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A morphologic and morphometric analysis of the ocular surface from patients with dry eye obtained by impression cytology led us to draft a new grading system containing one normal level and five levels of squamous metaplasia. This new grading system is based on a significant decrease in the number of goblet cells with less periodic acid-Schiff-hematoxylin-positive staining, an increase in nonsecretory cell size, more marked cell separation, a lower N:C ratio, and an increase in nuclear alterations. The clinical severity of the dry eye correlates with these alterations.

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