International Journal of Science and Healthcare Research

Vol.5; Issue: 2; April-June 2020

Website: ijshr.com
Original Research Article ISSN: 2455-7587

Study to Find the Burden of Dry Eye in Diabetic

Patients in a Tertiary Care Hospital
Vivek Kumar1, Ratnesh2, Swati3
1
Department of Ophthalmology, Dumka Medical College, Dumka, Jharkhand, India
2
Department of Community Medicine, Dumka Medical College, Dumka, Jharkhand, India
3
Department of Ophthalmology, Aravind Eye Hospital, Madurai, Tamil Nadu, India
Corresponding Author: Swati

ABSTRACT discomfort, visual disturbance, and tear-film

instability with potential damage to the
Introduction: Dry eye refers to reduced tear ocular surface. It is accompanied by
production and/or excessive tear evaporation in increased osmolarity of the tear film and
the tear film of the eye and is often associated inflammation of the ocular surface. (1)
with symptoms of ocular discomfort. Dry
It is due to reduced tear production
eye disease is more commonly seen in people
with type 2 diabetes. The objective of the and/or excessive tear evaporation associated
present study is to find the burden of dry eye in with symptoms of ocular discomfort. (2)
diabetic patients. Symptoms of dry eye include pain,
Methodology: A hospital based observational heaviness, foreign body sensation,
study was conducted among the diabetic grittiness, ocular fatigue, redness, burning,
patients registered during October 2017 to stinging, photophobia and reflex watering
September 2018 under Regional institute of due to corneal irritation. (3)
Ophthalmology (RIO), RIMS, Ranchi. Previous study shows that dry eye
Purposive sampling was carried out and a total has been associated with diabetes mellitus
of 54 diabetic patients were interviewed. which was confirmed with Schirmer’s test.
Logistic regression (LR) was used for statistical (4-6)
analysis.
Results and Conclusion: In the present study, Dry eye syndrome (DES) is also
total 54 diabetic patients were interviewed in referred as Keratoconjunctivitis sicca, which
which 31 (57.4%) had dry eye. Most of the is more commonly associated with diabetes
study participant belonged to the age group of mellitus (DM). Risk of DES is more
41 - 60 years (51.9%); 55.6% (30) were female. prevalent in people who suffer from
51.85% of the cases were having diabetic advanced stages of diabetic retinopathy. (7)
retinopathy. By applying LR the strength of Poor glycemic control affects both the
association for dry eye was seen more in > 60 anterior and the posterior segments of the
years of age group, having diabetes > 5 years eye and increasing the prevalence of
and patients having diabetic retinopathy which diabetes-associated DES (DMDES). The
were found to be statistically significant.
risk of dry eye is related with the elevated
Keywords: Dry eye, Diabetes, Observational levels of glycated hemoglobin: the higher
study the level the higher the incidence of dry eye.
(8)
Diabetic patients have a high risk for dry
INTRODUCTION eye because they have chances of
Dry eye workshop 2007(DEWS) developing decreased corneal sensitivity,
defined dry-eye syndrome as “a neuropathy involving innervations of
multifactorial disease of the tears and ocular lacrimal gland and loss of goblet cells. (9)
surface that results in symptoms of

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 Vivek Kumar et.al. Study to find the burden of dry eye in diabetic patients in a tertiary care hospital

Dry eye is recognised as a participants and confidentiality was assured.

