Classification of Fluorescein Breakup Patterns: A Novel Method of Differential Diagnosis for Dry Eye

Am J Ophthalmol. 2017 Aug;180:72-85. doi: 10.1016/j.ajo.2017.05.022. Epub 2017 Jun 1.


Purpose: To investigate the relationship between fluorescein breakup patterns (FBUPs) and clinical manifestations in dry eye cases.

Design: Cross-sectional study.

Methods: In 106 eyes of 106 subjects (19 male, 87 female; mean age: 64.2 years), FBUPs were categorized into 1 of the following 5 break (B) types: area (AB, n = 19); spot (SB, n = 22); line (LB, n = 24); dimple (DB, n = 19); random (RB, n = 22 eyes); and dry eye-related symptoms using the visual analog scale (VAS, 100 mm = maximum), tear meniscus radius (TMR, mm), tear film lipid layer interference grade (IG) (grades 1-5; 1 = best) and spread grade (SG) (grades 1-4; 1 = best), tear film noninvasive breakup time (NIBUT, seconds), fluorescein breakup time (FBUT, seconds), corneal-epithelial damage (CED) score (15 points = maximum), ocular surface epithelial damage (OSED) score (9 points = maximum), and the Schirmer 1 test (ST1, mm) were examined and compared between each FBUP.

Results: In each FBUP, eye dryness and fatigue were the severest symptoms. Characteristic symptoms were sensitivity to light, heavy eyelids, pain, foreign body sensation, difficulty opening the eye, and discharge for AB, heavy eyelids for SB, and foreign-body sensation for LB. Statistically significant differences were found in TMR (AB-SB, -DB, and -RB; LB-RB), IG (AB-all other FBUP; LB-SB and -DB), and SG (AB-all other FBUPs), FBUT (AB-LB, -DB, and -RB; SB-DB and -RB; LB-RB; DB-RB), and NIBUT (AB-all other FBUPs; SB-DB and-RB, and LB-RB), CED (AB-all other FBUPs; LB-SB, -DB, and -RB) and OSED (AB-SB, -LB, and -DB; LB-SB, -DB, and -RB), and ST1 (AB-SB, -DB, and -LB) (P < .05 in each comparison).

Conclusions: The 5 different FBUPs constituted different groups, reflecting different pathophysi-ologies.

MeSH terms

  • Aged
  • Cross-Sectional Studies
  • Diagnosis, Differential
  • Dry Eye Syndromes / diagnosis*
  • Dry Eye Syndromes / metabolism
  • Female
  • Fluorescein / metabolism*
  • Fluorescent Dyes / metabolism*
  • Fluorophotometry / classification*
  • Fluorophotometry / methods
  • Humans
  • Male
  • Middle Aged
  • Surveys and Questionnaires
  • Tears / metabolism*


  • Fluorescent Dyes
  • Fluorescein