Recently published research on lid wiper epitheliopathy (LWE) concludes that using only a single drop of dye to diagnose the little-understood condition is insufficient. To truly reveal the full extent of LWE through staining, two drops are superior, the data shows. In a number of cases the research team, led by Christopher Lievens, OD, reviewed, patients didn’t even show any LWE damage after that first drop. However, after a second drop, Dr. Lievens says, the condition proved to be widespread. “Unlike staining the cornea, it requires two sequential drops—doing it wrong risks a misdiagnosis,” he explains.

While that finding has a practical purpose in optometric clinics, Dr. Lievens, a professor and the chief of internal clinics at Southern College of Optometry, has an ulterior motive to evangelize about LWE.

“If you surveyed 100 optometrists, 99 probably wouldn’t know what you’re talking about,” he says about the condition. And those who do know about it “don’t know how best to look for it or what to specifically do if they find it.” And that’s not any doctors’ fault. Even the known research on LWE shows variations on how to diagnose, grade and treat it.2,3 Dr. Lievens is hoping to change that.

Primarily, Dr. Lievens explains, contact lens wearers are at particular risk due to the device's propensity for collecting debris and physical interaction with various anterior segment structures. A daily disposable might be the best option for avoiding LWE damage, he says, because this lens choice can offer quality lubrication and the least issues with surface deposits.

But the recent publication in Contact Lens & Anterior Eye narrows in on diagnostics. It relied on data from 37 participants with LWE. The team applied a single drop of 1% lissamine green (LG) (10μL) to the superior bulbar conjunctiva in the right eye, and took photographs of the lid margin at one, three and five minutes after instillation. Then, they repeated the measurements using two drops of 1% LG instead. The same procedures were followed using 2% sodium fluorescein (NaFl) (2μL) to the left eye.

For both LG and NaFl, the timing was significant. For ease, investigators suggest clinical observation take place three minutes after the second drop of LG or NaFl is administered. The analysis shows that with two drops of each respective dye, LG could be optimally viewed anywhere between one and five minutes (three minutes had the greatest staining) and NaFl viewed three to five minutes, Dr. Lievens explains.

This study establishes a protocol for diagnosing a patient, but that’s just the tip of the iceberg, according to Dr. Lievens. Next on his agenda, he hopes to examine more of the natural course of LWE.  Additionally, he would like to restructure the grading scale since “the current model is time consuming,” he explains. “Ideally, we should have a picture match system.”

Once such a system is in place, clinicians can better target treatment with artificial tears, cyclosporine, refitting contact lenses with more appropriate materials or perhaps even initiating an omega-3 supplement.

1. Lievens C, Norgett Y, Briggs N. Optimal methodology for lid wiper epitheliopathy identification. Contact Lens & Anterior Eye. May 14, 2020. [Epub ahead of print].

2. Efron N, Brennan N, Morgan P, Wilson T. Lid wiper epitheliopathy. Prog Retin Eye Res. 2016;53:140-74.

3. Korb D, Greiner J, Herman J, et al. Lid-wiper epitheliopathy and dry eye symptoms in contact lens wearers. CLAO J. 2002;28(4):211-6.