Lid wiper epitheliopathy (LWE) is a condition in which the epithelium of the lid wiper, located at the lowermost part of the upper tarsal conjunctiva, is damaged. The lid wiper refers to the area that contacts the ocular surface like a wiper during blinking. It is a relatively new concept first reported and defined by Korb et al. in the CLAO Journal in 2002 1). Anatomically, the lid wiper is a stratified epithelial region about 0.6 mm wide from the lid margin and has conjunctival characteristics 4).
When the lubricating function of the tear film is reduced, excessive friction occurs between the lid wiper and the ocular surface with each blink. This repeated mechanical stimulation causes epithelial damage 4). In contact lens wearers, direct contact between the lens surface and the palpebral conjunctiva further increases friction.
LWE is attracting attention as a cause of dry eye symptoms in contact lens wearers. In the initial report by Korb et al. (2002), 80% of symptomatic contact lens wearers showed lid wiper staining, compared to only 13% of asymptomatic wearers, with a significant difference between the two groups (P < 0.0001) 1). It is also observed in non-contact lens wearers with dry eye, and is expected to serve as an indicator of tear film dysfunction.
The most common complaints are dryness and foreign body sensation during contact lens wear. Symptoms such as “the lens feels dry” or “wearing comfort worsens in the evening” are reported. In non-contact lens wearers, it is perceived as general dry eye symptoms (dryness, eye fatigue, foreign body sensation).
Notably, some patients with LWE have normal conventional dry eye tests (Schirmer test, BUT). Korb et al. (2005) reported that 76% of symptomatic patients with negative standard dry eye tests had LWE, compared to only 12% of asymptomatic individuals 2). In patients with dry eye symptoms but few objective findings, it is important to suspect LWE.
Lissamine Green Staining Findings
Band-shaped staining of the lid wiper area: A band-shaped staining area is observed at the lowermost part of the tarsal conjunctiva upon upper eyelid eversion.
Changes near Marx’s line: Shows an epithelial damage pattern along the mucocutaneous junction.
May also be observed in the lower eyelid: Similar findings may be seen in the lid wiper area of the lower eyelid.
Differences in detection ability by staining method
Lissamine green: Most sensitive for detecting LWE, first-choice staining method
Fluorescein: Detectable but less sensitive than lissamine green
Rose bengal: Detectable but irritating, clinical use is limited
After upper eyelid eversion, evaluate by the staining area of the lid wiper with lissamine green staining.
| Grade | Horizontal width | Sagittal width |
|---|---|---|
| 0 | None | None |
| 1 | Linear (<2mm) | <25% |
| 2 | 2 mm or more | 25–50% |
| 3 | Extensive (>4 mm) | >50% |
The overall assessment is made by combining the horizontal and sagittal widths. Many reports consider Grade 2 or higher as clinically significant LWE. In a study by Korb et al. (2010), the prevalence of LWE in the dry eye symptom group was 88% (Grade 1: 22%, Grade 2: 46%, Grade 3: 20%), approximately 6 times that of the asymptomatic control group (16%). In particular, LWE of Grade 2 or higher was 16 times more frequent in the dry eye group, indicating that it is a significant diagnostic indicator 3).
LWE can also be detected with fluorescein staining, but lissamine green is more sensitive. If lissamine green is not available in daily clinical practice, fluorescein can be used as a substitute, but mild LWE may be missed. Lissamine green staining is recommended for the most accurate evaluation.
The essence of LWE is mechanical epithelial damage due to friction during blinking.
The main causes and risk factors include the following:
The diagnosis of LWE is based on vital staining after upper eyelid eversion.
Diagnostic procedure:
Tests that should be performed together:
LWE is positioned as an indicator of “friction-related dry eye” in the dry eye subtype classification. It has clinical significance as a finding that reflects tear film abnormalities not detectable by conventional BUT or Schirmer tests.
The goal of LWE treatment is to reduce friction on the ocular surface and improve epithelial damage.
Contact Lens-Related Measures
Discontinuation of contact lens wear: The most reliable treatment; symptoms improve rapidly upon cessation.
Change of contact lens type: Consider switching to low-water content lenses or silicone hydrogel lenses.
Daily disposable lenses: Avoids accumulation of deposits and is effective in reducing friction.
Reduction of wearing time: For mild symptoms, adjusting wearing time may be sufficient.
Pharmacotherapy
Rebamipide ophthalmic suspension (Mucosta®): Promotes mucin secretion and improves ocular surface lubrication.
