Vol. 2, #21   •   Thursday, September 9, 2021


Review's Chief Clinical Editor
Paul M. Karpecki, OD, FAAO

Provides you with cutting-edge clinical strategies for optimal management of ocular surface disease and beyond.


Dry Eye Disease With Morning Symptoms

Let’s look at one of the most common causes of DED with morning symptoms: non-tight lid seal.

Symptoms in the morning point to a number of conditions that include recurrent corneal erosion (sharp pain upon wakening), demodex blepharitis (itchy eyelids), or lagophthalmos. But the most likely condition causing morning dryness, pain, or discomfort is a condition termed inadequate or non-tight lid seal.

The Korb-Blackie (KB) Lid Light Test1
When morning symptoms are present or inferior corneal staining is noted, this test is essential. It involves having the patient close their eyes like they are sleeping without squeezing them closed. In a darkened room, a transilluminator (or penlight) is placed in close proximity to the closed upper eyelid without pushing on it so as to force open the eyelid. A beam of light evident inferiorly will indicate incomplete or inadequate lid seal.

This is not lagophthalmos, which is the inability to close the eye. With inadequate lid seal, the patient’s lids appear shut when looking directly at them. Think of the eyelids as being more like teeth, with the upper eyelid being slightly over the lower eyelid. This is where the seal takes place. With inadequate lid seal, the lids do not protect the ocular surface during sleep, resulting in desiccation and corresponding inflammation.

Dr. Korb’s incredible observations and research provide an answer for why so many patients with inferior corneal staining and morning symptoms don’t respond to traditional DED therapies, changing how we manage DED.

Treatment for non-tight lid seal has traditionally been artificial tear ointments at night (or gel products in some cases). An exciting new daily disposable device is called SleepTite. Patients simply place these on the eyelids before bed. There is no irritating tape, and the adhesive won’t pull on lashes or skin. It has a tab on the lateral edge for easy removal. Patients must be taught to place it such that the eye fully closes or “seals.” I’ve tested over 400 to date, with remarkable patient response accompanied by significant improvement or resolution of symptoms and signs. Many patients have even commented on being able to get a good full night sleep.

Dry Eye Flares
Keep in mind that in DED patients, incomplete closure can be a trigger for dry eye flares. The only approved drop for the short-term treatment of dry eye signs and symptoms is EYSUVIS. Consider prescribing it up to QID for two weeks, while also initiating non-tight lid seal treatments.

KEY TAKEAWAY: Morning symptoms, inferior corneal staining, and treatment-resistant dry eye are often the result of non-tight lid seal. The KB Lid Light test is essential in making this diagnosis, and new treatment options show incredible promise for millions of patients.


1. Korb D; Blackie C. The Korb-Blackie Lid Light Test. Invest Ophthalmol Vis Sci. 2013 June; 54:942.

Supported by an independent medical grant from Kala Pharmaceuticals

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