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Examination Techniques

How to Manage your Patients' Tear Film Quality

Published on May 21, 2018
10 Minutes Read

What You Need to Know

Slit Lamp Viewing

  1. Low light intensity
  2. High magnification (25-40x)
  3. Direct focal illumination

Use flourescein to measure tear break-up time (TBUT)


Grade 0: Amorphous/ Marble
Grade 1: Polluted tear film
Grade 2: Lipid
Grade 3: Excessive lipid, foam in tears
Grade 4: No lipid layer

Assessment of Tear Film

Questionnaires - such as:

  • Standardized Patient Evaluation of Eye Dryness Questionnaire (SPEED)
  • Ocular Surface Disease Index (OSDI)
  • Contact Lens Dry Eye Questionnaire (CLDEQ)
  • CLDEQ-8
  • McMonnies Dry Eye Index
  • Dry Eye Questionnaire (DEQ)
  • Invasive, using flourescein and non-invasive break up time (NIBUT) 
  • Other instrumentation - Tearscope, Keratometer, LipiView® 


  • Variation in individual tear chemistry (blinking pattern, tear film, ocular physiology, medication, age, diet)
  • Reduction in lipid layer leads to marginal dry eye problems and lens contamination
  • Lid margin disease
  • Contact lens (material, design, wearing schedule, care regimen)
  • Cosmetics, soap contamination 
  • Environment


  • Dryness symptoms including discomfort, grittiness and irritation
  • Blurred or variable vision

Patient Recommendations


  • Low pre-ocular tear break-uptime (TBUT), poor tear mixing
  • Thin (or absent) tear film lipid layer or excess lipid (debris in tear film)
  • Meibomian gland dysfunction, blepharitis (refer to image D below)
  • Bulbar conjunctival hyperemia
  • Superficial punctate epithelial erosions
  • Bulbar conjunctival staining
  • Reduced wettability, deposited CL (refer to image E below)
  • High tear osmolarity (>316 mOsmol/L)
  • Reduced tear ferning
(D) Blepharitis
(E) Reduced Wettability


  • Manage all grades if signs or symptoms exist - improve tear film quality
  • Treat any lid margin disease - lid hygiene, warm compresses, LipiView®
  • Consider lens type (design, material, modality, replacement frequency and care system)
  • Maintain good lens cleaning including rub and rinse step
  • Use of lipid containing drops or sprays, visco-elastic agents or overnight lubricants
  • Alter diet, alter environment, change cosmetics, blink training
  • Recommend Omega-3 supplements


Good, unless fundamental imbalance of tear film (keratoconjunctivitis sicca)


Adapted from a handbook of Contact Lens Management (3rd Edition)