Diquafosol sodium ophthalmic solution (Diquas®): Promotes water and mucin secretion
Artificial tears: Supplement tear fluid and temporarily reduce friction
Ophthalmic ointment (before bedtime): Reduces nighttime friction and promotes epithelial repair
Stepwise treatment approach:
Some cases improve with changes in lens material or water content. Switching to silicone hydrogel lenses or daily disposable lenses can be effective. However, this alone is often insufficient, and combination with mucin secretagogues or reduction of wearing time may be necessary. If no improvement, discontinuation of contact lens wear is considered.
Anatomically, the lid wiper is located at the lowest part of the upper tarsal conjunctiva, near Marx’s line. It is the area that makes the most intimate contact with the ocular surface during blinking, and a thin tear film provides lubrication at this interface.
Normal blink mechanics: During blinking, the lid wiper glides over the corneal or contact lens surface. If the tear film is sufficient, boundary lubrication works and friction is minimized.
Mechanism of LWE onset:
Exacerbating factors during CL wear: The CL surface has a higher coefficient of friction compared to the corneal epithelium. In particular, dehydration of the CL surface markedly increases the coefficient of friction. The tear film on a CL is thinner and less stable than on bare cornea, making lubrication failure more likely.
Relationship with dry eye: LWE is directly linked to the concept of “friction-enhanced dry eye.” In the TFOS DEWS II report, ocular surface friction is incorporated into the vicious cycle model of dry eye, and LWE is regarded as an important clinical indicator.
LWE can also be observed in dry eye patients who do not wear CLs. If lubrication function is impaired due to decreased tear volume or mucin abnormalities, friction during blinking increases regardless of CL wear. In cases where dry eye symptoms are present but routine tests show no abnormalities, LWE evaluation may be useful.
Research on LWE has been active in recent years.
Efficacy of mucin secretagogues: Multiple studies have shown that rebamipide ophthalmic suspension and diquafosol ophthalmic solution, developed in Japan, are effective in improving LWE. Itakura et al. (2013) reported that rebamipide administered four times daily led to marked improvement in LWE findings within 2–3 weeks6). Furthermore, Kase et al. (2017) demonstrated histologically that rebamipide significantly increased goblet cell count (P=0.0367) and EGFR expression (P=0.0237) in the lid wiper region7). These agents increase the mucin content of tears and improve ocular surface lubrication.
Development of low-friction CLs: Technological development to reduce the coefficient of friction on CL material surfaces is progressing. Surface treatment technologies and CLs containing moisturizing components are expected to reduce friction during wear.
Advances in diagnostic techniques: Research is underway on objective evaluation methods for the lid wiper region using anterior segment OCT and confocal microscopy. If quantitative assessment independent of vital staining becomes possible, improvements in early diagnosis and treatment efficacy evaluation are expected.
Positioning in dry eye subtype classification: The importance of LWE as an indicator of friction-related dry eye is being recognized. In future dry eye clinical practice guidelines, LWE evaluation may be incorporated as a standard examination item.
Korb DR, Greiner JV, Herman JP, et al. Lid-wiper epitheliopathy and dry-eye symptoms in contact lens wearers. CLAO J. 2002;28(4):211-216. PMID: 12394549.
Korb DR, Herman JP, Greiner JV, et al. Lid wiper epitheliopathy and dry eye symptoms. Eye Contact Lens. 2005;31(1):2-8. PMID: 15665665.
Korb DR, Herman JP, Blackie CA, et al. Prevalence of lid wiper epitheliopathy in subjects with dry eye signs and symptoms. Cornea. 2010;29(4):377-383. PMID: 20168216.
Efron N, Brennan NA, Morgan PB, Wilson T. Lid wiper epitheliopathy. Prog Retin Eye Res. 2016;53:140-174. PMID: 27094372.
Lievens CW, Norgett Y, Briggs N, Allen PM, Vianya-Estopa M. Optimal methodology for lid wiper epitheliopathy identification. Cont Lens Anterior Eye. 2021;44(3):101332. PMID: 32418871.
Itakura H, Kashima T, Itakura M, Akiyama H, Kishi S. Topical rebamipide improves lid wiper epitheliopathy. Clin Ophthalmol. 2013;7:2137-2141. PMID: 24204116.
Kase S, Shinohara T, Kase M, Ishida S. Effect of topical rebamipide on goblet cells in the lid wiper of human conjunctiva. Exp Ther Med. 2017;13(6):3516-3522. PMID: 28587435.
