Effects of Prolonged Reading on Dry Eye

Sezen Karakus, MD,1 Devika Agrawal, BS,1 Holly B. Hindman, MD, MPH,2 Claudia Henrich, MD,1,3
Pradeep Y. Ramulu, MD, PhD,1 Esen K. Akpek, MD1

Purpose: To demonstrate the effects of prolonged silent reading on tear film and ocular surface parameters.
Design: Prospective, observational clinical study.
Participants: A total of 177 patients with dry eye and 34 normal controls aged 50 years and older.
Methods: After evaluating symptoms using the Ocular Surface Disease Index (OSDI) questionnaire, the
following tests were performed in consecutive order: automated noninvasive tear break-up time (TBUT), surface
asymmetry and regularity indices, Schirmer’s testing without anesthesia, corneal staining using fluorescein, and
conjunctival staining using lissamine green. The participants were then asked to read a 30-minute validated
passage silently. The tests were repeated after the reading task.
Main Outcome Measures: Changes in tear film and ocular surface parameters after reading.
Results: All parameters, with the exception of surface asymmetry index, worsened after the reading task in
patients with dry eye and in controls. The worsening reached a statistical significance for corneal and conjunctival
staining in the dry eye group (P < 0.001) and for corneal staining in the control group (P < 0.01). At baseline, OSDI
scores correlated only with corneal and conjunctival staining scores (r ¼ 0.19, P ¼ 0.006 and r ¼ 0.27, P < 0.001).
Among postreading measurements, baseline OSDI scores correlated with TBUT (r ¼ 0.15, P ¼ 0.03) in addition
to corneal and conjunctival staining (r ¼ 0.25, P < 0.001 and r ¼ 0.22, P ¼ 0.001). Changes in TBUT and
Schirmer’s test correlated significantly with their respective baseline values (r ¼ 0.61, P < 0.001 and r ¼ 0.44,
P < 0.001), indicating that the more unstable the tear film and the lower the aqueous tear secretion, the worse
they became after the prolonged reading task. Worsening in corneal staining directly correlated with the baseline
conjunctival staining (r ¼ 0.17, P ¼ 0.02) and surface regularity index (r ¼ 0.21, P ¼ 0.01).
Conclusions: Evaluating tear film and ocular surface parameters at rest may miss clinical findings brought
about by common everyday tasks such as reading, leading to discordance between patient-reported symptoms
and clinician-observed signs. Quantifying dry eye after visually straining activities such as prolonged silent
reading may help better understand patient symptomatology. Ophthalmology 2018;-:1e7 ª 2018 by the
American Academy of Ophthalmology

Modern lifestyle requires increasingly demanding visual
tasks such as book reading for leisure or use of electronic
devices for work-related productivity.1 Previous
questionnaire-based studies indicated self-reported diffi-
culty with reading as one of the most common symptoms of
dry eye, suggesting that reading difficulty is an important
component of how dry eye affects the quality of life of
affected patients.2-6 In fact, symptoms after sustained
reading are not unique to patients with dry eye, and even
healthy individuals with no prior dry eye diagnosis experi-
ence visual symptoms after prolonged reading.7,8 Computer
work is particularly problematic, with prolonged use of
computer displays causing significant worsening in dry eye
symptoms.6,8-10
One shortcoming with regard to the diagnosis and
treatment of dry eye has been the absence of objective
measurable parameters that can help quantify the disease
state and evaluate the efficacy of treatments. As clinicians
who care for patients with dry eye, we are aware of the lack
of correlation between patient-reported symptoms experi-
enced on an everyday basis and objective findings as
currently measured in the clinic. For example, many patients
with dry eye with perfect visual acuity and mild corneal
staining report that they are unable to read comfortably
because of their symptoms. We hypothesized that quanti-
fying dry eye at rest may miss clinical findings brought about
by common daily tasks such as reading. Therefore, in this
study, we aimed to quantify the objective dry eye pa-
rameters measured at baseline and after sustained reading,
and correlate them with baseline patient symptoms.
Methods
The study protocol was approved by the Johns Hopkins University
and the Rochester University Institutional Review Boards in
accordance with the Declaration of Helsinki, and the study proced-
ures were performed according to Health Insurance Portability and
Accountability Act. New and return patients with dry eye, older than
50 years of age and with a binocular visual acuity of 20/25 or better,
who presented to the Ocular Surface Diseases and Dry Eye Clinic at
the Wilmer Eye Institute, the Johns Hopkins University (Baltimore,
MD), and the Dry Eye Clinic at the Flaum Eye Institute, Rochester
University (Rochester, NY) were identified by a study coordinator.
Patients with self-reported illiteracy or language problems, contact

