the dry eye tool box

Usage is only permitted together with the Dry Eye Tool Box App. Thanks for your fairness 12.02.2014 ©2014 Dr. Heiko Pult

The Dry Eye Tool Box:

The professional APP to improve your dry eye management, your patients`

loyalty and compliance and to decrease drop-out rate in contact lens

wearers.

This Tablet-APP gives you the answers to the fundamental questions:

Is this a dry eye patient?

What is the patient`s dry eye type?

What are the best management options for the analysed dry eye type?

How can we measure management success?

Will the patient claim dry eye symptoms after contact lens fitting?

What are the best contact lens options for symptomatic contact lens

wearers?

How can we measure success after a contact lens update?

This is an evidence based APP easily and comfortable to be used with optimal

involvement of your patient in the dry eye assessment. This APP leads you

through a professional dry eye management scheme making dry eye

evaluation and management easy and repeatable. The patient can easily

be involved in this process to highlight your professionalism and improve

patient loyalty and compliance.

Please note: This software aims to assist professionals in the evaluation and

management of mild to moderate dry eye. It cannot replace the professional

skills and profound knowledge of an eye doctor. Please note the importance

of a comprehensive patient history, observations, treatment plans and

potential differential diagnoses. It cannot be guaranteed that this software

will save or backup any data during its use and that data will not retrievable

thereafter. The user of this software accepts any liability and responsibility

when using this software. The user declares and accepts to use this software

in agreement with local legislations and regulations. The developer warrants

no liability. Copyright of the APP, the manual and images are solely with

Dr. Heiko Pult, Weinheim, Germany. Any copying, misusing and forwarding to

third parties is prohibited.

Based on recent data protection of many countries the user is responsible for

anonymous data handling, especially submitting data by email, cloud or

similar and the user being responsible for data back-up. To support the user to

not offence against the law we decided not to include a full database. Thank

you for your sympathy.


Table of Contents

Table of Contents ............................................................................................................................... 2

Required technical equipment: .................................................................................................... 3

Screening Module: ............................................................................................................................. 4

Non-Contact Lens Wearer: ......................................................................................................... 4

Naïve-Contact Lens Wearer: ...................................................................................................... 4

New Contact Lens Wearer: ......................................................................................................... 5

Dry Eye Manager: .............................................................................................................................. 5

Non-Contact Lens Wearer: ......................................................................................................... 5

Naïve / Experienced Contact Lens Wearer: .......................................................................... 6

Contact Lens Recommendation: .......................................................................................... 6

Coexisting Dry Eye: .................................................................................................................... 6

Symptometer: ...................................................................................................................................... 6

Description of Dry Eye Tests: ............................................................................................................ 7

Ocular Surface Disease Index: ................................................................................................... 7

Lids: ..................................................................................................................................................... 7

Lid-Parallel Conjunctival Folds: ................................................................................................... 8

Lipid Layer: ....................................................................................................................................... 9

Lid-Wiper Epitheliopathy: ........................................................................................................... 11

Meibomian Glands Expression: ................................................................................................ 11

Meibography: ............................................................................................................................... 12

Osmolarity: ..................................................................................................................................... 13

Tear film stability:........................................................................................................................... 13

Tear meniscus height: ................................................................................................................. 14

Selected Literature: ......................................................................................................................... 15


Required technical equipment:

· iPad

· Internet connection (for help/support only)

· Slit lamp microscope

· TearLab*

· Meibograph*

· Tearscope or equivalent*

*(optional)

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Screening Module:

The Screening Module calculates dry eye risk of your patient based on

subjective and objective observations. In naïve contact lens wearers, this APP

can predict likelihood of later dry eye symptoms and of course the APP can

analyse contact lens relevant dry eye in experienced lens wearers.

