Narrative review: Do spontaneous eye blink parameters provide a useful assessment of state drowsiness?

Most objective drowsiness measures have limited ability to provide continuous, accurate assessment of drowsiness state in operational settings. Spontaneous eye blink parameters are ideal for drowsiness assessment as they are objective, non-invasive, and can be recorded continuously during regular activities. Studies that have assessed the spontaneous eye blink as a drowsiness measure are diverse, varying greatly in respect to study design, eye blink acquisition technology and eye blink parameters assessed. The purpose of this narrative review is to collate these studies to determine 1) which eye blink parameters provide the best state drowsiness measures; 2) how well eye blink parameters relate to and predict conventional drowsiness measures and 3) whether eye blink parameters can identify drowsiness impairment in obstructive sleep apnoea (OSA) - a highly prevalent disorder associated with excessive sleepiness and increased accident risk. In summary, almost all eye blink parameters varied consistently with drowsiness state, with blink duration and percentage of eye closure the most robust. All eye blink parameters were associated with and predicted conventional drowsiness measures, with generally fair to good accuracy. Eye blink parameters also showed utility for identifying OSA patients and treatment response, suggesting these parameters may identify drowsiness impairment in this group.