CLINICAL ADVICE OPTOMETRY TODAY 21/09/07 In the blink of an

By Karen French and Jane Veys

id you know that in a lifetime distribution and drainage of . we will spend the same Blinking helps to spread lacrimal fluid amount of time blinking as down and across the eyeball. The Dwe do eating? We spend downward action of the upper lid About the authors about five years with our shut wipes away debris from the anterior because we are blinking. The average surface of the eye into the lower tear Karen French PhD BSc (Hons) person blinks 15 to 20 times a minute, meniscus. The retraction of the upper MCOptom is a practicing which amounts to more than six lid then pulls tear fluid from the lower optometrist in million blinks a year. tear meniscus up over the anterior Cambridgeshire. With a PhD in surface of the eye, restoring the pre- material ocular tear film1. The goblet cells properties, she has authored So why do we blink? Blinking is a rapid closure movement within the tarsal produce several continuing education of the lasting 300-400ms. mucus which is spread over the articles in the area of contact blinking occurs in response to corneal epithelium during a blink to lenses, and also teaches at external stimuli and protects the eye form the deepest layer of the tear film. City University. Jane Veys from foreign particles, bright light and Efficient blinking maximises the MSc MCOptom FBCLA FAAO from injury. Spontaneous blinking is spread and distribution of the mucin is Education Director for The the regular blinking that occurs with over the . Bringing the lids Vision Care Institute™ , no apparent external . Its together during blinking promotes Johnson & Johnson Vision main purpose is to moisturise the eye secretion of lipids from the meibomian Care Companies, Europe, by forming the tear film, to wipe debris glands2. The inner edge of the lid Middle East & Africa. She has from the surface of the eye and to aid margin then spreads these lipids over authored an award winning tear drainage. the tear film with each blink. This online continuing education mechanism is illustrated in Figure 1. series and a textbook on Blinking is also important in tear Contact Lens Practice. Blinking and the tear film The eyelids are essential for the drainage, which is an active process utda nweefo 0t 20 to 10 minute per from blinks anywhere as are rates quoted blink average literature the o n niiulbti a be can it conditions but external by individual affected constant any fairly for usually is rate Blink blinking affecting Factors muscle the oculi of contraction orbicularis the by mediated notenslcia utadinto cavity. drain and nasal the duct tears canaliculi. nasolacrimal sac the the into lacrimal via the From and the sac enter superior then lacrimal and the puncta, into inferior They drawn blink. each are with lid of lower movement the angle medial canthal the by medial assisted the at collect hw ordc h aefo an from rate the reduce to been has shown reading reduce General can rate. blink activity mental 20 of of certain types However, excess minute. in per to rate. blinks rate can the blink recall increase verbal on and Conversation effect significant etlatvt a aea have can activity Mental 5 . 3 Tears . 