ª 2018 by the American Academy of Ophthalmology https://doi.org/10.1016/j.ophtha.2018.03.039 1

Published by Elsevier Inc. ISSN 0161-6420/18
 Ophthalmology Volume -, Number -, Month 2018
lens wearers, and patients who had any ocular surgery within the
preceding 3 months were not considered. Patients who did not take
any prescription eye drops (including topical cyclosporine, steroids,
and antiglaucoma eye drops) within 30 days of the study visit were
consented by a study investigator. Individuals who were using over-
the-counter drops (including artificial tears) were asked to refrain for
24 hours before the study visit. Similarly aged accompanying friends
or family members, as well as healthy volunteers, with no history of
dry eye or current dry eye symptoms, or other ocular diseases
requiring topical treatment were recruited as controls at both sites.
First, the Ocular Surface Disease Index (OSDI) questionnaire was
administered to evaluate dry eyeerelated symptoms. A total OSDI
score and 3 subscoresd(1) ocular symptoms subscore (questions 1 to
5), (2) vision-related function subscore (questions 6 to 9), and (3)
environmental triggers subscore (questions 10 to 12)deach ranging
from 0 to 100 were calculated as previously described.11
The following tests were then administered to both eyes in the
order listed with at least 5-minute breaks in between. First, the Tear
Stability Analysis System incorporated into the Tomey Top-Ref-
Keratometer RT-7000 (Tomey, Phoenix, AZ) corneal topography
machine was used to measure noninvasive tear break-up time
(TBUT). Values greater than 3.0 seconds were considered normal as
previously recommended.12 The surface irregularity indices (surface
asymmetry index and surface regularity index) were measured by the
Tomey TMS-4 videokeratoscopy (Tomey, Waltham, MA). Greater
values represent greater irregularity of the ocular surface.13 Finally,
Schirmer’s testing was performed without anesthesia using sterile
strips (Tear Flo; Sigma Pharmaceuticals, Monticello, IA), and the
length of paper wetting was measured after 5 minutes.
Ocular surface staining was graded according to the Sjögren’s
International Collaborative Clinical Alliance grading system.14
Conjunctival staining was evaluated first, using a neutral density
filter over the light source immediately after instillation of
lissamine green dye (Green-Glo; HUB Pharmaceuticals, LLC.,
Rancho Cucamonga, CA). The nasal and temporal conjunctiva,
within the interpalpebral fissure, were graded separately with a
maximum score of 3 for each area. The area where the Schirmer’s
test strips were placed was not taken into consideration when
grading the temporal conjunctiva. Corneal staining was evaluated
using the cobalt blue filter at least 2 minutes after instillation of
fluorescein dye (Ful-Glo; Akorn, Inc., Lake Forest, IL). The
maximum possible fluorescein score (the punctate epithelial
erosions grade plus any extra points for modifiers [central corneal
staining, confluent staining, and filaments]) was 6 for each cornea.
The total possible maximum ocular staining score, derived by
summing the corneal and conjunctival scores, was 12 for each eye.14
At this point, participants were given a standardized, validated
reading task consisting of a 7200-word story to be read silently for 30
minutes or until finished.15,16 Participants were allowed to wear their
habitual correction for near vision. Reading was performed in a 12
feet wide by 17 feet long room with standardized lighting between
400 and 600 lux15 and environmental conditions (relative humidity
level between 30% and 50% and temperature level between 73 F
and 75 F).
After completion of the reading task, the following tests were
repeated as described previously in this order: noninvasive TBUT,
the irregularity indices (surface asymmetry index and surface
regularity index), Schirmer’s test, conjunctival lissamine green
staining, and corneal fluorescein staining.
Statistical Methods