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Non-Contact Lens Wearer:

Please complete the questionnaire together with your patient and start slit-

lamp microscope observation. You need to use at least one of the listed tear

film tests and one of the ocular surface tests. If the test result is at the test`s

cut-off value, please press “borderline”, if the result is more severe please

press “abnormal”. In normal observation please press “normal”. Based on the

patient`s symptoms and your observations the Screening Module

automatically calculates likelihood of dry eye. If the result indicates “dry eye”,

please proceed with the Dry Eye Manager. Tests are detailed described in

test section.

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Naïve-Contact Lens Wearer:

This is the appropriate procedure if a patient will be fitted with contact-lenses

for the first time and you want to know if this patient may suffer from contact

lens dry eye in later contact lens wear. Please complete the questionnaire

together with your patient and measure the non-invasive break up time

(NIBUT, Tearscope® with fine grid) and evaluate lid parallel conjunctival folds

(LIPCOF). NIBUT is an optional measurement, if you do not have a Tearscope®

please have a go with LIPCOF, only (please note that video keratometer can

measure NIBUT too, but the results are very different to the Tearscope

measurements and such you cannot use those here). After having completed

this modul the APP calculates the risk of your patient to suffer from contact

lens dry eye in later contact lens wear. This is not an exclusion criterion for

contact lenses; you simply need to proceed with the Dry Eye Manager to give

your patient the best options to improve later wearing comfort. Tests are

detailed described in test section.

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New Contact Lens Wearer:

This module analyses contact lens dry eye in experienced contact lens

wearers who already wear lenses since at least some month. You do need to

complete the questionnaire and to classify lid parallel conjunctival folds

(LIPCOF). If this test indicates contact lens dry eye, please proceed with the

Dry Eye Manager. Tests are detailed described in test section.

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Dry Eye Manager:

The Dry Eye Manager assists you to classify dry eye type and gives you

appropriate managment options for your patient and or it lists the options to

remarkable improve contact lens wearing comfort. Please not that you

should start with the Dry Eye Manager only after having completed the Dry

Eye Screening Module, or you are sure this is a symptomatic dry eye patient.

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Non-Contact Lens Wearer:

Please follow the order of the tests to ensure that you do not influence results.

Such first is always the tear film. There are two tests, Meibography and

Schirmer I, which are marked as optional, but it is recommended to apply

them, if possible.

As in the Screening Module, please press “borderline” if test result is the test`s

threshold, otherwise “normal” for normal measurements or “abnormal” if more

severe than threshold. Tests are detailed described in test section.

This module analyses your measurements and classifies dry eye type. Simply

click on the marked dry eye type and management recommendations will

be shown.

Please select the most appropriate management option. You may start with

option one followed by two then three, etc. Management success should be

measured using for example the Symptometer. Please note: This software aims

to assist professionals in the evaluation and management of mild to moderate

dry eye. It cannot replace the professional skills and profound knowledge of

an eye doctor. Please note the importance of a comprehensive patient

history, observations, treatment plans and potential differential diagnoses.

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Naïve / Experienced Contact Lens Wearer:

Pressing the Contact Lens Wearer button leads you to the next menu, in

which you can directly go to “Contact lens recommendation” for optimized

contact lens design, fit, material and care.

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Contact Lens Recommendation:

Most promising management options for improved contact lens wearing

comfort are shown. This helps you to choose initially the best contact lens

options of your naïve contact lens wearer. In an experienced contact lens

wearer, please try to change most of the options of the current worn contact

lens, which are different to the listed options in the recommendation table.

Coexisting Dry Eye:

Since in most of the symptomatic lens wearers a generally dry eye disease

can be assumed, the evaluation of potential coexisting dry eye is strongly

recommended. Coexisting dry eye management combined with optimized

lens options will be most effective treating contact lens dry eye. Pease

proceed as described in “Dry Eye Manager – Non Contact Lens Wearer”.

Since you need to wait 15min to 30min for normalization of the tear film after

contact lens removal, you may schedule the patient for an extra dry eye

management follow-up (not wearing contact lenses).