4 In . aea o-naiecreaeof function correlate non-invasive dopamine a blink as rate spontaneous of use In field the psychology in rate. researchers many blink brain fact increased in the activity results to dopamine in increased connected where activity is dopamine state and emotional blinking between relationship ni ifcl agtrecognition completed been target have tasks difficult blinks between until time the sustaining blinking, spontaneous exists inhibiting mechanism for a suggested been vrg f1 lnsprmnt to minute minute per per blinks 8 blinks approximately 15 of average c satigrfrtenx blink. next the for may trigger film a tear as the act of re- thinning break-up to that and seems assume it is to film, reasonable tear the stable blinking of ocular a establish one of by As functions affected condition. is surface rate blink lowt tiredness and with excitement or also with anxiety increasing anger, states, emotional ln aei lordcdi down in reduced also gaze is rate Blink ylwlvl fdpmn,results rates whilst blink dopamine, decreased of in levels have rates, low characterised by disease, , blink Parkinson’s as increased psychoses, certain such from suffering vrg ie–fl eraein decrease In fold use screen – during rate on five blink computer. is a the there average people of healthy use normal the rate blink is affecting factors reported further even rate can blink tasks visual reduce demanding More with (courtesy Figure ayatosrpr h atthat fact the report authors Many lnigcnb fetdby affected be can Blinking

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21/09/07 OPTOMETRY TODAY 21/09/07 OPTOMETRY TODAY CLIN u l f s b o h t s a e s e r s s e d e r u s e b p i w F ( e v e n i s c e w m o c e l c a e y e s l a t a r t I Incompl p i w n e l u e h s o t h t n i l b u l c n a d e o t a n i p e l a d i w h w f o v i g e h t a e f o n i m e v o m c i r f t a m t a m s n i e d e w h t m a p a h s u g i a t w o h e r p t i p t n o c n u j n o - o n i s c i t r a n A T e u g i d a t a i c i r b a e r c e a d h c h f r d e g e c n i s o p r e s a t s e l o f s e r o o s n u n t r e r a i n i a t t h t e t n e i b t s l i s f e r e i e p n i a t u s e t a u q e d n n i n o i t e h s a d i l a i r e a i r e r e ’ r e y l e t e c a e t u . k l b l e h t r o f t l g a t a u q e y d c a d e c m r e t a m e h f o e h t e l i h e i f e r d i l CAL w o l n i n i s e r c n s d a v l i b l p o r c n i a m s s e l u p e g n n o k n i s r s a u l f e s h g i n a b n h c h c u s i c yt , n i r o s n s t c d e t p i w s d e u a r a c i s i y b l l s t i n e e i h T l l r a b b n i e o o r c 2 n e o v i t c n i i i r e d e s a p b u n e p a m l r u d d h t t e o t d e s a e a n a s i r s t e t et e l r s l b i w a p a n e . ) g n r e r a e h t t o c m e p h t t e y i s e m l e e c s e r h t y r y b u a r d n i y e h v o d w t A m i p m o u s p a h t o t h e r e e e w , t r a l a a c i r n i s c h s e g s s i h . a u l e m a i r o h t e s e e t a h t d h t n e l y a n r e t s n r e i i i n a n a f i DVI o h t i s e a h g e . t g n I m e g n e c n e s b a i m c a f r m e k p a h c t m i d p n a bl r r b a w o l r b c d t m n , e f e o p n o s y t i r f n e c y i l e h a d p u l e s u c o o r e t h c r o t o s d n i f y a , s , n i f e t e l r i a e h t o o m s e b h T et a r h i t s m o t p m y s d p u - k a e i l a n r e t x e i t u a r o p a i f f u d n a d s n e l r g n i l l e L n e t l u s e s e t a m t a r t s n o nkig f o n o i t c c o h n o i t a c e n r o c t t s r a a m i x s s e n e r a w p tn a t e n CE a h g n i r o i t c i r , s n o p g n b L( e r e p p t l u c i c i n a e h y e o i v i d n i e h t e r u s t u e g a t e s o r e t o t t l u s e r a l p m o c n i n i r u d r a l t c i r f l u d o l a e r a e l r e e l a r g n o i t f o e s n i t a v r e s b o s i e r p l u )E W n i k n i e h t . 