Microsoft Word - 7. Munir Amjad Baig - MM Pakistan Journal of Ophthalmology, 2020, Vol. 36 (3): 221-225 221 ORIGINAL ARTICLE Dry Eye Disease and Diabetes Mellitus Munir Amjad Baig1, Rabeeya Munir2 1Azad Jammu Kashmir Medical College Muzaffar Abad, 2Islamic International Medical & Dental College Islamabad ABSTRACT Purpose: To find out the frequency of dry eye disease in patients of type II Diabetes Mellitus. Study Design: A hospital based descriptive cross sectional study. Place and Duration of Study: Federal Government Services Hospital Islamabad, from January 2015 to May 2016. Material and Methods: Four hundred patients of type II Diabetes, diagnosed according to American Diabetic Association (ADA) criteria, were selected by convenient sampling technique. Patients with any ocular surgery, any systemic disease or medication affecting tear production, pregnancy, and contact lens users were excluded. Clinical data was obtained by direct patient interviews and their medical records. Basic demographics were recorded and a 6-item standardized Dry eye questionnaire (DEQ-6) was administered by a trained researcher to all patients. Detailed eye assessment was performed by a single surgeon under the same physical conditions. DED was assessed using Dry eye workshops DEWS (2007) recommendations. Results: Participants had mean age of 55.6 ± 10.2 years. There were 61.5% males and 38.5% females. Mean duration of diabetes was 12.02 ± 7.5 years. Frequency of DED in this study was 58%. There were 19.7% patients who had an HbA1c ≥ 9.0%. Oral glucose lowering drugs (OGLDs) were used by 61% of the participants, while 22.5% were on insulin and 16.5% were on both. The most common symptom was burning and the most frequent sign was frothy discharge. TBUT was positive in 43.5% patients. Schirmer test was positive in 33.1% and corneal staining was present in 37% subjects. Conclusion: Dry eye disease is a common finding in diabetes Mellitus which increases with the duration of Diabetes. Key Words: Diabetes Mellitus, Flourescein stain, Dry eye, Schirmer test, Tear film breakup time. How to Cite this Article: Baig MA, Munir R. Dry Eye Disease and Diabetes Mellitus. Pak J Ophthalmol. 2020; 36 (3): 221-225. Doi: 10.36351/pjo.v36i3.1003 INTRODUCTION Dry eye disease (DED) is a multi-factorial disease of the tears resulting in tear-film instability with damage to the ocular surface1. About 4.7% of American men and 7.8% of women over 50 years have DED and 7–10 Correspondence to: Munir Amjad Baig Azad Jammu Kashmir Medical College, Muzaffar Abad E-mail: drmuniramjad@gmail.com Received: February 9, 2020 Revised: May 4, 2020 Accepted: May 4, 2020 million Americans use artificial tears consuming US $100 million/year2. A study in Pakistan showed the DE prevalence was 16%3. Various risk factors influence DED like female sex, age, and hormones4. The word Diabetes was used by Arashes Cappodocia (81-133 AD) and the word mellitus was used by Thomas Willis in 1675. Egyptians, 3000 years ago, described DM and its clinical features5. Type 2 Diabetes, which accounts for nearly 90% of diabetes worldwide, is a chronic hyperglycaemia due to insulin deficiency, insulin resistance or both. It causes corneal neuropathy and corneal epithelium Munir Amjad Baig, et al 222 Pakistan Journal of Ophthalmology, 2020, Vol. 36 (3): 221-225 dysfunction. Human cornea contains both unmyelinated C and myelinated A-δ fibers6. The corneal complications like epithelial defects, trophic ulcers and superficial punctate keratopathy are caused by hyperglycemia all closely related with DE6. A review of the literature showed that DED was present in more than half of diabetic patients. DED is present in 55% of people with type 2 diabetes compared to 27% people having type 1 and 29% of those having no diabetes.7 Results also showed relations between diabetes duration and onset of diabetic retinopathy. It varied from 28.8% to 77.8% in persons having 5 years and 15 years duration respectively8. Studies have shown that DED is correlated with glycated hemoglobin level; higher the level of HbA1c, the higher is the DED symptoms9. The aim of this study is to know the effect of type 2 diabetes on tear film parameters. MATERIAL AND METHODS A descriptive cross sectional study was carried out among 400 type 2 diabetic patients attending diabetic eye clinic and referred from other departments of the Federal Government Services Hospital Islamabad from January 2015 to May 2016. Patients consent was taken and permission from Ethical committee was sought. All cases of diabetes diagnosed according to the American Diabetic Association (ADA) criteria, were consecutively selected. Those with any surgery, any systemic disease or medication affecting tear production, pregnancy, and contact