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    Corneal Surface Regularity and the Effect of Artificial Tears in
    Aqueous Tear Deficiency

    Zuguo Liu, MD, PhD,1,2 Stephen C. Pflugfelder, MD2

    Purpose: To evaluate corneal surface regularity and the effect of artificial tears on the
    regularity of the corneal surface in dry eye.
    Design: A prospective, clinic-based, case-control study.
    Participants: A total of 64 eyes of 33 normal subjects and 42 eyes of 22 patients with
    aqueous tear deficiency were evaluated.
    Methods: Indices of the TMS-1 corneal topography instrument (Tomey Technology,
    Cambridge, MA) were used to evaluate corneal surface regularity and potential visual acuity
    (PVA) in patients with aqueous tear deficiency dry eye before and after the instillation of
    artificial tears and in normal subjects. The TMS-1 topographic maps were classified into
    round, oval, symmetric bow-tie, asymmetric bow-tie, and irregular pattern.
    Main Outcome Measures: The surface regularity index (SRI), surface asymmetry index
    (SAI), PVA index, and topographic pattern of the TMS-1 were compared between normal and
    dry eyes and in dry eyes before and after the instillation of artificial tears.
    Results: The SRI and SAI were significantly elevated and the PVA was significantly reduced
    in dry eye patients compared with normal subjects: 0.31 ± 0.22, 0.30 ± 0.16, and 20/17.89 ±
    20/3.04, respectively, in normal subjects and 1.28 ± 0.73, 1.05 ± 1.17, and 20/33.45 ±
    20/13.99, respectively, in patients with dry eye (P < 0.001 for all indices). The average amount
    of astigmatism was also increased in dry eyes (2.10 ± 1.96 prism diopters) compared with
    normal eyes (1.13 ± 0.53 prism diopters, P = 0.02). In dry eyes, the SRI and SAI were
    positively correlated with corneal fluorescein staining scores (P = 0.005 for SRI and P = 0.016
    for SAI). The mean PVA was not significantly different from the mean actual corrected visual
    acuity. The dry eyes had a significantly lower percentage of symmetric bow-tie patterns and a
    greater percentage of irregular patterns on topographic maps than normal eyes. After the
    instillation of artificial tears, the SRI, SAI, and mean astigmatism all decreased significantly (P
    < 0.001 for SRI, P < 0.002 for SAI, P = 0.04 for astigmatism) and the PVA improved (P <
    0.001) in dry eyes. An irregular topographic pattern was observed in 45.24% of dry eyes, and
    this decreased to 30.95% after the instillation of artificial tears (P < 0.005).
    Conclusions: Patients with aqueous deficiency have an irregular corneal surface that may
    contribute to their visual difficulties. The SRI and SAI could be used as objective diagnostic
    indices for dry eye as well as for evaluating the severity of this disease and the effect of
    artificial tears. Artificial tears have the secondary benefit of smoothing the corneal surface in
    dry eye.

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