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Symptometer:

Use the Symptometer to measure treatment success based on the patient`s

symptoms. This also can be used as an extra quick screening module for dry

eye. After 1-2 minutes you know the subjective dry eye status of your patient.

For example, this can be very helpful in the daily routine of refractions since it

is known that dry eye can remarkable impact visual acuity. Also any staff, like

assistants or dispensing optician, can use this to easily pre-screen patients.

Ocular Surface Disease Index score and dry eye severity are shown in the

non-contact lens wearer module. Ratings of results of the contact lens wearer

module are not shown.


Likely abnormal

Discomfort ≥3

Dryness ≥3

Daily wearing time - comfortable wearing time ≥2h

Table 1: Rating of the Symptometer for contact lens wearers

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Description of Dry Eye Tests:

Ocular Surface Disease Index:

This is one of the most acknowledged dry eye questionnaires. Please note that

this questionnaire ask the patients symptoms retrospectively of the last week.

If a question cannot be answered by the patient please mark N/A. To

optimize questioning, please interview the patient and fill in the form, instead

of the patient. Also please advise the patient to answer spontaneously. You

should do so with all questions of the Dry Eye Tool Box

Lids:

Please observe the lid margins for any meibomian gland orifices plugging, lid

margins irregularity, hyperaemia, telangiectasia, posterior migration of gland

orifices. Also observe eye lashes for blepharitis which can secondly result in

meibomian gland dysfunction (MGD) and consequently abnormal lipid layer.

There are different grading scales published, an example for “borderline” is

shown in example image below. If lids are looking normal this does not

exclude MGD. Therefore you need to proceed with meibomian gland

expression and if possible meibography.


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Lid-Parallel Conjunctival Folds:

Lid-parallel conjunctival folds (LIPCOF) are sub-clinical folds (mild conjunctivo-

chalasis) in the lateral, lower quadrant of the bulbar conjunctiva, parallel to

the lower lid margin, easily observable by slit-lamp microscope. LIPCOF are

evaluated in the area perpendicular to the temporal and nasal limbus on the

bulbar conjunctiva above the lower lid using the slit-lamp microscope (no

lens, white light, no fluorescein) using 18 to 27 x magnification as necessary,

and classified according to the optimised grading scale. Care should be

taken to differentiate between LIPCOF and micro-folds. LIPCOF thickness is

commonly 0.08mm (around half of the normal tear meniscus height), while a

micro-fold is much smaller at approximately 0.02mm. LIPCOF Sum is adding

nasal and temporal LIPCOF scores together (LIPCOF Sum 2 = “borderline”).


LIPCOF

Grade

No conjunctival folds 0

One permanent and clear parallel fold 1

Two permanent and clear parallel folds, (normally lower than

0.2mm) 2

More than two permanent and clear parallel folds, (normally

higher than 0.2mm) 3

Table 2: LIPCOF grading scale.

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Lipid Layer:

Lipid layer thickness can be observed by classifying colour fringes. This can be

done in specular reflection using your slit lamp microscope or using a

Tearscope®. One grading scale is based on the dominant colour (Table 2) of

the inference fringes a more advanced one additional classifying lipid

distribution (Table 3).


Dominant Colour Lipid layer thickness (nm)

Blue 180

Blue/brown 165

Brown/blue 150

Brown 135

Brown/yellow 120

Yellow/brown 105

Yellow 90

Grey/yellow 75

Grey 60

Grey/white 45

White 30

Table 3: Lipid layer grading based on the dominant colour of the colour fringe.

Degree Description

Open

meshwork

Very thin, poor and minimal lipid layer stretched over the ocular

surface. The darker area is the thinnest

Closed

meshwork

More lipid than open meshwork (less stretching of the lipid film),

darker shade of grey represents thinner coverage. Easier to see

than open meshwork. Can sometimes be confused with the

amorphous pattern however closed meshwork has a more mottled

appearance and is not as bright.

