REFERENCES patients with aqueous deficient dry eyes, and possibly
those undergoing laser-assisted in situ keratomileusis
1. Stroop WG, Chen TM, Chodosh J, et al. PCR assessment of
HSV-1 corneal infection in animals treated with rose bengal
and lissamine green B. Invest Ophthalmol Vis Sci 2000;41:
2096 –2102.
2. Ganatra JB, Chandler D, Santos C, Kuppermann B, Margolis
TP. Viral causes of the acute retinal necrosis syndrome. Am J
Ophthalmol 2000;129:166 –172.
3. Grigg ME, Ganatra J, Boothroyd JC, Margolis TP. Unusual
abundance of atypical strains associated with human ocular
toxoplasmosis. J Infect Dis 2001;184:633– 639.
4. Wiedbrauk DL, Werner JC, Drevon AM. Inhibition of PCR
by aqueous and vitreous fluids. J Clin Microbiol 1995;33:
2643–2646.
5. Wadowsky RM, Laus S, Libert T, States SJ, Ehrlich GD.
Inhibition of PCR-based assay for Bordetella pertussis by using
calcium alginate fiber and aluminum shaft components of a
nasopharyngeal swab. J Clin Microbiol 1994;32:1054 –1057.
Correlations in a Change in Aqueous
Tear Evaporation With a Change in
Relative Humidity and the Impact
James P. McCulley, MD, Joel D. Aronowicz, MD,
Eduardo Uchiyama, MD, Ward E. Shine, PhD,
and Igor A. Butovich, PhD
PURPOSE: To establish scientific relationship between
relative humidity (RH) and aqueous tear evaporation to
elucidate possible significance of this relationship in
normals and aqueous tear deficiency patients.
DESIGN: Prospective experimental laboratory study.
METHODS: Ocular surface evaporation was determined
using evaporometry and calculated for two ranges of RH,
25% to 35%, and 35% to 45% in a randomized clinical
patient population.
RESULTS: Average evaporative rate in the higher humidity
range was between 0.029 ⴞ 0.009 through 0.043 ⴞ
0.016 ␮l/cm2/min. At lower humidity, range was be-
tween 0.044 ⴞ 0.013 through 0.058 ⴞ 0.018 ␮l/cm2/
min. Differences in the corresponding evaporative rates
were statistically significant (between P < .003 through
P < .043) for each analysis.
CONCLUSIONS: A decrease of 10% RH resulted in an
average difference of between 28.33% to 59.42% in-
crease in evaporation. The increase in evaporation at
lower humidity has significant clinical implications for
Accepted for publication Oct 31, 2005.
From the Department of Ophthalmology, The University of Texas
Southwestern Medical Center at Dallas, Dallas, Texas.
This study was supported in part by grants NIH EY12430, EY016664,
and an unrestricted grant from the Research to Prevent Blindness, New
York, New York.
Inquiries to James P. McCulley, MD, The University of Texas Southwest-
ern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-9057; e-mail:
james.mcculley@utsouthwestern.edu
758 AMERICAN JOURNAL
(LASIK). (Am J Ophthalmol 2006;141:758 –760. ©
2006 by Elsevier Inc. All rights reserved.)
C LINICAL ANECDOTE HAS LONG HELD THAT DRY EYE
symptoms are exacerbated under certain environmen-
tal conditions: low humidity, windy situations, and close
work.1,2 It has been suggested previously that lower humid-
ity results in an increase in ocular surface tear film
evaporation.3 Although there is agreement that evapora-
tion is involved in the dry eye process,4 it is uncertain
whether evaporation is a cause of dry eye or an exacerbating
factor.5 The purpose of this investigation is to scientifically
establish the relationship between relative humidity (RH)
and aqueous tear evaporation. This will determine if there is
solid evidence of an environmental factor in determining
severity of symptoms and the impact of tear loss.
We conducted a prospective experimental laboratory
study comparing changes in evaporative rates under differ-
ent RH conditions. Data pool for the current study was a
random selection of our evaporometry database and con-
sisted of 47 subjects; 29 females and 18 males, age range of
47.6 ⫾ 20.4 years. Thirty-two had dry eye diagnosis, and
15 were considered normals. Tear evaporation study data
were the major requirement for inclusion in this study. All
clinical studies had prior approval from the appropriate
institutional review board. Informed consent was obtained
from each patient and HIPAA regulations were followed.
Statistical analyses were carried out using SigmaStat
2.03 Software (Systat Software Inc, Richmond, California,
USA) and included mean, standard deviation, and one-
way analysis of variance. Data from each eye of all study
subjects were included in the analyses.
The evaporometer utilized an air pump to direct dry air
into an eye goggle that contained a humidity/temperature
sensor.3,6 When 15% RH was reached, the pump was
turned off. The following increase in humidity was con-
stantly monitored, and the time needed to go from 25% to
35%, and then from 35% to 45% was measured. The skin
evaporation component was measured and subtracted as
described before.3,5 The continuous increase in RH in the
goggles is considered to be the tear component of evapo-
rative rate.5 Exposed ocular surface area was measured by
digital photography.5 Evaporation was calculated in two
different ranges of RH from 25% to 35%, and from 35% to
45%, and reported in ␮l of water evaporated/cm2 of
exposed ocular surface per minute.