Measurements only from the right eye were used for all analyses. A t
test was used to compare the continuous variables, and a chi-square
test was used to compare categoric variables between groups. A
paired t test was used to compare before and after observations
2
within the study groups. Pearson and Spearman’s rank correlation
coefficients were used to analyze the associations between variables.
Values of P < 0.05 were considered statistically significant. All
statistical analyses were performed using IBM SPSS Statistics
version 23 (IBM Corp., Armonk, NY).
Results
A total of 224 participants completed the study-related procedures.
Thirteen participants who finished the reading task in less than 20
minutes (8 patients with dry eye and 5 controls) were excluded.
The remaining 211 patients (177 patients with dry eye and 34
controls) were included in the analyses.
Table 1 displays the baseline clinical characteristics in each
group. There were no significant differences between patients
with dry eye and controls with regard to age or sex. Mean
duration of reading was 28.3 minutes (20.6e31.6 minutes; standard
deviation, 2.2) in the dry eye group and 27.7 minutes (20.2e30.5
minutes; standard deviation, 2.8) in the control group (P ¼ 0.15).
At baseline, patients with dry eye had a higher mean symptom
score and objective clinical parameters compared with controls
except for the surface regularity indices (Table 1).
All measured parameters worsened in the dry eye group and in the
controls (with the exception of surface asymmetry index); however,
not all of these changes were statistically significant (Table 2). The
worsening reached a statistical significance for corneal and
conjunctival staining in patients with dry eye (P < 0.001 and P ¼
0.001, respectively) and for corneal staining in the control group
(P ¼ 0.003).
Table 3 displays correlations between OSDI scores and tear film
and ocular surface parameters at baseline, postreading, and the
change from baseline. The total OSDI score and all 3 OSDI
subscores (ocular symptom, vision-related function, and environ-
mental triggers) correlated significantly with baseline corneal and
conjunctival staining. The strongest correlation was observed between
the environmental triggers subscore and baseline temporal conjunctival
staining (r ¼ 0.32, P < 0.001). Although there was no significant
correlation at baseline, the TBUT measured after the prolonged reading
test correlated with the baseline total OSDI score as well as ocular
symptom and environmental triggers subscores. In addition, correla-
tions between all OSDI scores and the corneal staining became more
robust after the reading task. When correlations between baseline OSDI
scores and worsening of tear film or ocular surface parameters after
reading were analyzed, the increase in corneal staining correlated well
with the total OSDI score and environmental triggers subscore. Among
the 3 modifiers of corneal staining (presence of central staining,
confluent staining, and presence of filaments), confluent staining at
baseline significantly correlated with total OSDI score and all 3 sub-
scores. Central staining was found to correlate with all OSDI scores not
at baseline but postreading. Moreover, correlations between confluent
staining and OSDI scores became stronger after reading.
Table 4 displays correlations between baseline tear film
parameters and changes from baseline after the sustained reading
task. Changes in TBUT and the Schirmer’s test correlated
significantly with their respective baseline values, indicating that
the more unstable tear film and the lower aqueous tear secretion,
the worse they became after the prolonged reading task. Of note,
worsening in corneal staining directly correlated with the
baseline conjunctival staining and surface regularity index.
Discussion
This study demonstrates that prolonged reading causes
significant alterations on the ocular surface not only in
 Karakus et al Prolonged Reading and Dry Eye

