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Inferior Quadrant of Tear Film Is More Likely to Break and Breaks Early in Patients With Dry Eyes

Zhuo, Ran, MD*,†; Zhang, Bin, MD, PhD; Hou, Lijie, MD*; Shen, Meixiao, PhD*; Lu, Fan, MD, OD*; Jiang, Jun, MD*

doi: 10.1097/ICO.0000000000001886
Basic Investigation

Purpose: To investigate the temporal and spatial distribution of tear film breakup time via a noninvasive topographer in normal subjects and patients with dry eye disease (DED).

Methods: A total of 77 subjects were separated into normal and DED groups based on their symptoms and tear film instabilities. In noninvasive evaluation with Oculus Keratograph, the precorneal tear film was recorded and reconstructed into a two-dimensional map that evolved with time. Whether or not each sector broke and the breakup time if it did were recorded. The map was further grouped into 4 quadrants to reveal the spatial variation.

Results: By the end of recording, the inferior quadrant in DED subjects had a higher number of broken sectors than other quadrants (P < 0.01). Over the recording period, the cumulative percentage of sectors that were broken rose much quicker in the inferior quadrants, and the inferior quadrant is the only quadrant that showed a significant difference between the normal and DED groups (P < 0.01). This difference peaked at 12 seconds and declined after 15 seconds. Receiver operating characteristic curve for each index always showed the largest differential value in the inferior quadrant.

Conclusions: Tear film breakup is not homogenously distributed, with sectors in the inferior quadrant being more likely to break and to break earlier. Between normal and DED subjects, a significant difference of tear film instability is more likely to be found in the inferior quadrant.

*Eye Hospital and School of Ophthalmology and Optometry, Wenzhou Medical University, Wenzhou, Zhejiang, China; and

College of Optometry, Nova Southeastern University, Davie, FL.

Correspondence: Jun Jiang, MD, Eye Hospital and School of Ophthalmology and Optometry, Wenzhou Medical University, No. 270, West Xueyuan Rd, Wenzhou 325027, China (e-mail:

Supported by Health Department of Zhejiang Province (Medical and health projects of Zhejiang 2018KY542).

The authors have no conflicts of interest to disclose.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (

Received July 11, 2018

Accepted December 19, 2018

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