1 e v e e x e i l b t i w r a e t 6 i t d a l a u s i v i l t c a p m i o t e h t 71 e c a f r u s r a . e s n o c o c e c a f r u s i r u d . d e d l a y l e t l l b r a l u c n o c y n i - o l a d s e r o m t n e t o w t a . n d i r e p p u n o i w n i k n f o . i l s n e l a f s u f o f o t s e b b e v e l d e s t i t f t e b h 81 l a u d s . l e e f g f o t n i b m i G e m i r t d n e a f h t i o . g g i t i f i p e h t o r i s s e l w c a f r u s . h g n i n i a t s o t l b v a i k n h t i g r a m g n d i l s e s i , 0 1 n I n e v s r o t c c d a e r f i t s e t e m l n e e w a e t c a t n o h t i g r a m e g d e n a w o . l a g h t i i t a n i t n e u q g f o t n o e u l u f o . s k s a t k n i s p o r d r a e t a . g n n o e s h t l l e n a t s i i e h t r e t a s s e l v a h a f o h c f o r i w e p d 0 0 0 i l t h T y a m c n I i l c f e s h T , i r r i e r e h n i g r a m d n a u i l e i v o r p l b e n d i l u c i t r a d h t e c b t c a g n i w n i k h t g n i t i r e v e s y r d i 1 h i l c h t f h c u s n n o c n e u n i l s la t n e m n o a a c i n y l e s i n r u l f g i h i k n i e i f A h t 2 - 0 l l e e r e l u c o s s v a e g l b re p i w t a h W i r t a t i e c i l a e t d a m l o i t c a c i n m ne e b i .k s a t o p i w e s a m e n v e v o n i k e l g n sn e l yl e k l e l sn e l ,k n i ta h t i w i w m n i t h T dn a o l ev i f a n a dn a tc a t na c ‘ sn e se d e s %0 h no i yr a eh t t i l di l yl i yl l ra l dn b gn ne eh sn sn ro e sa ht fo e t ot s ra fo la w i ll ll i d d n d y o y e e a g g s s s r r l t Figur (courtesy Figur Ta h c e r n i a t o c l b i f o M h n • • • • F • • • tm a c • F • . k s ble k n i l M c m o c o a a n e c n n e l l a n i t a T An Co Co P I Re P Co n c c n i ir ro o di o i b to to cre e e m o c e ed or xi a rn m n s n o g n i 1: ti vo d di ve rs rs p e 2b: 2a: t on l p p e n a he te ty of c n r t ute al n i g Co s e rs n t a g i tha tha a e t e s ed s n o t n i t a re l p Don ti a e H se i a r o p m Sche Stain iv g, r ndito na ) fil g e d e t e on u y a c m if 61 se n a t n e c n s i v e may may Korb) e v i t c a en i l b g fic s n b sta m the vi tra n o s b ng u r ns u k n ron g u p e l n i k n i l a ty s l de increas a s u o e ti il ia yt i . h ty a afe l l i mental t s e g g n i c of s e r i e ty creas n pica y y l l a u s i v ting,a rep visual c n e cting e r e h T s g o y a m l b l r es s a l t a h t t i condits y smoky s blink k n i task blink n a enta s d e i a blink ec n e u q e s n o c t n e n i h t e b n i d g n i l e n t a tion m e rate rate et e l p m o c a r l i t p m e t n ra c e yl t c e r i d r e n (air t n a L te s l i h w s e of u t WE gn i d a ra e t the l l o ot y t f ‘l id wiper’ n o e r r o o p m t s n i s a e l i h t s k o o l e R a m B s s k n i l b f e h t f n i c M l a m o c d n a l a s d a e l y s T Bl r o t o h p s o t s e n i m o c n i p u t a h t m m m f e l i f a p d e c u d e s d n o c e r u s k n i l e h o s f o s f s u n i c u r o d e g a n a l M s i l b a t r i e t m p m inkg t c u d i i s r e a y r e g o M i n i c c l l u f d t u r x e r- e M c s e l c s e n e t e l p r t n o c s o p x e y l i i r o i r e x e t n d e n i e e 1 u s o t e d b . n o i t a l b a i r p h t t c y, o t t e l p c n t n e n n n f n n i i l d n a c c s s e i n n o n i t t i f s o k e e w n i h s m d s b r u t a . d e e e n o d l u o h c u a o e h t k n d n a r o c s o p f r o l y r g e r n a e i s i c f o y b e n r a s e t u b i e u r e f n i t I u q e e ef f u e s g o c r e t a e a s i l r e p p m o c n i a e r . a e n d , l a x e s i o t s e c n e m o l 1 g fic e s i l b n i g a r u o c n e s . o