Table 1. Comparison of Baseline Characteristics According to Dry Eye Status

Variables Dry Eye (n[177) Controls (n[34) P Value

Demographics
Age, yrs 63.2 (8.2) 60.4 (7.9) 0.07
Female, n (%) 131 (74) 23 (67) 0.44
Duration of reading, min 28.3 (2.2) 27.7 (2.8) 0.15
OSDI total score, 0e100 32.0 (22.0) 4.8 (5.6) <0.001
Discomfort-related subscore, 0e100 33.8 (22.8) 6.6 (7.9) <0.001
Vision-related subscore, 0e100 26.1 (24.7) 2.3 (5.6) <0.001
Environmental triggers subscore, 0e100 37.5 (31.1) 5.5 (8.7) <0.001
TBUT, sec 3.4 (3.5) 4.8 (3.7) 0.04
Surface irregularity indices
Surface asymmetry index 0.49 (0.29) 0.49 (0.45) 0.94
Surface regularity index 0.48 (0.30) 0.43 (0.33) 0.49
Schirmer’s test, mm 12.9 (9.0) 17.5 (9.9) 0.009
Total corneal staining, 0e6 1.8 (1.7) 0.4 (0.7) <0.001
Corneal staining score, 0e3 1.4 (1.2) 0.4 (0.6) <0.001
Central corneal staining present, n (%) 33 (19) 0 0.006
Confluent corneal staining present, n (%) 42 (24) 1 (3) 0.006
Filaments present, n (%) 4 (2) 0 >0.99
Total conjunctival staining, 0e6 1.9 (2.2) 0.5 (1.1) <0.001
Nasal conjunctival staining score, 0e3 1.1 (1.2) 0.3 (0.9) <0.001
Temporal conjunctival staining score, 0e3 0.9 (1.1) 0.1 (0.4) <0.001
Total OSS, 0e12 3.8 (3.3) 0.9 (1.5) <0.001

OSDI ¼ Ocular Surface Disease Index; OSS ¼ Ocular Staining Score; TBUT ¼ tear break-up time.
Results are represented as mean (standard deviation) for continuous variables and number (percentage) for a binary variable. The t test was used for
comparison of continuous variables between groups and the chi-square testing for categoric variables. Bolded values represent P < 0.05.

patients with dry eye but also in older individuals with a
healthy ocular surface. The baseline patient symptoms
measured using the OSDI correlated well with the tear film
parameters and ocular surface staining measured after the
sustained silent reading task, including some of the dry eye
signs that did not seem to correlate at rest (e.g., TBUT).
These findings may explain the puzzling discrepancy
between physician-measured dry eye and patient-reported
symptoms often observed in clinical practice.
Environmental factors such as temperature, humidity
changes, and airflow/wind are well known to exacerbate
clinical signs and symptoms in patients with dry eye.17,18 To
quantify the effects of adverse environmental conditions on the
ocular surface, the controlled-environment chamber has been
developed, and various versions have been used in clinical
trials since then.19-22 However, an adverse environmental
chamber is expensive to build and provides exaggerated
environmental conditions rather than mimicking a real-life

Table 2. Changes in Ocular Surface and Tear Film Parameters after Sustained Reading Task

Dry Eye (n[177) Control (n[34)

Variables Baseline After Reading P Value Baseline After Reading P Value
TBUT, sec 3.4 (3.6) 3.1 (3.3) 0.23 4.8 (3.7) 4.3 (3.5) 0.52
Surface irregularity indices
Surface asymmetry index 0.49 (0.29) 0.54 (0.40) 0.21 0.50 (0.45) 0.45 (0.18) 0.62
Surface regularity index 0.48 (0.31) 0.51 (0.32) 0.12 0.43 (0.34) 0.44 (0.26) 0.83
Schirmer’s test, mm 12.6 (8.9) 11.8 (8.1) 0.05 17.5 (9.9) 16.2 (9.7) 0.31
Total corneal staining, 0e6 1.8 (1.7) 2.6 (1.9) <0.001 0.4 (0.7) 1.0 (1.4) 0.002
Corneal staining score, 0e3 1.4 (1.2) 1.8 (1.2) <0.001 0.4 (0.7) 0.7 (1.0) 0.003
Central corneal staining present, n (%) 34 (19) 64 (36) <0.001 0 5 (15)
Confluent corneal staining present, n (%) 42 (24) 75 (43) <0.001 1 (3) 4 (12) 0.12
Filaments present, n (%) 4 (2) 4 (2) 0 0
Total conjunctival staining, 0e6 1.9 (2.2) 2.1 (2.2) 0.001 0.5 (1.1) 0.6 (1.2) 0.13
Nasal conjunctival staining score, 0e3 1.06 (1.2) 1.14 (1.2) 0.03 0.3 (0.9) 0.4 (0.9) 0.18
Temporal conjunctival staining score, 0e3 0.86 (1.1) 0.98 (1.2) 0.001 0.1 (0.4) 0.2 (0.5) 0.16
Total OSS, 0e12 3.8 (3.3) 4.7 (3.5) <0.001 0.9 (1.5) 1.6 (2.0) 0.001

OSS ¼ Ocular Staining Score; TBUT ¼ tear break-up time.

