An examination of the relationship between ocular surface tear osmolarity compartments and epitheliopathy

A 2014 PubMed search for tear hyperosmolarity and corneal stain yielded 2960 results. Selections from those providing evidence of variations in osmolarity were used to refine the compartmentalization model of tear osmolarity over the ocular surface. This new model includes the low point of freshly produced isotonic tears in the upper conjunctival sac, with osmolarity increasing successively in the upper meniscus, the upper area of exposed ocular surface, the lower area of over-exposed ocular surface, the lower meniscus, and the lower conjunctival sac. Compartmentalization is used to explain epitheliopathy over the ocular surface as resulting from variable degrees of exposure to hyperosmolarity-induced insult and/or friction-related mechanical damage. Also recognized is the role of localized increases in osmolarity, which appear likely to occur in the black lines and tear breakup areas of the exposed ocular surface. Variables such as the influence of ambient conditions of air humidity, temperature and movement have been considered, as well as rates of complete and incomplete blinks and associated potential for over-exposure of the inferior area of the normally exposed ocular surface. The exacerbating contribution from contact lens wear has been included. Friction-related damage may be the primary basis for lid wiper epitheliopathy, but tear hyperosmolarity could have an important contributory role. Subcompartmental consideration of variation in osmolarity may improve understanding of different presentations of epitheliopathy.