t n i d i p e h t l a e h t t l y l b i 8 o c a h t n e o r o y h t a p o t a r e k f o r e s s d o i r o i v e r e p s r o i r e f T b l s w g n i k n d e t s e g g u n i a f p g i s t s e g g u t i w m b ency c e e o t t n o C e h o t i c l n i l b y r e i c a r t p t r a e t l s w o r b e y e s r e y a yt i l i b a t s . o r p r t h b p n r a e h s a i p a r i i . a e n r o c p m o c n I n o y l r o o s t f o s e d h t k n l o t u o h e t e l e t e l g e e d e f o s i s a h p m e i n d e s i t n s a e d . g n i k t c a p o n a a , a e n r o c i r e t f l a h s . c k n i l i f , d m l i f y a m exrcis a l n c i n e r e t s a f s s o e p p t l u s e r e r i w n i l b e v g g s t a h t g n , s k n i l b e t m e s i t a c l w o t o g n i k a t s n e l s e y e h t i s a n i h t i r e g n o o c 4 2 i v l o v n a P c l s g e b n i t t e r a e t e d n a o h i i r n i p a v e e a r c n i i k r t a p m e h T n o r o e t c r a e t t a f y t o c e i r f o e h f o r u g n c o c e n r a e w s i i h w r a c f e s i h t f b h t b o r d i g i n e t e l e c m r d h t e s a e e l t u o b a .s k e e h c c n o k n i l m m a r t h i w d g n o o de c a l p i t t a r n a c e l r -k a e r b se s n e l i r r o f r k n s p a o ss e n y f r u n a f u a e h c y e l p a p no i t a c w t l b h t re g n n r a t r a e i t e dn a t e na c u o a h t i i h t t i h t gn i a m i c e r yn eh gn gn h 3 t v eb ae t ni r fo et ta e y. si s h 0 e e a a e a e e s t t - . . o eudrsiae.I the dryness In with associated ocular of discomfort complaints underestimated. room should consulting be eye the of not comfort the and maintain health regular to for blinking need complete and the of awareness The Summary cleaning with efficient an lubricity, regime. material ensuring and a and wettability surface using enhanced of levels deposits, lens minimal the frequent ensure maintains more to may lenses to replacement Solutions switching material include of lens appropriate. possibility contact where obvious the the improving not ignore blinking to incomplete and dryness blinking incomplete influencing Conditions 2: Table of management the in important of healing the aiding keratopathy. of exposure in benefit ocular drops the the these increasing onto and drops surface massaging lubricant lid of effect drop the upper the have the to after efficiency allow margin will blink immediately instillation lens out exercises carrying contact suggests that McMonnies and/or drops. rewetting dryness tear of artificial substitutes symptoms recommending the include and signs efficiency blinking out exercises. carry to for instructions how as and well blinking as important, efficient is explanations why of illustrations contains has Guide, Instruction which his McMonnies Blink for the leaflet patients, 3. take-home a Figure developed in from as such that photographs gained be showing can by This be aided exercises. the to out and carrying advantages blinking the incomplete of the of the problem significance make the to of aware important the patient is It out carry exercises. to in patients key is encouraging education patient Obviously otc lenses Contact • surgery Refractive task • visual of difficulty Increased • use Computer • alertness Mental • Fatigue • atmosphere) smoky heating, central conditioning, (air conditions environmental Provocative • blinking incomplete of increased rates to contribute may that Factors ncnatln err tis it wearers lens contact In the for strategies management Other cuts fTui Dave) Trusit of (courtesy blinking incomplete result from can that