Abstract
BACKGROUND: Acute acquired concomitant esotropia (AACE) causes diplopia and asthenopia, severely affecting quality of life. This study aimed to explore the association between dry eye (DE) tear film biomarkers and Type III AACE. METHODS: We enrolled 52 patients (52 eyes) with Type III AACE and 50 controls (50 eyes). Assessments included tear meniscus height (TMH), tear film non-invasive break-up time (NIBUT), corneal fluorescein staining (CFS), Schirmer's test (ST), and the Dry Eye-Related Quality of Life Score (DEQS). Tear samples were analyzed for cytokine levels using a multiplex immunoassay. Logistic regression analyses identified risk factors, and a random forest classifier evaluated predictive performance. RESULTS: Patients with Type III AACE without DE showed significantly reduced NIBUT and elevated levels of cytokines (e.g., MMP-2, MMP-13, and IFN-γ) compared to normal controls (all P < 0.05). Near-distance work duration showed a moderate positive correlation with Galectin-3 (r = 0.64, P < 0.05). MMP-2, MMP-13, and IFN-γ were identified as independent risk factors (arear under the curve (AUC): 0.91, 0.91, 0.94). The random forest model achieved an AUC of 1.00. CONCLUSION: Elevated tear levels of MMP-2, MMP-13, and IFN-γ were strongly associated with Type III AACE, highlighting their potential as predictive biomarkers.