The Table summarizes the evaporative rate findings
based upon clinical diagnosis and gender. Although these
two humidity ranges were contiguous in a single measure-
ment, the difference in the corresponding evaporative
rates was statistically significant P ⬍ .008 for normal
females, P ⬍ .003 for dry eye females, P ⬍ .043 for normal
males, and P ⬍ .004 for dry eye males. No statistically
significant difference was found between evaporative rates
OF OPHTHALMOLOGY APRIL 2006
 TABLE. Tear Film Evaporative Rates Under Two Different
Relative Humidity (RH) Conditions in Normal Subjects and
Dry Eye Patients Divided by Gender
Number of Evaporative Rate Evaporative Rate
Subgroup Subjects at 25–35% RH* at 35–45% RH*
Normal
1. Female 10 0.058 ⫾ 0.018 0.043 ⫾ 0.016
2. Male 6 0.047 ⫾ 0.022 0.029 ⫾ 0.009
Dry eye
3. Female 19 0.048 ⫾ 0.017 0.037 ⫾ 0.011
4. Male 12 0.044 ⫾ 0.013 0.034 ⫾ 0.009
*Values expressed in ␮l/cm2/min as mean ⫾ SD.
†
Comparison of the evaporative rates under the two RH
ranges within subgroups 1 to 4.
FIGURE 1. The effect of a 10% increase in the range of
relative humidity (RH) on the ocular surface tear film evapo-
ration of both normals and dry eye patients. *P ⴝ .001,
evaporative rate at 25% to 35% RH vs 35% to 45% RH in
normals. †P < .001, evaporative rate at 25% to 35% RH vs
35% to 45% RH in dry eye patients. Error bars represent the
standard deviation from the mean.
of normals and dry eye patients at the same RH, or
between males and females within any group.
A 10% reduction in RH from 35% to 45% versus 25%
to 35% resulted in an average increase in evaporation of
35.5% in normal females, 28.3% in dry eye females, 59.4%
in normal males, and 31.2% in dry eye males.
Based upon these data, it is clear that aqueous tear
evaporation decreases as the RH increases over time (Figure
1). There is, on average, a 35.9% decrease in evaporation
associated with a 10% increase in RH. As a corollary, the
speed of evaporation also decreases as the RH increases
VOL. 141, NO. 4
P Value†
⬍.008
⬍.043
⬍.003
⬍.004
FIGURE 2. The effect of the initial humidity of the air on the
time required for the tear film to increase the humidity in the
immediate preocular tear film area. The time required to
increase RH from 25% to 35% was 14.47 seconds, and to
increase it from 35% to 45% was 22.5 seconds (P < .001).
Error bars represent the standard deviation from the mean.
(Figure 2), for example, 14.47 seconds is required to increase
RH from 25% to 35%, and 22.5 seconds to increase from 35%
to 45%. There is a 64.3% difference in evaporative times at
these two ranges of RH (P ⬍ .001).
From these studies, it is clear that RH considerably affects
both evaporative amount and speed of evaporation. Clinical
symptoms associated with low humidity are now supported by
studies on ocular surface evaporation. By extrapolation, these
data suggest that RH may play a significant role in the
predictability of LASIK outcomes. Furthermore, they suggest
that such procedures may be more predictable when per-
formed in an atmosphere of 45% RH that is consistently
maintained, since the evaporative water loss from the cornea
is considerably less than at lower humidity.
REFERENCES
1. Ousler GW 3rd, Abelson MB, Nally LA, Welch D, Casavant
JS. Evaluation of the time to “natural compensation” in
normal and dry eye subject populations during exposure to a
controlled adverse environment. Adv Exp Med Biol 2002;506:
1057–1063.
2. Abelson MB, Ousler GW 3rd, Nally LA, Emory TB. Dry eye
syndromes: diagnosis, clinical trials, and pharmaceutical treat-
ment—“improving clinical trials”. Adv Exp Med Biol 2002;506:
1079 –1086.
3. Mathers WD, Binarao G, Petroll M. Ocular water evaporation
and the dry eye. A new measuring device. Cornea 1993;12:
335–340.
BRIEF REPORTS 759
4. Mathers WD, Daley TE. Tear flow and evaporation in patients
with and without dry eye. Ophthalmology 1996;103:664 – 669.
5. McCulley JP, Shine WE, Aronowicz J, Oral D, Vargas J.
Presumed hyposecretory/hyperevaporative KCS: tear charac-
teristics. Trans Am Ophthalmol Soc 2003;101:141–152.
6. Rolando M, Refojo MF. Tear evaporometer for measuring
water evaporation rate from the tear film under controlled
conditions in humans. Exp Eye Res 1983;36:25–33.
