CLINICIANS SPEND A SIGNIFICANT amount of time during their slit lamp exams assessing many aspects of the ocular surface that relate to dry eye. Although assessing tear breakup time, ocular surface staining, meibomian glands, and the eyelid margins are typical steps, often the function and completeness of the blink are not considered. Ultimately, treatment of dry eye may be unsuccessful if a patient has an incomplete blink.

Blinking is an unconscious action completed by contraction of the orbicularis oculi muscle and aids in spreading tears evenly over the ocular surface as well as expressing the meibomian glands, removing debris, and reducing ocular surface evaporation (Rodriguez et al, 2018; Braun et al, 2015). Each blink also allows the tear film evaporation to reset, improving visual quality and clarity.

The Tear Film & Ocular Surface Society Dry Eye Workshop III (TFOS DEWS III) report describes an optimal blink as a core lifestyle modification that is important in maintaining the long-term success of dry eye treatment (Jones et al, 2025). Most patients’ lifestyles require the use of digital devices and screens every hour of the day. Reduced or incomplete blinking is known to be a common contributing factor in tear film instability and tear film evaporation, which leads to damage to the ocular surface (Wolffsohn et al, 2023) (Figure 1). 

The use of screens and digital devices reduces blinks per minute from 32 when talking face to face to 10.7 while using a digital device (Chidi-Egboka et al, 2023). The time between blinks also increases significantly from 1.5 seconds when performing nonscreen tasks to 9.6 seconds when using digital devices (Chidi-Egboka et al, 2023).

The combined increase of intervals and decrease of blinks both lead to significant evaporation of the tear film, reduced lid apposition aiding in meibomian gland secretions, and reduced tear film distribution, leading to the common dry eye symptoms of burning, foreign body sensation, and reduced quality of vision.

Assessing the blink in office can be completed using the slit lamp on low light, watching for completeness and the patient’s upper and lower lids fully contacting with each other, covering the entire ocular surface, and ruling out any anatomical or functional abnormalities that can cause incomplete blinking. It is best if you do not tell the patient that you are monitoring blink to avoid the patient intentionally blinking (Oganov et al, 2023).

Supplemental tools, such as slit lamp video and photography, can allow the patient to visualize how their blink is impacting the ocular surface and their symptoms. Patient education on the importance of blink quality and completeness of blink is more important than simply increasing blink quantity (Wolffsohn et al, 2023). The use of smartphone apps, reminders, and breaks while using digital devices also can improve blink completion. In addition to blinking exercises, preservative-free artificial tears, a slight downgaze while looking at the screen, and effective refractive error correction can improve symptoms (Wolffsohn et al, 2023; Kamøy et al, 2022). 

References

1. Rodriguez JD, Lane KJ, Ousler GW 3rd, Angjeli E, Smith LM, Abelson MB. Blink: characteristics, controls, and relation to dry eyes. Curr Eye Res. 2018 Jan;43(1):52-66. doi: 10.1080/02713683.2017.1381270

2. Braun RJ, King-Smith PE, Begley CG, Li L, Gewecke NR. Dynamics and function of the tear film in relation to the blink cycle. Prog Retin Eye Res. 2015 Mar;45:132-64. doi: 10.1016/j.preteyeres.2014.11.001

3. Jones L, Craig JP, Markoulli M, et al; TFOS Collaborator Group. TFOS DEWS III: management and therapy. Am J Ophthalmol. 2025 Nov;279:289-386. doi: 10.1016/j.ajo.2025.05.039

4. Wolffsohn JS, Lingham G, Downie LE, et al. TFOS lifestyle: impact of the digital environment on the ocular surface. Ocul Surf. 2023 Apr;28:213-252. doi: 10.1016/j.jtos.2023.04.004

5. Chidi-Egboka NC, Jalbert I, Chen J, Briggs NE, Golebiowski B. Blink rate measured in situ decreases while reading from printed text or digital devices, regardless of task duration, difficulty, or viewing distance. Invest Ophthalmol Vis Sci. 2023 Feb 1;64(2):14. doi: 10.1167/iovs.64.2.14

6. Oganov A, Yazdanpanah G, Jabbehdari S, Belamkar A, Pflugfelder S. Dry eye disease and blinking behaviors: A narrative review of methodologies for measuring blink dynamics and inducing blink response. Ocul Surf. 2023 Jul;29:166-174. doi: 10.1016/j.jtos.2023.05.011

7. Kamøy B, Magno M, Nøland ST, et al. Video display terminal use and dry eye: preventive measures and future perspectives. Acta Ophthalmol. 2022 Nov;100(7):723-739. doi: 10.1111/aos.15105