Interest in the temperature of the eye spans almost 130 years. It has been an area of research largely driven by prevailing technology. Current instrumentation offers the potential to measure ocular surface temperature with more accuracy, resolution, and speed than previously possible. The use of dynamic ocular thermography offers great opportunities for monitoring the temperature of the anterior eye.

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Contact lens wearers with dryness symptoms exhibit significantly more LWE and LIPCOF, but not increased corneal staining, bulbar hyperaemia or decreased PLBUT. LWE and LIPCOF are significantly correlated: this may reflect their common frictional origin. LIPCOF Sum severity scores appear to be most predictive for symptoms.

28 29Purpose: This paper reports on the development of a new tear ferning (TF) subjective 30 grading scale, and compares it with the Rolando scale. 31Method: TF patterns obtained from tear film samples collected from normal and dry eye 32 subjects in previous studies were collated into a large image library. From this library, 60 33 images were selected, to represent the full range of possible TF patterns, and a further sub-34 set of 15 images was chosen for analysis. Twenty-five optometrists were asked to rank the 35 images in increasing order between extreme anchors on a scale of TF patterns. Interim 36 statistical analysis of this ranking found 7 homogeneous sub-sets, where the image rankings 37 overlapped for a group of images. A representative image (typically the mean) from each 38 group was then adopted as the grade standard. Using this new 7-point grading scale, 25 39 optometrists were asked to grade the entire 60 image library at two sessions: once using the 40 4-point Rolando scale and once using the new 7-point scale, applying 0.25 grade unit 41 interpolation. 42Results: Statistical analysis found that, for the larger image set, the Rolando scale produced 43 3 homogeneous sub-sets, and the 7-point scale produced 5 homogeneous sub-sets. With this 44 refinement, a new 5-point TF scale (Grades 0−4) was obtained. 45 Conclusions:The Rolando grading scale lacks discrimination between its Type I and II 46 grades, reducing its reliability. The new 5-point grading scale is able to differentiate between 47 TF patterns, and may provide additional support for the use of TF for both researcher and 48 clinician. 49 50

A healthy tear film is very important for many major functions of the ocular surface. Dry eye disease is a significant clinical problem that needs to be solved but the poor correlation between clinical signs and reported symptoms makes it difficult for the clinician to apply a scientific basis to his clinical management. The problem is compounded by the difficulties of evaluating the tear film due to its transparency, small volume and complex composition. Practical insight into tear film composition would be very useful to the clinician for patient diagnosis and treatment but detailed analysis is restricted to expensive, laboratory-based systems. There is a pressing need for a simple test. The tear ferning test is a laboratory test but it has the potential to be applied in the clinic setting to investigate the tear film in a simple way. Drying a small sample of tear fluid onto a clean, glass microscope slide produces a characteristic crystallisation pattern, described as a 'tear fern'. This test is currently not widely used because of some limitations that need to be overcome but several studies have demonstrated its potential. Such limitations need to be resolved so that tear ferning could be used in the clinic setting to assess the tear film.

Purpose To evaluate (i) the relationship between traditional and new clinical tests (lid-wiper epitheliopathy (LWE), lid-parallel conjunctival folds (LIPCOF)) and dry eye symptoms in non-contact lens wearers, and (ii) that a combination of these tests can improve predictive ability for the development of dry eye symptoms. Methods Tear meniscus height (TMH), non-invasive break-up time (NIBUT), ocular hyperaemia, LIPCOF, phenol red thread test (PRTT), corneal and conjunctival staining, and LWE grades were observed in a cohort of 47 healthy, non-lens wearers (male ¼ 17, female ¼ 30, median age ¼ 35 years, range ¼ 19-70). Symptoms were assessed using the Ocular Surface Disease Index (OSDI). Results LWE was significantly correlated to both temporal and nasal LIPCOF (0.537or o0.607, Po0.05). LIPCOF and LWE were significantly correlated to NIBUT and PRTT (r4À0.248, Po0.001). Significant correlations were found between NIBUT and TMH (r ¼ 0.461, P ¼ 0.001) and PRTT (r ¼ 0.640, Po0.001). OSDI scores were significant correlated to NIBUT, TMH, PRTT, LIPCOF, and LWE (r4|0.31|; Po0.05). Significant discriminators of OSDI þ /À were NIBUT (area under the receiver operative characteristic curve (AUC) ¼ 0.895), TMH (0.715), PRTT (0.781), LIPCOF (temporal/nasal/Sum 0.748/0.828/0.816), and LWE (0.749). Best predictive ability was achieved by combining NIBUT with nasal LIPCOF (AUC ¼ 0.944). Conclusions The individual tests NIBUT, TMH, PRTT, LIPCOF, and LWE were significantly, but moderately, related to OSDI scores. The strongest relationship appeared by combining NIBUT with nasal LIPCOF.

Symptomatic contact lens wearers exhibit significantly more LWE and LIPCOF, and decreased MUC5AC reactivity. LWE and LIPCOF are significantly correlated; this may reflect their common frictional origin. Increased friction might follow from insufficient mucins, or an altered composition of the resident mucins at the ocular surface. In this study, we show that decreased mucin production is associated with the severity of LWE and LIPCOF.