirmer II test may be performed. A
Schirmer II test is performed by irritating the nasal mucosa with a cotton-tipped applicator prior to measuring tear
production.

Many clinicians regard the Schirmer test as unduly invasive and of little value for mild to moderate dry eyes. Other less
invasive methods to assess the adequacy of tear production have been developed. The Phenol Red Thread test is one
such test and is commercially available. A cotton thread impregnated with phenol red dye is used. Phenol red is pH
sensitive and changes from yellow to red when wetted by tears. The crimped end of a 70mm long thread is placed in the

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lower conjunctival fornix. After 15 seconds, the length of the color change on the thread - indicating the length of the
thread wetted by the tears -is measured in millimeters. Wetting lengths should normally be between 9mm and 20mm.
Patients with dry eyes have wetting values of less than 9 mm.

Tear Break Up Time (TBUT)

The Tear Break Up Time test measures the quality of the tear film. Normal tear film is continuous. Blinking maintains the
tear film continuity. If you keep your eyes open long enough, without blinking, the tear film will start breaking up.
Consequently, your eye will feel uncomfortable forcing you to blink. In patients with dry eyes the tear film is unstable,
and breaks up faster. The tear break up time in patients who have dry eyes is shorter.

Fluorescein Break Up Time (FBUT)

The most commonly used break up time test is the fluorescein break up time
test. A strip of fluorescein is applied in the upper or lower eyelid fornix and
then removed. The patient is asked to blink three times and then look straight
forward, without blinking. The tear film is observed under cobalt-blue filtered
light of the slit lamp biomicroscope and the time that elapses between the last blink and appearance of the first break in
the tear film is recorded with a stopwatch (a break is seen as a dark spot in a sea of blue). FBUT results of less than 10
seconds are consistent with dry eyes.

FBUT has important limitations. Touching of the filter paper strip to the conjunctiva can stimulate reflex tearing.
Although special fluorescein strips designed specifically for FBUT are available and claim to deliver a fixed micro volume
of fluorescein without stimulating reflex tearing, the mere presence of fluorescein in the tears perhaps also changes the
tear film properties, so FBUT measurements may not be truly physiological.

Non-Invasive Break up time (NIBUT)

To overcome limitations, non-invasive break up time (NIBUT) methods have been developed. They are called non-
invasive because the eye is not touched. Instruments such as a keratometer, hand-held keratoscope or tearscope,
keratography or a burton lamp are required to measure NIBUT. The pre-rupture phase is termed tear thinning time
(TTT).

When using a keratometer, measurement is achieved by observing the distortion (TTT) and/or break up (NIBUT) of a
keratometer mire (the reflected image of keratometer grid). The clinician focuses and views the crisp mires, and then
records the time taken for the mire image to distort (TTT) and/or break up (NIBUT). NIBUT measurements are longer

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than fluorescein break up time. NIBUT values of less than 15 seconds are consistent with dry eyes. TTT / NIBUT are
considered to be more patient-friendly, repeatable and precise7

The Lid Wiper Epitheliopathy (LWE)

Lid wiper epitheliopathy is a recently described syndrome8 that occurs in the presence of dry eye symptoms - dryness,
grittiness (scratchiness), soreness (Irritation), and burning (watering) – despite the absence of negative dry eye test
results. It represents a new frontier for ocular surface disease. It is becoming obvious that LWE is a missing link in the
disease and treatment of dry eye.

‘Lid wiper’ itself is defined as that portion of the

marginal conjunctiva of the upper lid that wipes
the ocular surface during blinking9. The
nomenclature reflects its role in wiping the
ocular surface during blinking9.

Etiology of LWE
It is believed that LWE is probably a result of a combination of inadequate lubrication between the lid wiper surface and
the ocular surfaces, with resulting physical trauma and resultant damage to the lid wiper and, to lesser degree, the
ocular surfaces10. Since the lid wiper is in constant contact with the ocular surfaces and travels across the ocular surfaces
with every lid movement, it is constantly susceptible to mechanical trauma in the presence of inadequate lubrication in
contrast to the ocular surfaces, where any particular area is minimally exposed to potential trauma from the lid wiper
for a fraction of second during blinking.

This syndrome involves an epitheliopathy (a disease involving the epithelium) of a portion of the marginal conjunctiva of
the upper eyelid designated the lid wiper.