Results are represented as mean (standard deviation) for continuous variables and number (percentage) for a binary variable. The t test was used for
comparison of continuous variables between groups and the chi-square testing for categoric variables. Bolded values represent P < 0.05.

3
 Ophthalmology Volume -, Number -, Month 2018

Table 3. Correlations between Ocular Surface Disease Index Scores and Baseline Tear Film Parameters in All Participants
Ocular Symptom Vision-Related Function Environmental Triggers OSDI
r P Value r P Value r P Value r P Value
TBUT

Baseline e0.05 0.50 e0.09 0.20 e0.09 0.28 e0.08 0.27

After reading e0.14 0.04 e0.09 0.18 e0.15 0.04 e0.15 0.03
Change from baseline e0.09 0.19 e0.01 0.87 e0.03 0.63 e0.07 0.35
SAI
Baseline e0.03 0.69 e0.003 0.97 0.04 0.65 e0.001 0.99
After reading e0.007 0.93 e0.01 0.86 0.007 0.93 e0.01 0.90
Change from baseline 0.03 0.72 0.002 0.98 e0.02 0.85 0.003 0.97
SRI
Baseline e0.12 0.15 e0.09 0.29 e0.03 0.72 e0.10 0.25
After reading e0.07 0.39 e0.03 0.69 e0.03 0.73 e0.05 0.54
Change from baseline 0.03 0.71 0.05 0.58 e0.002 0.98 0.03 0.72
Schirmer’s test
Baseline e0.003 0.96 e0.04 0.60 0.009 0.89 e0.009 0.90
After reading e0.05 0.48 e0.12 0.01 e0.07 0.32 e0.09 0.21
Change from baseline e0.03 0.68 e0.05 0.45 e0.08 0.28 e0.06 0.39
Corneal staining
Baseline 0.19 0.006 0.15 0.03 0.17 0.01 0.19 0.006
After reading 0.23 0.001 0.19 0.006 0.25 <0.001 0.25 <0.001
Change from baseline 0.13 0.05 0.12 0.09 0.19 0.006 0.16 0.02
Central staining
Baseline 0.12 0.08 0.10 0.13 0.09 0.17 0.12 0.09
After reading 0.18 0.007 0.17 0.01 0.17 0.02 0.20 0.004
Change from baseline 0.11 0.10 0.11 0.11 0.12 0.10 0.13 0.05
Confluent staining
Baseline 0.21 0.002 0.14 0.04 0.16 0.02 0.19 0.006
After reading 0.24 0.001 0.16 0.02 0.25 <0.001 0.23 0.001
Change from baseline 0.08 0.26 0.05 0.46 0.16 0.02 0.10 0.16
Conjunctival staining
Baseline 0.25 <0.001 0.21 0.002 0.29 <0.001 0.27 <0.001
After reading 0.19 0.006 0.18 0.01 0.25 <0.001 0.22 0.001
Change from baseline e0.17 0.02 e0.09 0.17 e0.11 0.11 e0.14 0.04

OSDI ¼ Ocular Surface Disease Index; SAI ¼ surface asymmetry index; SRI ¼ surface regularity index; TBUT ¼ tear break-up time.
Pearson correlation coefficient (r) was used to analyze the associations between variables. Bolded values represent P < 0.05.