Wave (flow) Thicker than meshwork with wavy, grey streak effect. This is the

most common lipid pattern seen and it represents average tear

film stability

Amorphous A thick, white even and well mixed lipid layer that may show

colours during the blink.

Colour fringes Thicker lipid layer with mix of brown and blue colour fringes well

spread out over the surface

Colour fringes Thicker lipid layer with mix of red and green colour fringes

Globular Multiple colours with clumps of lipid that will not spread

Table 4: Grading scale of the lipid layer, to be used applying white light illumination

like Tearscope®.

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Lid-Wiper Epitheliopathy:

LWE is a clinically observable alteration in the epithelium of the advancing lid

margin, the lid wiper. LWE is visible using a combination of instilled 1% lissamine

green and 2% fluorescein, and is evaluated for the upper lid. A second

instillation of both dyes should be carried out after 5 minutes. LWE is classified

by width and length. LWE is calculated length + width / 2 (LWE score of 1 =

borderline). Care should be taken to differentiate between staining

associated with Marx’s line and that from staining of the lid wiper.

Horizontal length of staining Grade Grade

2 mm 0

2–4 mm 1

5–9 mm 2

>10 mm 3

Sagittal width of staining Grade

25% of the width of wiper 0

25%–50% of the width of wiper 1

50%–75% of the width of wiper 2

>75% of the width of wiper 3

Table 5: LWE grading scale

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Meibomian Glands Expression:

Please gently express meibomian glands (pressure should be as low as you

use for contact lens push up test), best is using the meibomian gland


evaluator (Tearlab®, USA) of the lower lids nasal, central and temporal

portion. If all glands of the lower lid obtain liquid secretion with good quality

(fluid and clear) this is “normal”. Only 6 glands doing so is classified as

“borderline”. This number 6 is dependent on how the data is gathered, being

pressure dependent. Digital examination will yield results based on the

pressure and technique. Research also shows that for contact lens wearers

you likely need a higher number of functional lower lid glands, the highest

demand being a hard contact lens.

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Meibography:

Meibogarphy can be done using for example a Finoff transilluminator or more

comfortable non-contact infrared meibographs. Any meibomian gland loss of 29%

of the lower lid or 17% of the upper lid is “borderline” (pictorial MeiboScale is

available via download: www.heiko-pult.de).

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http://www.heiko-pult.de/


Osmolarity:

Osmolaroty of the lower temporal tear meniscus can be measured using the

TearLab. The traditional 316 mOsm/L threshold was found using an intersection

of severe subjects and normals. 308 mOsm/L was found to be the most

sensitive intersection between mild/moderate and normal subjects such to be

classified as “borderline”. Typically, if someone shows greater than an 8

mOsm/L difference between both eyes, it is a good indication of a transition

to tear film instability.

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Tear film stability:

There are many methods to measure tear film stability. Best option is non-

invasively (NIBUT) using a Tearscope® (Keeler, UK) or some new video

topographers do have such a tear film analysis option. Please note that

topographers and Tearscope® measurements are different. Such you cannot

use them for the contact lens wearer screening. Please ask your ophthalmic

instrument suppliers for such values when using video topographers. Most

commonly tear film break up time (TBUT) will be measured by colouring the

tear film with fluorescein. Please note that it is fundamental important to not

use too much fluorescein (max 2µl). Good option to control this is using a

micropipette or the Dry Eye Test@, an extra small fluorescein strip available by

Amcon (www.dryeyetest.com). Alternatively you can fold the first 1mm of a

fluorescein strip (in terms of hygiene please do so in package), this is named

the Modified Fluor Strip. Or simply try to touch the superior or inferior temporal

bulbar conjunctiva with a fluorescein strip, so that 1–2 mm of the flat side

make contact with the ocular surface. Please gently shake the strip before

http://www.dryeyetest.com/


doing so to remove excess fluorescein solution from the strip. Start measuring

BUT after a normal blink and it is helpful to use a stop watch. A break-up time

of 10sec is reported to be “borderline”.

