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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 110  |  Issue : 3  |  Page : 77-82

Prevalence of dry eye in diabetics


1 Memorial Institute of Ophthalmological Research, Giza, Egypt
2 Department of Ophthalmology, Ain Shams University, Cairo, Egypt

Date of Submission16-Jan-2017
Date of Acceptance30-Mar-2017
Date of Web Publication6-Nov-2017

Correspondence Address:
Thanaa H Mohammed
Department of Ophthalmology, Ain Shams University, Cairo 11361
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ejos.ejos_19_17

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  Abstract 

Purpose
The aim of this work is to study the prevalence of dry eye in type II diabetic patients and to correlate the dry eye with the duration of the diabetes and the level of Glycosylated Hemoglobin (Hb 1 Ac).
Patients and methods
It is a prospective randomized study in which 100 eyes (50 diabetics, 50 control) with type II diabetes mellitus is included in the study attending in department of ophthalmology Ain Shams University. Dry eye was confirmed by tear film break up time (TBUT) and Schirmer I test.
Results
Schirmer and tear film BUT values were lower among the uncontrolled diabetic patients. There is highly statistically significant relation between severity of dry eye by Schirmer test with duration of diabetes, hypertension, Debris in tear film, degree of diabetic retinopathy, Glycosylated Hemoglobin (HbA1C), with P value 0.003, 0.044, 0.000, 0.000, 0.000 respectively. There is highly statistically significant relation between severity of dry eye by BUT test with duration of DM, HTN, Debris in tear film, DR, HbA1C, with P value 0.002, 0.032, 0.000, 0.001, 0.000 respectively.
Conclusion
Diabetic patients are more prone to suffering from dry eye than normal subjects. These abnormalities can result in severe complications. Early examination of the diabetic patients for the detection of the ocular surface disorders is indicated.

Keywords: dry eye, HbA1C, type II diabetics


How to cite this article:
Kamel SS, Mohammed TH, El Zankalony YA, Saad AH. Prevalence of dry eye in diabetics. J Egypt Ophthalmol Soc 2017;110:77-82

How to cite this URL:
Kamel SS, Mohammed TH, El Zankalony YA, Saad AH. Prevalence of dry eye in diabetics. J Egypt Ophthalmol Soc [serial online] 2017 [cited 2017 Dec 18];110:77-82. Available from: http://www.jeos.eg.net/text.asp?2017/110/3/77/217695

Type 1 diabetes is primarily due to autoimmune-mediated destruction of pancreatic β-cells; resulting in insulin deficiency. the frequency of type 1 diabetes is low relative to type 2 diabetes; which accounts for nearly 90% of diabetes worldwide. the phrase ‘ diabetes epidemic’ refers predominantly to type 2 diabetes; which is increasing in both developed and developing countries [1].

Ocular surface disease in diabetes is characterized by reduced corneal sensitivity and by alteration in tear quantity and quality [2].

Diabetic patients might exhibit dry eye symptoms probably due to neuropathy, metabolic dysfunction, or abnormal lacrimal secretions [3].

Damage to the microvasculature of the lacrimal gland accompanied by autonomic neuropathy might impair lacrimation in persons who suffer from diabetes for a long time. Patients with diabetic retinopathy do not complain of symptoms of dry eye, but they have pathological and clinical signs of Keratoconjunctivitis Sicca [4].


  Aim Top


The aims of this study were to determine the prevalence of dry eye in type II diabetic patients and to correlate dry eye with the duration of diabetes and the level of Hb1Ac.


  Patients and methods Top


This was a prospective randomized study in which 100 eyes (50 eyes of diabetic patients and 50 control eyes) were included. Participants were selected from patients with type II diabetes mellitus (DM) who visited outpatient and inpatient departments of ophthalmology at Ain Shams University.

Inclusion criteria

All type II diabetic patients diagnosed by the American Diabetes Associations criteria were included.

Exclusion criteria

  1. Patients using medications such as antihistamines or antidepressants, oral contraceptives, and diuretics.
  2. Patients who had undergone LASIK surgery.
  3. Patients wearing contact lenses.
  4. Patients having Sjogren syndrome, rheumatoid arthritis, systemic lupus erythematosus, and Parkinson’s disease.
  5. Patients who smoked.
  6. Patients with vitamin A deficiency.
  7. Pregnant women.


Data of all patients including sex, age, duration of diabetes, as well as a history of other diseases were obtained by reviewing medical records and through direct patient interviews.

Dry eyes were suspected on the basis of a history of ocular discomfort, including soreness, gritty sensation, itchiness, redness, blurred vision that improves with blinking, and excessive tearing.

Dry eye was confirmed by tear film break up time (TBUT) and Schirmer’s I test. Diagnosis was established by positivity of one or both the tests (TBUT or Schirmer’s test).

Structures of the eye were assessed with slit-lamp biomicroscopy examination. Retinal status was evaluated by indirect ophthalmoscopy after dilation with tropicamid drop, and diabetic retinopathy was graded according to early Treatment Diabetic Retinopathy Study.