disturbance of the Lacrimal Functional Unit Patients who were not willing to give
(LFU), an integrated system comprising the consent; not having DM; patients with pre-
lacrimal gland, ocular surface (cornea, existing systemic disease like Sjogren’s
conjunctiva and Meibomian glands) and syndrome, connective tissue diseases
lids, and the sensory and motor nerves that (Rheumatoid arthritis, Wegener’s
connect them. This functional unit controls granulomatosis, Polyarteritis nodosa, etc.)
the major components of the tear film, and patients on medications with Anti-
transparency of cornea, and the quality of histaminics, Anto-cholinergic group of
image projected onto the retina. (4) drugs, Tricyclic Antidepressants, topical or
Several previous studies have systemic beta blockers, oral contraceptive
investigated the relationship between pills, systemic or topical NSAIDS, long
diabetes and dry eyes. Although some found term Anti-glaucoma medications, post
an increased risk for dry eyes among ocular surgery, ocular trauma which causes
diabetic individuals, (10-12) others found dry eye are specifically proven were
neither a significant decrease in the amount excluded from the study.
of aqueous tear flow nor impaired tear All the patients selected for study
breakup time among insulin-treated diabetic have undergone routine investigations and
patients. (13) were subjected to Dry Eye Questionnaire.
There are only three published Schirmer’s test, Tear Break Up Time
reports on prevalence of dry eye among (TBUT) and Fluorescein staining was used
hospital based population from North and to diagnose dry eye.
Eastern India and the prevalence varies Diagnostic Tests
between 18.4% and 40.8% (Gupta SK-2002,  For patients with mild irritation
Sahai A-2005, Gupta N-2010, and Basak symptoms: a reduced tear breakup time
SK-2012). (12-14) One small study from high (TBUT) may indicate an unstable tear
altitude showed a higher prevalence of 54% film with normal aqueous tear
(Gupta N-2008). (13) production, and there may be minimal or
Our study aims to find the burden of dry eye no dye staining of the ocular surface
in diabetic patients and associated risk (Pflugfelder SC-1998)[60].
factors.  For patients with moderate to severe
symptoms: the diagnosis can be made by
MATERIALS & METHODS using one or more of the following tests:
A hospital based observational study o Tear break-up time (TBUT) test – to
was conducted from October 2017 to evaluate tear-film stability;
September 2018 to determine the burden of o Ocular surface dye staining
dry eye in diabetic patients in Regional (Fluorescein/rose Bengal/Lissamine
institute of Ophthalmology (RIO), RIMS, green) test: to evaluate ocular
Ranchi by using a predesigned, pretested surface disease (KCS);
semi-structured questionnaire. All the o Schirmer’s test: to evaluate aqueous
patients getting registered in EYE OPD, tear production. These tests should
RIO, RIMS, RANCHI from October 2017 be performed in this sequence
to September 2018 and having diabetes because the Schirmer’s test can
mellitus (DM) were taken into consideration disrupt tear film stability and cause
for evaluation of Dry Eye Syndrome. A total false-positive ocular-surface dye
of 54 patients were selected during the study staining.
period. Purposive sampling was carried out. The information collected was tabulated and
The study protocol was approved by analysed using standard statistical software
the Institutional Ethics Committee. (Microsoft Excel 2010 and SPSS Version
Informed consent was collected from the 25).

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 Vivek Kumar et.al. Study to find the burden of dry eye in diabetic patients in a tertiary care hospital

Statistical Analysis: Logistic Regression 6.5 times more chance of having dry eye as
was applied to find out the association and compared to participants in age group <40
their strength between the variables to years. Study participants having diabetic
validate the findings of the study. retinopathy had a risk of developing dry eye
54 times as participants not having diabetic
RESULT retinopathy. Study participants having
In our study the prevalence of dry diabetes > 5 years had 5 times greater risk
eye in the study subjects came out to be for dry eye as compared to newly diagnosed
57.4%. diabetics (<1 year).
Table – 1 shows the socio-
demographic and clinical profile of study Table 1: Profile of Study participants
Variable Frequency Percentage
subjects who participated in the study. The Age
age distribution revealed that maximum < 40 9 16.7
41 – 60 28 51.9
subjects 28 (51.9%) were in the age group >60 17 31.5
of 41 - 60 years. Female cases contributed Gender
Female 30 55.6
55.6% of the study population while 44.4% Male 24 44.4
were males. Most of them (40.7%) had Occupation
history of duration of diabetes of 1- 5 year. Housewife 19 35.2
Farmer 22 40.7
More than one third of the study population Office Worker 7 13.0
that is 38.9% were having hypertension. Field Worker 6 11.1
Hypertension
Almost half (51.7%) of the study subjects Absent 33 61.1
had diabetic retinopathy. Present 21 38.9
Dry Eye
Figure 1 represents the clinical Absent 23 42.6
features of the participants in the study. The Present 31 57.4
most common complaints were redness of DM duration
< 1 year 16 29.6
eye, burning sensation, painful eye, blurring 1 – 5 year 22 40.7
of vision and problem in low humid areas. > 5 year 16 29.6
Diabetic Retinopathy
By applying logistic regression, we Present 28 51.85
saw that in the age group > 60 years have Absent 26 48.15