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Tear meniscus height:

Height of the lower tear meniscus will be measured (without fluorescein) from a

frontal view, perpendicular below the pupil. Please use a reticule or the scale of your

slit lamp beam or similar to assure you get proper results. A tear meniscus height of

0.2mm is “borderline”.

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Selected Literature: 1-41

1. Savini G, Prabhawasat P, Kojima T, Grueterich M, Espana E, Goto E. The

challenge of dry eye diagnosis. Clin Ophthalmol 2008;2:31-55.

2. Sullivan BD, Crews LA, Sonmez B, de la Paz MF, Comert E, Charoenrook V, de

Araujo AL, Pepose JS, Berg MS, Kosheleff VP, Lemp MA. Clinical utility of objective

tests for dry eye disease: variability over time and implications for clinical trials and

disease management. Cornea 2012;31:1000-8.

3. Lemp MA, Bron AJ, Baudouin C, Benitez Del Castillo JM, Geffen D, Tauber J,

Foulks GN, Pepose JS, Sullivan BD. Tear osmolarity in the diagnosis and management

of dry eye disease. Am J Ophthalmol 2011;151:792-8 e1.

4. McGinnigle S, Naroo SA, Eperjesi F. Evaluation of Dry Eye. Survey of

Ophthalmology 2012;57:293-316.

5. Craig JP, Willcox MD, Argueso P, Maissa C, Stahl U, Tomlinson A, Wang J, Yokoi

N, Stapleton F, members of TIWoCLD. The TFOS International Workshop on Contact

Lens Discomfort: Report of the Contact Lens Interactions With the Tear Film

Subcommittee. Invest Ophthalmol Vis Sci 2013;54:TFOS123-56.

6. Dumbleton K, Caffery B, Dogru M, Hickson-Curran S, Kern J, Kojima T, Morgan

PB, Purslow C, Robertson DM, Nelson JD, members of the TIWoCLD. The TFOS

International Workshop on Contact Lens Discomfort: Report of the Subcommittee on

Epidemiology. Invest Ophthalmol Vis Sci 2013;54:TFOS20-36.

7. Efron N, Jones L, Bron AJ, Knop E, Arita R, Barabino S, McDermott AM, Villani E,

Willcox MD, Markoulli M, members of the TIWoCLD. The TFOS International Workshop

on Contact Lens Discomfort: Report of the Contact Lens Interactions With the Ocular

Surface and Adnexa Subcommittee. Invest Ophthalmol Vis Sci 2013;54:TFOS98-

TFOS122.

8. Foulks G, Chalmers R, Keir N, Woods CA, Simpson T, Lippman R, Gleason W,

Schaumberg DA, Willcox MD, Jalbert I, members of the TIWoCLD. The TFOS


Clinical Trial Design and Outcomes. Invest Ophthalmol Vis Sci 2013;54:TFOS157-83.

9. Jones L, Brennan NA, Gonzalez-Meijome J, Lally J, Maldonado-Codina C,

Schmidt TA, Subbaraman L, Young G, Nichols JJ, members of the TIWoCLD. The TFOS

International Workshop on Contact Lens Discomfort: Report of the Contact Lens

Materials, Design, and Care Subcommittee. Invest Ophthalmol Vis Sci

2013;54:TFOS37-70.

10. Nichols JJ, Jones L, Nelson JD, Stapleton F, Sullivan DA, Willcox MD, members

of the TIWoCLD. The TFOS International Workshop on Contact Lens Discomfort:

Introduction. Invest Ophthalmol Vis Sci 2013;54:TFOS1-6.