Informed consent was obtained from all individuals, and the study obtained approval of the institutional review board and ethics committee of the Faculty of Medicine at Ain Shams University.

Tear film break up time

Moistened with nonpreservative saline fluorescein strips (Omni Strips Fluro; Ophthalmic Strips U.S.P.) were introduced into the conjunctival sac with minimal stimulation, undetected by the patients. The individuals were then instructed to blink several times for a few seconds to ensure adequate mixing of fluorescein. The tear film was examined with a broad beam and a cobalt blue filter.

The interval between the last complete blink and the appearance of the first corneal black spot or line in the stained tear film was measured using a stopwatch ([Figure 1]).
Figure 1 Interval between the last complete blink and the appearance of the first corneal black spot or line in the stained tear film as measured using a stopwatch.

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A TFBUT value more than 10 s was considered normal, a value of 8–10 s was considered mild dryness, a value of 5–7 s was considered moderate dryness, and a value less than 5 s was considered severe dryness.

Schirmer’s test

This test measures tear secretion over a specified time.

Schirmer test I without topical anesthesia (total tear secretion) was carried out with standardized strips.

The strip was folded at the notch and placed at the junction of the middle and lateral thirds of the lower eyelids and allowed to stay in place for 5 min with patient’s eyes gently closed.

The filter paper was removed, and the amount of wetting was measured ([Figure 2]).
Figure 2 Amount of wetting measured after removal of filter paper.

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More than 10 mm of wetting after 5 min was considered normal, 8–10 mm of wetting was considered mild dryness, 5–7 mm of wetting was considered moderate dryness, and less than 5 mm of wetting was considered severe dryness at the end of 5 min.

In this study, we determined the changes in tear film parameters and ocular surface in a group of noninsulin-dependent diabetes mellitus (NIDDM) patients and compared the results with a nondiabetic control group.
  1. The tear secretion test and the tear stability test were performed and assessed. We also investigated systemic factors such as age, sex, and duration of disease.
  2. Diabetes was diagnosed at the department of internal medicine. The duration of diabetes and Hb1Ac values were reported.
  3. We studied 50 eyes (50 patients) with NIDDM (21 men and 29 women) and 50 eyes (50 normal) of controls (21 men and 29 women). The mean±SD of diabetic patients was 52.46±9.10 years and that of the normal individuals was 48.32±9.20 years. The mean±SD duration of DM in the study group was 10.26±6.88 ranging from 2.0 to 27.0 years.
  4. Schirmer’s test I without topical anesthesia (total tear secretion) was performed, and TBUT was measured. Tear secretion of less than 10 mm and a BUT value of less than 10 mm were regarded as abnormal.
  5. Data are expressed as mean±SD. Parameters between groups were analyzed by the Student’s t-test, and analysis of variance was performed with the χ2-test. A P value of less than 0.05 was considered statistically significant.


Probability values is as follows:
  1. P more than 0.05 was considered statistically nonsignificant.
  2. P lower to 0.05 was considered statistically significant.
  3. P lower to 0.01 was considered statistically highly significant.



  Results Top


There was a statistically significant difference between nondiabetics and diabetics regarding age with a P value of 0.026, whereas there was no statistically significant difference regarding sex with a P value of 1.000 ([Table 1]).
Table 1 Comparison between diabetic and nondiabetic groups regarding age (years) and sex

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[Table 2] shows a highly significant increase in severity by Schirmer’s test and TBUT in diabetics compared with nondiabetics ([Table 3]).
  1. Duration of DM: DM in the study group was 10.26±6.88 years ranging from 2.0 to 27.0 years.
  2. Control of blood sugar: in the study group, 24% showed good control, 68% showed fair control, and 8% showed poor control.
Table 2 Comparison between diabetic and nondiabetic groups regarding Schirmer’s test and break up time scores

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Table 3 Descriptive data of the diabetic group

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[Table 4] shows highly statistically significant relationships between severity by Schirmer’s test and duration of DM, hypertension, debris in tear film, diabetes risk, and HbA1C with P values of 0.003, 0.044, 0.000, 0.000, and 0.000, respectively.
Table 4 Relationship between Schirmer’s scores and data of diabetic patients

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[Table 5] shows highly statistically significant relationships between severity by BUT test and duration of DM, hypertension, debris in tear film, diabetes risk, and HbA1C with P values of 0.002, 0.032, 0.000, 0.001, and 0.000, respectively.
Table 5 Relationship between break up time scores and data of diabetic patients

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  Discussion Top


Dry eye syndrome is common among patients with DM, with tear film stability and TBUT being decreased. The mucin layer of the tear film is necessary for tear film spreading and wetting. Deficiency in the mucous layer may reduce tear film stability and TBUT. Tear secretions are reduced in patients with DM as shown by the significantly decreased Schirmer’s test values as well as TBUT. The reduced Schirmer’s value is linked to an advanced stage of diabetic retinopathy. The reduction in reflex tearing may be due to a decrease in corneal sensitivity [2],[3],[5],[6],[7].

