Comparing Non-Invasive and Fluorescein Tear Break-Up Time in a Pre-Operative Refractive Surgery Population: Implications for Clinical Diagnosis

Abstract

Objectives: Fluorescein break-up time (FBUT) is commonly used to assess tear film stability. However, the instillation of fluorescein destabilises the tear film, impacting validity and clinical applicability, while the subjective nature and variation in volume and concentration reduces repeatability. Non-invasive break-up time (NIBUT) offers an alternative method with less potential bias. Normal tear break-up time is conventionally accepted as 10 seconds (s); however, FBUT is expected to be lower than NIBUT. This study was designed to compare FBUT and NIBUT values in a pre-operative refractive surgery population, where diagnosis of dry eye disease may alter the risk-benefits ratio and contraindicate surgical procedure(s). Improved understanding of the relationship between these two methods will aid appropriate pre-operative patient counselling and consent. Methods: Data from consecutive participants presenting to a private ophthalmology clinic, for initial refractive surgery pre-operative assessment, were analysed. NIBUT and FBUT were performed. Paired and unpaired comparisons were made using the Wilcoxon signed-rank and Mann-Whitney U tests, respectively, and relationships with demographics were explored using Spearman's rank correlation coefficient. Results: Median and interquartile range (IQR) for the first NIBUT was 12.5 s (7.0-18.0 s) and 14.2 s (9.4-18.0 s) for the right and left eyes, respectively. Median and IQR for the average NIBUT was 14.0 s (6.9-18.0 s) and 14.6 s (10.1-18.0 s) for the right and left eyes, respectively. Median and IQR for FBUT was 7 s (5-8 s) and 6 s (5-8 s) for the right and left eyes, respectively. There was a statistically significant difference between NIBUT and FBUT (p < 0.001). Conclusions: The findings suggest that the commonly used diagnostic threshold of 10 s cannot be uniformly applied to both FBUT and NIBUT, as FBUT systematically underestimates tear stability.

Keywords: dry eye disease (DED); fluorescein break-up time (FBUT); non-invasive break-up time (NIBUT).

Figure 1

Difference (NIBUT-FBUT) versus median (NIBUT and FBUT) plot for FBUT and (a) right first NIBUT; (b) right average NIBUT; (c) left first NIBUT; (d) left average NIBUT. Each patient’s median (NIBUT and FBUT) value was plotted on the x-axis, and the difference between these values on the y-axis, enabling comparison of the two clinical tests, with evaluation of bias. Non-parametric lower and upper limits of agreement (LOA), the 2.5th and 97.5th percentiles, respectively, are shown for Difference (NIBUT-FBUT).

Figure 1

Difference (NIBUT-FBUT) versus median (NIBUT and FBUT) plot for FBUT and (a) right first NIBUT; (b) right average NIBUT; (c) left first NIBUT; (d) left average NIBUT. Each patient’s median (NIBUT and FBUT) value was plotted on the x-axis, and the difference between these values on the y-axis, enabling comparison of the two clinical tests, with evaluation of bias. Non-parametric lower and upper limits of agreement (LOA), the 2.5th and 97.5th percentiles, respectively, are shown for Difference (NIBUT-FBUT).