11. Nichols JJ, Willcox MD, Bron AJ, Belmonte C, Ciolino JB, Craig JP, Dogru M,

Foulks GN, Jones L, Nelson JD, Nichols KK, Purslow C, Schaumberg DA, Stapleton F,

Sullivan DA, members of the TIWoCLD. The TFOS International Workshop on Contact

Lens Discomfort: Executive Summary. Invest Ophthalmol Vis Sci 2013;54:TFOS7-TFOS13.

12. Nichols KK, Redfern RL, Jacob JT, Nelson JD, Fonn D, Forstot SL, Huang JF,

Holden BA, Nichols JJ, members of the TIWoCLD. The TFOS International Workshop on

Contact Lens Discomfort: Report of the Definition and Classification Subcommittee.

Invest Ophthalmol Vis Sci 2013;54:TFOS14-9.

13. Papas EB, Ciolino JB, Jacobs D, Miller WS, Pult H, Sahin A, Srinivasan S, Tauber J,

Wolffsohn JS, Nelson JD, members of the TIWoCLD. The TFOS International Workshop

on Contact Lens Discomfort: Report of the Management and Therapy

Subcommittee. Invest Ophthalmol Vis Sci 2013;54:TFOS183-203.


14. Stapleton F, Marfurt C, Golebiowski B, Rosenblatt M, Bereiter D, Begley C, Dartt

D, Gallar J, Belmonte C, Hamrah P, Willcox M, Discomfort TIWoCL. The TFOS


Neurobiology. Invest Ophthalmol Vis Sci 2013;54:TFOS71-97.

15. Geerling G, Tauber J, Baudouin C, Goto E, Matsumoto Y, O'Brien T, Rolando M,

Tsubota K, Nichols KK. The International Workshop on Meibomian Gland Dysfunction:

Report of the Subcommittee on Management and Treatment of Meibomian Gland

Dysfunction. Investigative Ophthalmology & Visual Science 2011;52:2050-64.

16. Green-Church KB, Butovich I, Willcox M, Borchman D, Paulsen F, Barabino S,

Glasgow BJ. The International Workshop on Meibomian Gland Dysfunction: Report of

the Subcommittee on Tear Film Lipids and Lipidâ€“Protein Interactions in Health and

Disease. Investigative Ophthalmology & Visual Science 2011;52:1979-93.

17. Knop E, Knop N, Millar T, Obata H, Sullivan DA. The International Workshop on

Meibomian Gland Dysfunction: Report of the Subcommittee on Anatomy,

Physiology, and Pathophysiology of the Meibomian Gland. Investigative

Ophthalmology & Visual Science 2011;52:1938-78.

18. Nelson JD, Shimazaki J, Benitez-del-Castillo JM, Craig JP, McCulley JP, Den S,

Foulks GN. The International Workshop on Meibomian Gland Dysfunction: Report of

the Definition and Classification Subcommittee. Invest Ophthalmol Vis Sci

2011;52:1930-7.

19. Nichols KK. The International Workshop on Meibomian Gland Dysfunction:

Introduction. Investigative Ophthalmology & Visual Science 2011;52:1917-21.

20. Nichols KK, Foulks GN, Bron AJ, Glasgow BJ, Dogru M, Tsubota K, Lemp MA,

Sullivan DA. The International Workshop on Meibomian Gland Dysfunction: Executive

Summary. Invest Ophthalmol Vis Sci 2011;52:1922-9.

21. Schaumberg DA, Nichols JJ, Papas EB, Tong L, Uchino M, Nichols KK. The

International Workshop on Meibomian Gland Dysfunction: Report of the

Subcommittee on the Epidemiology of, and Associated Risk Factors for, MGD.

Investigative Ophthalmology & Visual Science 2011;52:1994-2005.

22. Tomlinson A, Bron AJ, Korb DR, Amano S, Paugh JR, Pearce EI, Yee R, Yokoi N,

Arita R, Dogru M. The International Workshop on Meibomian Gland Dysfunction:

Report of the Diagnosis Subcommittee. Investigative Ophthalmology & Visual

Science 2011;52:2006-49.