Ocular Trauma Score in Deadly
Weapon–related Open-globe Injuries
Güngör Sobacı, MD, Tŭgrul Akin, MD,
Üzeyir Erdem, MD, Yusuf Uysal, MD,
and Suat Karagül, MD
PURPOSE: To assess prognostic value of the ocular trauma
score (OTS) in deadly weapon–related open-globe injuries.
DESIGN: Retrospective, interventional case series.
METHODS: In 82 patients (88 eyes) with deadly weapon-
related open-globe injuries, certain numerical values
rendered to the OTS variables (visual acuity, rupture,
endophthalmitis, perforating injury, retinal detachment,
afferent pupillary defect) at presentation were summated
and converted into OTS categories. The likelihood of the
final visual acuities in the OTS categories were calculated
and compared with those in the OTS study.
RESULTS: The likelihood of the final visual acuities (no
light perception NLP, light perception LP/hand motion
HM, 1/200 to 19/200, 20/200 to 20/50, and >20/40) in
the OTS categories (1 through 5) in this group were
similar to those in the OTS study group except for
LP/HM in the category-2 (53% vs 26%, P < .001). No
study eye was in the category-5 (the best prognosis).
CONCLUSIONS: OTS calculated at initial examination may
provide prognostic information in deadly weapon–related
open-globe injuries. (Am J Ophthalmol 2006;141:
760 –761. © 2006 by Elsevier Inc. All rights reserved.)
O CULAR TRAUMA IS AN IMPORTANT CAUSE OF PRE-
ventable and predominantly monocular visual mor-
bidity and blindness in the world today.1 Heterogeneity of
the injuries in ocular trauma has made it difficult to
interpret results of clinical studies with respect to inter-
vention and prevention of blindness. Using the databases
of the United States and the Hungarian Eye Injury Registries,
Kuhn and associates described the ocular trauma score
(OTS), a simplified categorical system for standardized assess-
ment and visual prognosis in ocular injuries.2 We have
previously shown that deadly weapon–related open-globe
Accepted for publication Nov 1, 2005.
From GATA, Gülhane Military Medical Academy and Medical
School, Ankara, Turkey.
Inquiries to Güngör Sobacı, MD, GATA, Gülhane Military Medical
Academy and Medical School, 06018, Etlik, Ankara, Turkey; e-mail:
gsobaci@gata.edu.tr
760 AMERICAN JOURNAL
TABLE 1. Calculating the Ocular Trauma Score (OTS)
Variables and Raw Points in the OTS Study
Variables Raw Points
Initial vision
No light perception 60
Light perception/hand motion 70
1/200–19/200 80
20/200–20/50 90
ⱖ20/40 100
Rupture ⫺23
Endophthalmitis ⫺17
Perforating injury ⫺14
Retinal detachment ⫺11
Afferent pupillary defect ⫺10
injuries, especially those associated with land mines and
hand grenades, had devastating visual consequences.3 This
study aims to assess prognostic value of OTS in patients
with deadly weapon–related open-globe injuries.
The charts of 336 consecutive patients (367 eyes)
presenting with open-globe injury caused by deadly weap-
ons to the Ophthalmology Department of Gülhane Mili-
tary Medical Academy and Medical School (GMMA-MS)
between March l991 and April 2003 were reviewed with
permission of the institutional review board. Eighty-two
patients (88 eyes) for whom complete data for OTS
variables (Table 1) were available were included in the
statistical analysis. Sixty-eight (82.9%) patients had terror-
related injury, and 50 (73.5%) of them had been described
using the Ocular Trauma Classification System (OTCS).4
Certain numerical values rendered to the OTS variables
(visual acuity, rupture, endophthalmitis, perforating in-
jury, retinal detachment, and afferent pupillary defect) at
presentation were summated and converted into OTS
categories; the likelihood of the final visual acuities (NLP,
LP/HM, 1/200 to 19/200, 20/200 to 20/50, and ⱖ20/40) in
the OTS categories (1 through 5) in this study group were
calculated (Table 1), and compared with those in the OTS
study group.2 For this comparison, categorical distribution
of 88 eyes in this study and 2151 eyes in the OTS study
were taken into account. Categorical evaluations were
done for the numeric scores representing the likelihood of
the final visual acuity in the OTS study and this study group.
␹2 or Fischer exact test was used as appropriate. A P value of
less than .05 was considered statistically significant.
Patients’ age ranged from 9 to 50 years (mean, 23 years),
and follow-up from seven days to thirty-six months (mean,
7.1 months). The likelihood of the final visual acuities
(NLP, LP/HM, 1/200 to 19/200, 20/200 to 20/50, and
ⱖ20/40) in the OTS categories of this study group corre-
lated to that of the OTS study group2 in 14 of 15 cases
(93.3%) (Table 2).
Some of the OTS variables, used in the OTCS (type of
injury, grade of injury, zone of injury, and afferent pupillary
OF OPHTHALMOLOGY APRIL 2006