In our study, Schirmer’s I and the TBUT test results reduced in NIDDM patients and in patients with poorly controlled diabetics (70% in both Schirmer and TBUT) (P=0.000).

In Goebel’s study, the results of Schirmer’s test I and II were significantly lower in diabetic patients compared with controls (37%, P<0.001) [8].

A study was performed on tear function and ocular surface changes in NIDDM. All individuals underwent Schirmer’s test and a TBUT analysis. Patients and controls were compared for tear function parameters, the relationship with diabetic peripheral neuropathy, metabolic control, duration of disease, and status of retinopathy. The results showed that the BUT and the Schirmer test values were significantly lower in the diabetic group, in patients with peripheral neuropathy, and in patients with poor metabolic control. The examined parameters did not relate to duration of disease or status of diabetic retinopathy [3].

Ozdemir et al. [5] in his study did find that TBUT and Schirmer’s test values were significantly lower in diabetic patients compared with controls (P<0.001). In the diabetic group, more individuals had abnormal fluorescein stain compared with the control group (P<0.001). Abnormal tear function tests were associated with poorer metabolic glucose control and proliferative diabetic retinopathy (P<0.05) but not with duration of diabetes (P>0.05). It was concluded that poor metabolic control and proliferative diabetic retinopathy are high risk factors for ocular surface disorders in type 2 diabetes [5].

In our study, Schirmer’s and TBUT values were lower among the uncontrolled diabetes patients. It was statistically significant with bad metabolic control and duration of diabetes.

A study on the amount of tear production and stability of the tear film in diabetic and nondiabetic individuals was carried out to detect the possible tear film abnormalities in type 2 diabetic patients. The mean values of Schirmer 1 test and BUT significantly decreased in diabetes patients as compared with healthy controls as a general finding [9]. In our study, this was true in patients with uncontrolled diabetes.

An Indian study investigated the changes in tear film and ocular surface in diabetic patients. Corneal sensitivity, tear film break up time, Rose Bengal test, and Schirmer’s test without and with topical anesthesia were measured. Results showed that corneal sensitivity, TBUT, total and basal tear secretions were significantly lower in the diabetic group compared with the control group. This indicates that in patients with type II diabetes there is an ocular surface disorder [10].


  Conclusion Top


Diabetes can lead to ocular surface impairments with qualitative and quantitative tear disorders. These abnormalities, even if not currently mentioned by diabetic patients, can result in severe complications.

Our findings support the impression that diabetic patients have an elevated prevalence of dry eye syndrome. Diabetes and dry eyes appear to have a common association.

Although the results of our study and most of other similar studies remain controversial, they all suggest that diabetic patients are more prone to suffering from dry eye than normal individuals, and therefore these symptoms should be monitored. Early examination of diabetic patients for detecting ocular surface disorders is indicated.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Lam DW, LeRoith D. The worldwide diabetes epidemic. Curr Opin Endocrinal Diabetes Obes 2012; 19:93–96.  Back to cited text no. 1
[PUBMED]    
2.
Inoue K, Kato S, Ohara C, Numaga J, Amanto S, Oshika T. Ocular and systemic factors relevant to diabetic keratoepitheliopathy. Cornea 2001; 20:798–801.  Back to cited text no. 2
    
3.
Dogru M, Kani K, Inoue M. Tear function and ocular surface changes in noninsulin-dependent diabetes mellitus. Ophthalmology 2001; 108:586–592.  Back to cited text no. 3
    
4.
Nielsen NV, Lund FS. Diabetic polyneuropathy, corneal sensitivity, vibratory perception and Achilles tendon reflex in diabetes. Acta Neurologica Scadinavica 1979, 59:15–22.  Back to cited text no. 4
[PUBMED]    
5.
Ozdemir M, Buyukbese MA, Cetinkaya A, Ozdemir G. Risk factors for ocular surface disorders in patients with diabetes mellitus. Diabetes Res Clin Pract 2003; 59:195–199.  Back to cited text no. 5
[PUBMED]    
6.
Cousen P, Cockett P, Bemett H, Swa K, Dhillon B. Tear production and corneal sensitivity in diabetes. J Diabetes Complications 2007; 21:371–373.  Back to cited text no. 6
    
7.
Bikbova G, Oshitari T, Tawada A, Yamamoto S. Corneal changes in diabetes mellitus. Curr Diabetes Rev 2012; 8:294–302.  Back to cited text no. 7
    
8.
Goebbels M. Tear secretion and tear film function in insulin dependent diabetics. Br J Ophthalmol 2000; 84:19–21.  Back to cited text no. 8
    
9.
Gupta I, Mengi RK, Bhardwaj S. Tear secretion and tear film function in diabetes. JK Sci 2010; 12:172–174.  Back to cited text no. 9
    
10.
Shobha P, Sheila RP, Ashwin A, Nayanatara AK, Rekha DK. A comparative study of changes in tear film function in normal and type 2 diabetic subjects in South Indian population. Int J Biomed Adv Res 2011; 2:253.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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