Reducing the invasive nature of tear stability assessments

The clinical and experimental significance of blinking behavior

Evaluations of tear functions frequently involve some form of voluntary control over blink behaviour. To the degree that voluntary control of blinking risks departure from normal-range spontaneous blinking, the tear function findings from such studies may be confounded. Even subject awareness that blinking is being assessed may influence findings if such awareness results in any degree of voluntary control. Ideally, the influence on blink rate and tear functions induced by therapeutic or experimental interventions could be measured against a normal-range baseline spontaneous blink rate in order that any differences found could be validly attributed to those interventions. Sometimes pre-intervention 'rest-related' baseline blink rates have been incorrectly described as 'basal' blink rates without specification of pre-intervention conditions of 'rest' or consideration of any contributions from voluntary control. Also, studies which use only blink rates to measure blink efficiency ignore the critically important contribution of incomplete blinking to blink inefficiency. This review finds that the assessment of normal-range spontaneous blink rates depends on measurement conditions which have frequently been ignored previously. For example, normal-range spontaneous blink rates appear more likely to occur with fixation targets which have a disengaged affect and an associated neutral influence on and from dopamine activity. Ideally, fixation targets should also involve minimal cognitive loading and vision demands. In addition, normal-range (symptom free) spontaneous blink rates are more likely to be assessed in a comfortable ambient environment without subject awareness that blink behaviour is being assessed and when voluntary blinking is not involved.