lens users were excluded. Clinical data was obtained by direct patient interviews and their medical records. Demographic data was recorded and a 6-item standardized DE questionnaire (DEQ-6) was administered by a trained researcher to all the patients. Detailed eye assessment including visual acuity, like slit-lamp biomicroscopy, dilated fundus examination for retinal status and various dry eye tests were performed by a single surgeon under the same physical conditions. Early Treatment Diabetic Retinopathy (ETDRS) study criteria was used to grade diabetic retinopathy DR. Subjects having 1 or more symptoms often or all the time, tear film break-up time (TBUT) of < or = 10 seconds in 1 or both eyes, schirmer's test (ST) < or = 5 mm in 5 min, corneal fluorescein staining (CFS) of > or = 1 for presence of conjunctival injection, punctate epithelial erosions (PEE) and slit lamp examination of lid for mucous threads/telengiectasias and meibomian gland dysfunction (MGD) were positive signs according to Japanese diagnostic criteria for dry eye. The diagnosis was made on the presence of three of five DE tests. Suspected dry eyes based on symptoms like ocular discomfort, burning, redness, itchiness/gritty sensation, blurred vision which improved with blinking, excessive watering and confirmed by TBUT and ST test values were diagnosed as DE patients. Data was analyzed for frequencies/percentages using SPSS version 20. RESULTS A total of 400 type 2 Diabetic patients of varying duration, age ranging from 38-78 years, mean age 55.6 ± 10.2 years, were screened for DED. There were 246 (61.5%) male and 154 (38.5%) females and the mean duration of diabetes was 12.02 ± 7.5 years. Frequency of DED in this study was 58% (232/400), 56.0% male, 43.9% female and was found to increase with age 58–67 years’ group and with duration of diabetes 15–19 years’ group. The majority of our subjects were male (61.5%) who were in the age group of 48–57 years. Table 1: Baseline characteristics (n = 400) 38 – 78 years. Demographics Respondents (%) Age group (years) 38 – 47 98 24.5% 48 – 57 127 31.7% 58 – 6 7 104 26% 68 or above 71 17.8% Total 400 100% Sex Male 246 61.5% Female 154 38.5% Urban 281 70.2% Rural 119 29.8% Family history 136 34% Smokers >5 years 111 28% Glasses 82 20.5% Computer users 141 35.2% 218 (54.5%) patients had Diabetic retinopathy, 89 (40.8%) had mild changes, 91 (41.7%) had moderate and 38 (17.4%) had severe form of retinopathy. 37% (148) subjects had peripheral neuropathy (PN), 24.5% (98) had diabetic nephropathy. 35.5% (142) subjects had HbA1c value below 7.0% and 19.7% (97) had an HbA1c ≥ 9.0%. Oral glucose lowering drugs (OGLDs) were used by 61% of the participants, while 22.5% Dry Eye Disease and Diabetes Mellitus Pakistan Journal of Ophthalmology, 2020, Vol. 36 (3): 221-225 223 were on insulin and 16.5% were on both. 34% 136 patients had positive family history of diabetes. The most common symptom was burning (51%) and the least common symptom was lids stuck together in the mornings (23%). The most frequently observed sign was frothy discharge in 67 (16.7%) patients. TBUT was positive in 101 (43.5%) patients, Schirmer test (ST) was positive in 77 (33.1%), corneal staining was present in 86 (37%) subjects and 117 (50.4%) had telengiectasias and plugging of Meibomian openings and/or mucous threads. Decreased tear film function was found in patients with Table 2: Dry eye symptoms after smoking. Symptoms Never Rarely Sometimes Often All the Time % age Burning/dryness 89 54 53 75 129 51% F.B. sensations 92 90 56 69 93 40.5% Redness 108 91 67 58 76 33.5% Watering 122 104 61 68 45 28.2% Discharge 120 132 56 53 39 23% Table 3: DED detection by DEQ5, Positive results of TFBUT, Schirmer test, Fluorescein staining, Lid pathology. DEQ6 TFBUT Schirmer Test Fluorescein Staining Lid Pathology Dry eye disease (n = 232) 7 (20.2%) 101 (43.5%) 77 (33.1%) 86 (37%) 117 (50.4%) Normal (n=168) 21 (12.5%) 48 (28.5%) 33 (19.6%) 8 (5%) 20 (11.1%) Table 4: DED related to duration of diabetes. Duration Total No. Dry Eyes % Frequency 1 – 5 years 89 34 38.2% 6 – 10 years 110 63 57.2% 11 – 15 years 130 81 62.3% 16 – 20 years 71 54 76% Total 400 232 58% DR than in those with non-DR. DISCUSSION In Pakistan, about 10 percent of the population suffer from diabetes and the incidence of blindness is similar to other studies (5.5% and 3.6% in Nigeria and Barbados respectively) as reported by World Health Organization (WHO)10. Another study in Pakistan, showed that the prevalence of type 2 diabetes mellitus was 11.7% over 25 years of age which was higher in males than females and was more common in urban than the rural areas11 similar to our study. The frequency of DED among Diabetic patients in our study was 58%, is consistent with