Korb 9discovered in a study that 70% of his subjects had symptoms indicative of dry eye states, but with findings
considered normal: FBUT of 10 secs or more; Schirmer test value of 10mm or more, and the absence of fluorescein
corneal staining. They also stated that compromise to the epithelium of a dynamic wiping surface, the lid wiper, could
result in dry eye symptoms and thus explain the conundrum of patients with symptoms who lack clinical signs.

While LWE was more often noticed in contact lens wearers, it also occurred in 75% of non-contact lens wearers who
experience dry eye symptoms, regardless of whether other conventional signs of dry eye area are present10. In a recent
study, the prevalence of all grades of LWE was 6 times greater for the symptomatic than for the asymptomatic
population, and 18 times greater for the symptomatic population for grade 2 and 3 LWE than for asymptomatic patients.
Additionally, LWE among non-contact lens wearers occurred in the absence of fluorescein break up time (FBUT) and
Schirmer test values9.

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LWE commonly occurs with constant contact lens wear and is one of the primary reasons for discomfort experienced
when wearing contact lenses. LWE will remain a problem until the anterior surface of the contact lens provides a tear
film which is capable of meeting the lubrication requirements of the epithelia of the lid wiper.

Differential Diagnosis
LWE was found to occur mainly in the younger population; upper lid shortening procedures as used successfully for Lid
Imbrication (LI) appear to be contraindicated. LWE is a common side effect of contact lens wear, and cessation of
contact lens wear usually leads to the resolution of most LWE, indicating that LWE may be induced by contact lens.

Also, in a study by Korb9, they recommended that it was necessary to use fluorescein and rose bengal dyes to disclose lid
wiper staining but that if only one dye were used fluorescein would be the premier dye.

Other lid syndromes share commonalities with LWE, including Giant papillary conjunctivitis (GPC), floppy eye lid, vernal
conjunctivitis, and superior limbic conjunctivitis. The latter involve various foreign body sensation syndromes and
feature various forms of abnormalities of the tarsal plate, that portion of the marginal conjunctiva composing the lid
wiper, or both.

Korb 9has given 4 possible explanations for the lack of previous recognition of this syndrome to include the following:

1. The eyelid may not be everted during the anterior segment examination. Although it is
universally accepted that ocular examination of a symptomatic patient is never complete until
the lids are everted, lid eversion may not be performed.

2. Observation of the everted eyelid has traditionally been directed to the tarsal conjunctiva, with
and without contact lens rather than inspecting the area of the lid wiper.

3. Detection of LWE requires staining the tear film with an adequate concentration of vital stain
to show compromise to the epithelia. Contemporary methods of vital staining use dye
impregnated paper strips, a method that does not provide precise control of volume or
concentration11,12, and thus may be inadequate for detection of LWE.

4. The residence time of vital stain may not be adequate to allow the affected tissues to absorb
the stain8.

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Possible Causes of LWE
Possible causes of LWE include:

1. The surface of the lid wiper is in constant contact with the tear film, and in the event of
inadequate lubrication, the lid wiper traverses over any given portion of the corneal surface or
its adherent (fixed) components. The lid wiper traverses over any given portion of the corneal
surface for only a fraction of a second during blink. Thus, the lid wiper is subject to constant
trauma on all lid movements, whereas the cornea and conjunctiva are only fleetingly exposed9.

2. Disorders of the adherent protective coatings of the epithelium of the lid wiper.

3. Disorders of blinking as in essential blepharospasm.

4. Ocular surface abnormalities leading to excess trauma of the lid wiper or, conditions leading to
inflammation of the lid wiper.

5. Abnormal contact of the upper and lower lid margins on complete blinking could result in
trauma to the lid wiper as in floppy eyelid syndrome which usually occurs in obese men
because a loose upper lid and elastic tarsus allow the upper lid to evert during sleep9.

Treatment of LWE
Treatment options for LWE include:

1. Initial clinical strategy for treating lid wiper epitheliopathy should include both a corticosteroid
(e.g. loteprednol etabonate ophthalmic suspension, Lotemax, Bausch & Lomb) and a lubricant
(Soothe Emollient Eye Drops, Alimera Sciences) with the properties of Soothe. Long-term
management can usually then be achieved with the lubricant alone13

2. Treatment is also aimed at restoring adequate lubrication, achieved by restoring a normal tear
film. The role of the meibomian glands is paramount, and treatment of meibomian gland
disfunction (MGD) and obstruction is mandatory for long-term success10.

