Diagnosis and remediation of blink inefficiency.

To examine the role of incomplete blinking in contributing to blink inefficiency, symptoms of dry eye and ocular surface disease. To review methods for diagnosing blink inefficiency (including both reduced overall blink rate and increased incomplete blink rate) and the role of remediation for efficient complete blinking as an essential part of the lacrimal functional unit in maintaining tear homeostasis. Diagnosis and remediation of blink inefficiency appear to have been somewhat misunderstood in the management of dry eye disease. To the extent that a high incomplete blink rate ranks in significance with low blink frequency in contributing to blink inefficiency, measures and remediation of only total blink rate are of reduced usefulness in the diagnosis and treatment of blink inefficiency-related ocular surface exposure, dry eye symptoms and ocular surface disease. In addition, a patient's blink performance during a biomicroscopy or any other clinical assessment of blink efficiency, is unlikely to be characteristic of or relevant to the blink inefficiency that develops and causes symptoms during their various day-to-day activities. There appears to be a strong case for prescribing blink efficiency exercises in the management of many cases of dry eye symptoms and ocular surface disease. Remediation of spontaneous blink inefficiency may require that a motor memory of voluntary complete, rapid, relaxed and natural looking blink formation is established and maintained as the basis for efficient spontaneous blinking. Voluntary forceful blinking may undermine the motor memory of efficient blinking and risk the depletion of any reserves of lipid.