A Perspective on the Use of Fluorescent Imaging to Reveal Mechanisms of Breakup

Purpose: Tear film instability, which can lead to rapid tear film breakup (TBU), is considered to be a major etiological factor in dry eye. However, experimental support for many of the proposed theories for TBU mechanisms is relatively scarce. The major aim of this perspective is to show that fluorescence studies of TBU can be used to provide experimental evidence for two proposed underlying mechanisms of TBU, evaporation and divergent flow.Methods: To understand the effects of TBU on tear film fluorescence, we show that local fluorescence is the product of three main factors: tear film thickness, fluorescein concentration and fluorescent efficiency. In divergent tear flow, tear film thickness is reduced without change in fluorescein concentration and fluorescent efficiency, thus leading to reduced fluorescence intensity. Evaporation causes decreased fluorescence mainly by self-quenching due to high fluorescein concentration. Fluorescent efficiency is reduced by quenching at high fluorescein concentration but is independent of concentration for very low fluorescein concentration; thus, comparison of high and very low concentrations of fluorescein can be used to discriminate between divergent flow and evaporation. Finally, it is shown how the fluorescent pattern can change greatly during the development of breakup.Conclusions: This analysis demonstrates that the study of tear film fluorescence in TBU and dry eye may be underutilized as additional information pertinent to clinical practice may be obtained. A better understanding of TBU mechanisms may lead to improved diagnosis and treatment of dry eye.