23. Hinkle DM. Lid wiper epitheliopathy and dry eye symptoms. Eye Contact Lens

2006;32:160; author reply

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structure for preservation of ocular surface health and development of dry eye

disease. Dev Ophthalmol 2010;45:108-22.

25. Korb DR, Greiner JV, Herman JP, Hebert E, Finnemore VM, Exford JM, Glonek T,

Olson MC. Lid-wiper epitheliopathy and dry-eye symptoms in contact lens wearers.

CLAO J 2002;28:211-6.

26. Korb DR, Herman JP, Blackie CA, Scaffidi RC, Greiner JV, Exford JM, Finnemore

VM. Prevalence of lid wiper epitheliopathy in subjects with dry eye signs and

symptoms. Cornea 2010;29:377-83.

27. Schiffman RM, Christianson MD, Jacobsen G, Hirsch JD, Reis BL. Reliability and

validity of the Ocular Surface Disease Index. Arch Ophthalmol 2000;118:615-21.

28. Nichols KK, Smith JA. Association of clinical diagnostic tests and dry eye

surveys: the NEI-VFQ-25 and the OSDI. Adv Exp Med Biol 2002;506:1177-81.

29. Hoh H, Schirra F, Kienecker C, Ruprecht KW. Lid-parallel conjunctival folds

(LIPCOF): A definite diagnostic sign of dry eye. Ophthalmologe 1995;92:802-8.


30. Pult H, Murphy PJ, Purslow C. The longitudinal impact of soft contact lens wear

on lid wiper epitheliopathy and lid-parallel conjunctival folds. In: 6th International

Conference on the Tear Film & Ocular Surface: Basic Science and Clinical

Relevance. Florence, Italy; 2010.

31. Pult H, Murphy PJ, Purslow C. A novel method to predict the dry eye symptoms

in new contact lens wearers. Optom Vis Sci 2009;86:E1042-50.

32. Pult H, Purslow C, Berry M, Murphy PJ. Clinical tests for successful contact lens

wear: relationship and predictive potential. Optom Vis Sci 2008;85:E924-9.

33. Pult H, Purslow C, Murphy PJ. P-Test: The New Standard to Predict the Dry Eye

Symptoms in New Contact Lens Wearers? Investigative Ophthalmology & Visual

Science 2009;50:ARVO E-Abstract: 536.

34. Pult H, Purslow C, Murphy PJ. The relationship between clinical signs and dry

eye symptoms. Eye (Lond) 2011;25:502-10.

35. Pult H, Purslow C, Murphy PJ, Berry M. Lid wiper epitheliopathy, ocular surface

and tear film in symptomatic contact lens wearers. Acta Ophthalmologica 2008;86:0-

.

36. Guillon JP. Use of the Tearscope Plus and attachments in the routine

examination of the marginal dry eye contact lens patient. Adv Exp Med Biol

1998;438:859-67.

37. Guillon JP. Non-invasive Tearscope Plus routine for contact lens fitting. Cont

Lens Anterior Eye 1998;21 Suppl 1:S31-40.

38. King-Smith PE, Fink BA, Fogt N. Three interferometric methods for measuring the

thickness of layers of the tear film. Optom Vis Sci 1999;76:19-32.

39. Keech A, Senchyna M, Jones L. Impact of time between collection and

collection method on human tear fluid osmolarity. Curr Eye Res 2013;38:428-36.

40. Pult H, Bandlitz S. Leitfaden Trockenes Auge. Der Augenoptiker 2012;10:71-3.

41. Pult H, Riede-Pult BH. A new modified fluorescein strip: Its repeatability and

usefulness in tear film break-up time analysis. Contact Lens and Anterior Eye

2012;35:35-8.

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the dry eye tool box

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