Manaviat et al8, Najafi et al9 and Seirfart and Strempel who had found a it to be 54.3%, 53% and 52.8% respectively among their diabetic population. Out of 58% (232/ 400) patients who had DED, males were 56.0% while females were 43.9%. This is contrary to other study12 that showed females were more prone to DED. Some authors13 showed that DE incidence rises in women due to the low levels of protective hormones like androgens. Other studies in diabetics negate gender relation in diabetic keratoconjunctivitis sicca14. Majority of our subjects were in the age group of 48 – 57 years. There was an increase in DED with age (59 – 68 year group), which is comparable to Chia et al15 who found higher DED prevalence with age in diabetics. Liu et al16 also found that diabetes and increased age were risk factors for dry eye. Contrary to that, Manaviat et al.8 denied older age as a risk factor for DED in diabetics. In our study, decreased TFBUT and ST values with advancing age were consistent with another study11 which showed that with increasing age there was decrease in aqueous part of tear film causing symptoms of DED. Thirty-four percent patients had positive family history in this study. Patients with a family history of diabetes were also prone to DED is consistent with other study17. Zhang et al, showed that 33% of diabetic patients exhibited lower values of Schirmer test than normal18. In a series by Gupta and Dogru, 22.7% to 34% of eyes had lower Schirmer values19. In our study, 218 (54.5%) subjects had diabetic retinopathy, 89 (40.8%) had mild changes, 91 (41.7%) had moderate and 38 (17.4%) had severe form of retinopathy similar to other study showing 28.8% to 77.7% DR prevalence during five to over 15 years duration20. In our study 38 (17.4%) subjects with Munir Amjad Baig, et al 224 Pakistan Journal of Ophthalmology, 2020, Vol. 36 (3): 221-225 proliferative diabetic retinopathy (PDR) showed decreased tear film function than those with non-PDR is consistent to other study showing that both TBUT and ST values were decreased in the PDR group compared to the non-DR group21. In our study there was an interesting relation between sex and grades of DR. Lower grades of DR was common in women and more severe form of DR was common in men, similar relation was found in Rema et al22 study. Another interesting observation was that most of the DED patients had diabetes for longer duration 10-14 years and the decreased tear film function was present in patients with PDR than NPDR similar to studies of Chen et al17 and Manaviat et al8 while Imam et al mentioned fewer dry eye symptoms23 in those with longer duration of diabetes. The most commonly reported symptom in this study was burning (61% of Diabetics) and the least reported was eyelids stuck together in the morning. The study by Chia et al15 found that itchiness was the most commonly reported symptom. In our study, 37% of subjects had peripheral neuropathy (PN) leading to DED. This is consistent to Nakata et al24 showing that Diabetic neuropathy may be an important risk factor for lacrimal gland dysfunction. Dry eye incidence is related with the level of glycated hemoglobin; higher the glycated hemoglobin level, the higher is the DED. In our study DED symptoms were related to HbA1c but Najafi et al9 did not find the relationship while Zia et al25, found more use of artificial tears among diabetics with a higher HbA1c. Strength of our study is that we used 6-items questionnaire to detect DE symptoms. A single trained researcher helped reducing the scoring bias. Our results were closer to those studies utilizing the questionnaires similar to present study. CONCLUSION There is a link between Dry Eye disease and diabetes. DED is both public health and economic burden suggesting that dry eye tests must be part of the ocular examinations among diabetics. Ethical Approval The study was approved by the Institutional review board/Ethical review board. Conflict of Interest Authors declared no conflict of interest Author’s Designation and Contribution Munir Amjad Baig; Associate professor: Study design, data collection, manuscript writing. Rabeeya Munir; Demonstrator: Data collection, manuscript writing. REFERENCES 1. Lemp MA, Foulks GN. The definition and classification of dry eye disease: Report of the definition and classification subcommittee of the international dry eye workshop. Ocul Surf. 2007; 5: 75– 92. 2. Miljanović B, Dana R, Sullivan DA, Schaumberg DA. Impact of dry eye syndrome on vision-related quality of life. 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Possible answers to the questions were 'none', 'rarely or sometimes', and 'often or all the time'. Subjectively dry eye was defined as having one or more symptoms 'often or all the time'.