situation. Therefore, the utility of end points measured using an
environmental chamber in dry eye clinical trials is question-
able. Our findings indicate that prolonged reading represents
an inexpensive tool that simulates a real-life desiccating stress
with quantifiable changes on the ocular surface correlating well
with subjective patient symptoms measured at baseline.
Indeed, a previous study hypothesized that a reading challenge
can function similarly to an environmental challenge and in-
crease the magnitude of dry eye parameters to observable
clinical findings.23
Of all the available dry eye tests, corneal fluorescein
staining is reportedly the most commonly performed, and
the conjunctival lissamine is the least commonly used
test.24,25 This could be due to ease/difficulty of access to
these dyes or perhaps lack of knowledge or awareness
regarding the significance of each.26 Our study showed that
the degree of baseline conjunctival staining was a significant
predictor of the worsening in corneal staining after sustained
reading. In addition, subjective symptoms, particularly
environmental trigger-related symptoms, showed the stron-
gest correlation with baseline conjunctival staining of all the
dry eye parameters. On the basis of these findings, we
believe that conjunctival staining needs particular attention
when evaluating patients for dry eye.
Several noninvasive tests have been proposed to evaluate
the tear film stability, including automated TBUT and
corneal surface irregularity indices using computerized
videokeratoscopy.12,13,27 Noninvasive TBUT was proposed
to be a useful tool to evaluate tear film in dry eye with the
disadvantage of its variability, especially in patients with
severe dry eye.12 Although in our study the baseline TBUT
did not differ between the patients with dry eye versus
controls at rest, significant correlations were found
between baseline OSDI scores and postreading TBUT
values, indicating the variability/instability of the tear film,
as previously suggested to be the main mechanism
underlying dry eye.28
Surface regularity index, but not surface asymmetry
index, was previously reported to be significantly higher in
subjects older than 50 years of age with no significant dif-
ference between subjects with dry eye versus controls.13 In
our study, although all participants were 50 years of age or
older, the levels of both indices measured in either group at
any time point were much lower than the levels previously

4
 Karakus et al Prolonged Reading and Dry Eye

Table 4. Correlations between Baseline and Change from Baseline Tear Film Parameters in All Participants
DTBUT DSAI DSRI DSchirmer’s DCorneal Staining DConjunctival Staining DOSS
TBUT

r e0.61 e0.01 0.15 e0.07 e0.07 e0.08 e0.11

P value <0.001 0.91 0.08 0.32 0.29 0.23 0.12
SAI
r 0.16 e0.56 e0.44 0.01 0.09 0.05 0.11
P value 0.06 <0.001 <0.001 0.89 0.27 0.51 0.17
SRI
r 0.24 e0.17 e0.50 0.06 0.21 0.11 0.25
P value 0.005 0.04 <0.001 0.49 0.01 0.17 0.002
Schirmer’s test
r 0.00 e0.11 e0.07 e0.44 e0.01 e0.13 e0.09
P value 0.10 0.20 0.40 <0.001 0.89 0.06 0.21
Corneal staining
r 0.03 0.00 0.03 0.07 e0.02 0.04 0.01
P value 0.68 0.10 0.70 0.29 0.77 0.58 0.92
Conjunctival staining
r 0.09 e0.01 e0.01 0.07 0.17 e0.10 0.07
P value 0.19 0.92 0.90 0.31 0.02 0.13 0.31
Total OSS
r 0.08 e0.006 0.01 0.08 0.10 e0.05 0.05
P value 0.28 0.95 0.91 0.23 0.15 0.48 0.44

OSS ¼ Ocular Staining Score; SAI ¼ surface asymmetry index; SRI ¼ surface regularity index; TBUT ¼ tear break-up time.
Pearson correlation coefficient (r) was used to analyze the associations between variables. Bolded values represent P < 0.05.

