Blinking Exercises Help Ease Evaporative Dry Eye

Megan Brooks

November 21, 2014

In patients with evaporative dry eye, blinking exercises can help decrease partial blinking and improve meibomian gland function and symptoms, according to a new study.

Detecting and quantifying partial blinking and blink training might be important in the overall treatment and management of evaporative dry eye, the investigators report.

David Murakami, MPH, OD, from TearScience Inc. in Morrisville, North Carolina, and Korb Associates in Boston, presented the results at the American Academy of Optometry 2014 Annual Meeting in Denver.

Partial blinking is closely involved in evaporative dry eye, he explained in an interview with Medscape Medical News.

"We are a focused society; we stare at computers, smartphones, and video games, and we are trained not to blink. If you aren't blinking fully, you don't express the oil from the glands," he said.

We have hundreds of patients with evaporative dry eye who are on a blinking program," Dr Murakami reported.

Blink and Brain Training

Dr Murakami presented results on 10 patients diagnosed with partial blinking, symptomatic evaporative dry eye, and reduced gland function. Their mean age was 53 years.

All patients completed a dry eye questionnaire, and habitual blinking behavior was recorded for 20 seconds and analyzed with the LipiView (TearScience Inc.), an ophthalmic imaging device used to measure the tear film lipid layer. In addition, the number of functional lower lid meibomian glands was determined with the Meibomian Gland Evaluator (TearScience Inc.).

Each patient was trained in and performed individualized blinking exercises for at least 8 weeks.

"I tell patients to really pause and deliberately close their eyes," Dr Murakami said. "We are training the lids to be stronger, but we are also retraining the brain to do a full blink." A blinking reminder computer program helped remind the patients to do the exercises.

Patients were assessed before and after the intervention.

The percentage of partial blinks improved significantly with the intervention (70.9% vs 23.5%; P = .001). In addition, symptoms decreased (10.1 vs 6.7; P = .02) and the average number of functional glands increased (4.1 vs 5.9; P = .02).

"Blinking exercises have been a well known antidote for dry eye symptoms due to non or partial blinking for many years," Barry Farkas, OD, an optometrist in private practice in New York City, who was not involved in the study.

"We have employed such assistance for over 35 years. In the old days of mostly rigid contact lenses, those exercises were even more necessary for tear and oxygen flow and exchange," he told Medscape Medical News.

Compliance an Issue

"In today's world, where contact lens materials are all breathable, complete blinking still remains more than helpful in spreading both moisture and nutrients to the entire corneal surface," Dr Farkas explained. "Even for those not wearing lenses, failure to blink completely and regularly can push a marginally unstable tear layer toward a too-short contact time with the cornea and lead to corneal surface breakdown."

"The issue with blinking exercises has always been, and remains, finding individuals motivated enough to learn the technique and continue with the process. There are those who might find the treatment not enough of a cure and too much of a nuisance," he said.

Dr Murakami said he agrees that compliance is "always going to be an issue." However, education is important. Patients who demonstrate more severe partial blinking and who tend to be very symptomatic are likely to be compliant because they understand the problem, he pointed out.

Blinking is "important", said Mina Massaro-Giordano, MD, from the Penn Dry Eye and Ocular Surface Center and the Scheie Eye Institute at the University of Pennsylvania in Philadelphia.

She said she has been paying more attention to it. "I was kind of surprised to see the amount of partial blinks my patients have. I do give blinking exercises to some of my patients," she told Medscape Medical News.

"What's interesting about this study," Dr Massaro-Giordano said, "is that it shows you can improve the muscles involved in blinking. It's just like any muscle; if you work it, it improves."

But she said it is also important consider the eyelids. "Older patients may have lax lids or extropion, so even if they are blinking hard, it may be ineffective because that lower lid is just loose from age, prior surgery, or prior damage," she explained.

"You also have to look at the meibum. If you have meibum that is completely socked in and the concretions are really dense and it's very viscous, then you can blink all you want — it's not coming out."

This study was funded by TearScience Inc. Dr Murakami and his coauthors are employees of the company. Dr Farkas and Dr Massaro-Giordano have disclosed no relevant financial relationships.

American Academy of Optometry 2014 Annual Meeting: Poster F-039. Presented November 14, 2014.

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