keratopathy exposure the highlighting staining Fluorescein 3: Figure xrie a eehne when enhanced be ocular combined. may efficiency from exercises blinking of a and effect lubricants therapeutic relief tear offer The blinking for may discomfort. problems, exercises prospect of and as efficiency cause implicated incomplete be reading Where the to rate appears as blinking blink use. low such computer in activities are involved problems of those risk symptoms. greatest at reported People of an in rate result or to increased rate likely is blink efficiency in blink the reduction any moisturising and in eye role too plays important all mechanism an blink are The wearers common. lens contact and wearers non lens contact both amongst .Lm A elrH.Hwd tears do How exit? HH. Weiler MA, Lemp 3. 44 1989 Butterworths; ae n hl nconversation. in while and primary in gaze, use, terminal and display reading video during humans: normal activity in blink eye three spontaneous of of Consideration types MJ. Doughty 5. 9-10 d de’ hsooyo h y.9th eye. the of Ed., WM Hart physiology In: Adler’s eyelids. ed. The WM. Hart 4. 619-22 24(5): .RselG.Aaoyand Anatomy eds. J, related Stone AJ, and Phillips In: cornea structures. GL. the of physiology Ruskell 2. adnexa. 28-33 227(5940): ocular 2004; The – therapeutics 3; Ocular part J. Lawrenson 1. References her for Osborn review. Kathy expert Dr to you Thank Acknowledgements po i c 2001 Sci Vis Optom Lenses Contact .Yr ,OgJ obn JC. Robbins J. with Ong associated rate M, blink in Variation York 6. tLus ob erBook Year Mosby Louis: St netOhhlo i Sci Vis Ophthalmol Invest r d,London: Ed., 3rd . 81)712-25 78(10) ; Optician 1992 ; 1983; Institute Johnson & Johnson Vision Care Care Vision Johnson & Johnson An CLAO 8 obD ta.Ldwiper Lid al. et DR Korb 18. 2 rueJ,Nr .Relationship break-up time? and frequency M. blink Norn between JU, Prause 12. h nlec ftpclanaesthesia. of topical pattern of under influence the activity the blink of eye NF. spontaneous Button assessment MJ, Doughty An T, Naase 14. 70 rns,Pr aeilproperties. Material – 1 lens-related silicone Part contact new dryness, A for lens J. hydrogel Veys K, Osborn 17. 37-51 30(1): amitrA.Bikrt and involvement? rate for Blink evidence dopamine behaviour: stereotyped AA. RE, Arendt Baumeister DN, Bryson- Ellis MH, WA, Lewis Brockmann WE, MacLean 10. 151-4 90(1): 2007; tear and rate blink stability. L, visual on Optom of use Bradley Effect unit display R, L. Acad Hunter Henderson B, Am Galloway S, Patel Arch 7. 461-7 48(6): Optom 1971; J Am Optician eye, contact dry dry and lenses. surgery epitheliopathy, lid Incomplete refractive keratopathy, wiper exposure CW. corneal blinking: McMonnies and 16. 525-31 67(5): Blinking 1989; (Copenh) L, Campbell sensitivity. Ophthalmol M. R, Seeto Exp Ross M, Collins Clin 15. 306-12 243(4): Arch 2005; Graefes the in neonates sensation in infants. and blinking of corneal development morphology layer lipid and Murphy Tear-film R, Birhah PJ. JG, Lawrenson 13. 19-22 65(1): 1987; symptoms epitheliopathy yrpii otc lenses. with contact activity blink Eye hydrophilic JS. Poniter 8. 888-92 pnaeu y ln aefollowing rate wakefulness. Increased prolonged blink G. eye Ficca spontaneous E, Russo AR, L, Paolillo V, Arpaia Padova De G, Barbato 9. 498-504 Psychiatry ,BugrP lnigand Blinking thinking. P. Brugger schizotypal Fathi T, Landis M, PS, Sandor C, Mohr 11. ptaml(Copenh) Ophthalmol Psychopharmacol otc eswa n akdifficulty. task and wear lens contact

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21/09/07 OPTOMETRY TODAY