3. Cessation of contact lens wear usually resolves most cases of LWE if associated with CL wear.

4. Improving blink efficiency may also play an important role in LWE management. This is done
through reduction in the rate of incomplete blinking14.

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References
1. McMonnies CW.Key questions in a dry eye history.J Am Optom Assoc 1986;57:512-7
2. McMonnies CW & Ho A. Marginal dry eye diagnosis:history versus biomicroscopy. In:Holly FJ,
editor. The pre-ocular tear film.Lubbock Texas: Dry Eye Institute Inc.; 1986. p. 32-40
3. Vajdic C, Holden BA, Sweeney DF, et al. The frequency of ocular symptoms during spectacle
and daily soft and rigid CL wear.Optom Vis Sci 1999;76:705-11.
4. Fonn D,Situ P, Simpson T. Hydrogel lens dehydration and subjective comfort and dryness
ratings in symptomatic and asymptomatic CL wearers.Optom Vis Sci 1999;76:700-4.
5. Begley CG, Gaffery B, Nicolas KK, et al. Responses of CL wearers to a dry eye survey. Optom Vis
Sci 2001;77:40-6
6. Abelson MB, Welch D. How and why to treat dry eye. Rev Opthalmol 1994;1:58-9
7. The Eye Digest, University of Illinois Eye & Ear Infirmary, Chicago, IL
Page Reviewed 2009.
8. Korb DR, Greiner JV, Herman JP, et al. Lid-wiper epitheliopathy and dry eye symptoms in
contact lens wearers. CLAO J 2002; 28:211-16.
9. Korb DR, Herman JP, Greiner JV, Scaffidi RC, Finnemore VM, Exford JM, Blackie CA, Douglas T.
Lid wiper epitheliopathy and dry eye symptoms. Eye Contact Lens 2005;31:2-8
10. Korb DR. Discussion with Kenneth AP. Optom Vis Sci 2009;86:1146-7
11. Norn MS. External Eye: Methods of Examination. Copenhagen, Scriptor, 1974,pp 51-62
12. Tseng SC. Evaluation of the ocular surface in dry-eye conditions.Int Ophthalmol Clin 1994;
34:57-69.
13. Herman JP, Korb DR, Greiner JV, et al. Treatment of lid wiper epitheliopathy with a metastable
lipid emulsion or a corticosteroid. Invest Ophthalmol Vis Sci 2005; 46:2017.
14. McMonnies CW. Incomplete blinking:Exposure keratopathy,lid wiper epitheliopathy, dry eye,
refractive surgery, and dry contact lenses. Contact Lens & Ant eye 2007;30:37-51
15. Lynda Charters. Initial treatment for lid wiper epitheliopathy effective. Ophthalmology times.
Aug 15, 2006

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Post Test: Lid Wiper Epitheliopathy and Dry Eye Symptoms
Complete the following quiz based on the above information and submit the quiz via email, fax, or mail to the ACAO to
receive 1EC credit. Note: More than one answer may apply

Name: _______________________________________

License #: _________________________________________

Date: _________________________________

1. What causes dry eye?

a. Air conditioning and central heating

b. Cigarette smoke

c. Use of certain medications

d. Contact lens wear

2. What does NIBUT stand for?

a. Neo-invasive broken up tears

b. Non-invasive break up temperature

c. Non-invasive break up time

d. Non-invasive break up tears

3. What does TTT stand for?

a. Third Technical Theory

b. Tear Thinning Time

c. Theoretical Tang Test

d. Third Tier Test

4. True or False: The difference between a Schirmer test and a Schirmer II test is that a Schirmer II test uses a

cotton tipped applicator to irritate nasal mucosa prior to measurement.

a. True

b. False

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5. In a FBUT test, which result would be consistent with dry eyes?

a. less than 10 seconds

b. less than 20 seconds

c. less than 30 seconds

d. less than 40 seconds

6. True or False: The location of the “lid wiper” is a portion of the marginal conjunctiva of the lower lid.

a. True

b. False

7. Which of the following are tests that can be used to determine if a patient has dry eye?

a. Red thread test

b. TBUT

c. Fluorescein break up test

d. Non-invasice break up test

8. True or False: If LWE is diagnosed in a contact lens wearer, cessation of contact lens wear will likely resolve the

LWE.

a. True

b. False

9. True or False: LWE is a possible explanation for a patient who presents with typical complaints associated with

dry eye but no clinical signs (i.e. FBUT is less than 10 seconds and Schirmer value is 10mm).

a. True

b. False

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