Figure 1: Clinical features of the study participants

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 Vivek Kumar et.al. Study to find the burden of dry eye in diabetic patients in a tertiary care hospital

Table 2: Risk of dry eye in Diabetic patients by applying logistic regression

Dry Eye
Variables Present Absent Odds Ratio p-value
Age
< 40 3 6 - -
41 – 60 15 13 2.31 0.29
>60 13 4 6.5 0.03*
Gender
Female 11 19 - -
Male 20 4 8.63 <0.001*
Diabetic Retinopathy
Present 26 2 54.6 <0.001*
Absent 5 21 - -
Duration of DM
< 1 year 6 10 - -
1 – 5 year 13 9 2.4 0.19
> 5 year 12 4 5 0.03*
‘*’ – statistically significant

DISCUSSION and functional abnormalities of the cornea

The present study entitled “Study to and are at a high risk of developing corneal
find the burden of dry eye in diabetic lesions, as reported in several experimental
patients in a tertiary care hospital” was and clinical studies. (20-23)
planned to find out the burden of dry eye in In our study the risk of dry was 6.5
diabetic patients in Eye OPD. times in the age group > 60 years; 54 times
In our study the burden of dry eye in for participants having diabetic retinopathy
the study participants was 57.4% which was and 5 times in study participants having
similar to the findings of Nepp et al, (15) diabetes > 5 years.
Seifart and Strempel (3) and Home and De Secondary prevention i.e., early
Land (16,17) diagnosis and treatment of dry eye is
The findings of our study is similar to the essential to avoid complications. Till date
study conducted by Moss et al (18) and there is no fixed protocol for treatment of
Yazdani et al (19) which revealed association DES. Predominately application of artificial
of dry eye with increasing age. tears, including surfactants and various
Male diabetic patients had 8.6 times viscous agents are used for symptomatic
higher risk of developing dry eye than management. (24) Artificial tears temporarily
female diabetic patients. improve blurred vision and other symptoms.
Most common clinical features Corticosteroids, NSAIDs,
among our study participants were redness cyclosporin A, tacrolimus, autologous blood
of eye, burning sensation, painful eye, serum, and several new drugs are
blurring of vision and problem in low humid undergoing clinical trials for management of
areas. Other studies conducted also had DES. (25,26) Role of topical corticosteroids is
similar complaints of gritty sensation, to reduce the signs, symptoms, and
decreased visual acuity, photophobia, inflammation in dry eyes and prevent
itching, decreased corneal sensitivity, corneal epithelial damage. (27) Its use help in
tearing and pain concomitant with improvement of ocular surface disease
abnormalities in TUBUT, Schirmer's test, index score and dendritic cell density
and corneal staining. More severe cases may significantly. (28) Corticosteroids acts by
be complicated by corneal lesions, suppressing cellular infiltration and
conjunctivitis, keratopathy, and increasing synthesis of lipocortin which in
inflammation (17) and Manaviat et al. (11) turn block phosphorylation of phospholipase
In addition, Nepp et al. (15) revealed A2, which is the key step of the
that the severity of dry symptoms correlated inflammatory cascade (26,29) However, side
with the severity of diabetic retinopathy. effects such as bacterial and fungal
Diabetic subjects have structured metabolic infections, increase in intraocular pressure,

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 Vivek Kumar et.al. Study to find the burden of dry eye in diabetic patients in a tertiary care hospital

and cataracts have been reported. (30) Thus 8. U. Seifart and I. Strempel, “The dry eye and
application of lower concentration of topical diabetes mellitus,” Ophthalmologe, vol. 91,
steroid drugs for short duration (one or two no. 2, pp. 235–239, 1994
weeks) is recommended for those patients 9. Seifart U, Strempel I Trockenes Auge und
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