reported in the literature.13,29 In addition, these indices did
not differ between patients with dry eye and controls at
baseline or after prolonged reading, and there was no
correlation with subjective symptoms. However, baseline
surface regularity index measurement correlated signifi-
cantly with the worsening in TBUT and corneal staining,
indicating that a higher surface regularity index may predict
alteration of the ocular surface after visually straining
activities such as reading. Further studies are needed to
clarify these findings.
One of the limitations of this study is that we included
only older subjects (aged 50 years). The effects of
prolonged reading remain unknown in younger individuals,
such as students or individuals who work at an office setting
and perform reading-related functions daily. Second, we do
not know exactly how prolonged reading causes alterations
in the tear film and ocular surface because we did not record
the blink rate or pattern or measure the tear film secretion
rate or evaporation. Abnormal blink patterns, such as an
incomplete blink or a reduced blink rate during near tasks,
have been studied8,30,31 and may have an effect on the
magnitude of presumed desiccation effect during reading.
We do not know whether the effects of reading on the ocular
surface are due to changes occurring in the composition of
the tear film, such as osmolarity or inflammatory markers,
because those were not measured.32 In addition, 13 patients
who read the passage in less than 20 minutes were excluded
(8 patients with dry eye and 5 controls). Although it is
entirely possible that those excluded participants read
more quickly because they had better ocular surface, this
is not relevant to our research question because our aim
was to use prolonged reading as a stressor on the ocular
surface and we included normal individuals with healthy
ocular surface as controls. Last, the tests were performed
in a nonmasked fashion with the exception of corneal and
conjunctival staining, which could have affected the results.
In conclusion, this study demonstrates that prolonged
silent reading for as little as 30 minutes causes measurable
alterations on the tear film and ocular surface in individuals
aged 50 years and older. This effect is more pronounced in
patients with dry eye. The magnitude of these changes
correlates well with the baseline OSDI scores, arguing
against the common notion that dry eye signs and symptoms
do not correlate. Because assessing dry eye at rest may miss
clinical findings brought about by common everyday tasks
such as reading, we propose this previously validated test as
a tool to quantify dry eye, particularly in a clinical trial
setting to assess effects of various treatment modalities.
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Footnotes and Financial Disclosures
Originally received: December 9, 2017.
Final revision: March 13, 2018.
Accepted: March 20, 2018.
Available online: ---. Manuscript no. 2017-2809.
1
The Wilmer Eye Institute, Johns Hopkins University, Baltimore,
Maryland.
2 man medical records were part of this study protocol. No animal subjects
Flaum Eye Institute, University of Rochester, Rochester, New York.
3
Department of Ophthalmology, University of Ulm, Ulm, Germany.
Presented at: the American Society of Cataract and Refractive Surgery
Annual Meeting, April 13e17, 2018, Washington DC.
Financial Disclosure(s):
The author(s) have made the following disclosure(s): P.Y.R.: Grants
National Eye Institute, outside the submitted work.
6
19. Barabino S, Shen L, Chen L, et al. The controlled-environment
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26. Wolffsohn JS, Arita R, Chalmers R, et al. TFOS DEWS II
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Supported in part by an investigator-initiated research grant from Allergan,
Inc., and a grant provided by Jerome L. Greene Sjögren’s Center, Johns
Hopkins University (Baltimore, MD). The TMS-4 videokeratoscopy was
provided by Tomey (Waltham, MA) for the duration of the study. The
funding organizations had no role in the design or conduct of this research.
HUMAN SUBJECTS: Human subjects, human-derived materials, or hu-
were used in this study. Study protocol was approved by the Johns Hopkins
University and the Rochester University Institutional Review Boards in
accordance with the tenets of the Declaration of Helsinki. The study pro-
cedures were performed according to Health Insurance Portability and
Accountability Act
Author Contributions:
Conception and design: Karakus, Henrich, Ramulu, Akpek
Data collection: Karakus, Agrawal, Hindman, Henrich, Akpek
 Karakus et al Prolonged Reading and Dry Eye
Analysis and interpretation: Karakus, Ramulu, Akpek Abbreviations and Acronyms:
Obtained funding: Not applicable OSDI ¼ Ocular Surface Disease Index; TBUT ¼ tear break-up time.
Overall responsibility: Karakus, Agrawal, Hindman, Henrich, Ramulu, Correspondence:
Akpek Esen K. Akpek, MD, Ocular Surface Diseases and Dry Eye Clinic, The
Wilmer Eye Institute, 600 North Wolfe Street, Woods 372, Baltimore, MD
21287-9238. E-mail: esakpek@jhmi.edu.