A CLINICAL STUDY ON TEAR FILM & DRY EYE STATUS

IN DIABETIC PATIENTS IN TERTIARY CARE CENTRE

DR KUNAL MANDLIK

INTRODUCTION: • Diabetes is a serious global health problem. With 3.5 crore

persons with diabetes in India. Moss et al1 reported dry eye incidence of only18.1% in diabetic and 14.1% in non diabetic patients. Diabetic patients have also been found to have symptoms indicative of dry eye such as foreign body and burning sensations, itching, blurred vision, and photophobia, stinging, dryness, ocular fatigue and redness. There is, thus, an implication of a correlation between diabetes mellitus and tear film abnormalities.

PATHOPHYSIOLOGY:• In the absence of a normal pre-corneal tear film, the cornea tends to

dry out and becomes hazy, leading to a condition of dry eye.• Possible Explanations are:• An exocrine dysfunction of the main lacrimal gland in patients with

diabetes mellitus or perhaps the development of additional unknown proteins in the tear fluids.• The diminished sensitivity may be a kind of diabetic neuropathy can

lead to the reduction of stimulatory signals from the ocular surface to the lacrimal gland and the influence on regulatory systems.• The main protein peaks, lactoferrin, lysozyme, lipocalin, and albumin

were detected and quantified. The number of peaks were significantly increased in the tear protein pattern of diabetics.• Oxidative stress and free radical production are elevated in diabetes

mellitus

METHODOLOGY:• This study was conducted in the Department of

Ophthalmology Dr. Vasantrao Pawar Medical College Hospital And Research Centre, Nashik, from 2011 to 2012. Ethical approval from the institution had been obtained. 100 participants were enrolled from among individuals reporting to the Ophthalmology Out Patient Department of our hospital.

METHODOLOGY:INCLUSION CRITERIA

1. Known diabetic patients

2. Non diabetic patients as control group

 

EXCLUSION CRITERIA

1. Patients with any ocular disorder known to produce dry eye.

2. Patients suffering from any systemic diseases, (other than diabetes mellitus), associated with dry eye such as connective tissue disorders (Sjogren's syndrome, Rheumatoid arthritis, lupus erythromatosis)

3. Patients on any drug treatment which produces dry eye (such as MAO inhibitors, Alpha agonists, Beta blockers, Thiazides, NSAIDs etc)

4. Patients having undergone any ocular surgery in the past 2 years

5. Wearers of contact lenses

METHODOLOGY:A detailed history, general physical examination, detailed ophthalmologic examination and relevant investigations were recorded for each patient enrolled in the study. In addition to determining blood sugar levels following tests were done1. Corneal sensitivity test: Corneal sensation was tested using a wisp of cotton wool brought onto the cornea in order to elicit a blink response.2. Tear film Break up Time (TBUT): The tear film was stained using commercially available pre-sterilized strip impregnated with 1mg Fluorescein. The end point of the test occurred with the time taken, in seconds, for the appearance of the first dry spot formation from the last blink.

METHODOLOGY:3. Schirmer’s test: This test was performed using a commercial Whatman 41 paper strip. The strip was placed at the junction of the middle and lateral thirds of the lower eyelid and removed after 5 minutes. The amount of wetting of the strip was read off in millimetres.

METHODOLOGY:4. Dye tests:i) Fluorescein staining: It is used to delineate areas of epithelial discontinuity but does not pick up any dead or devitalized cells.ii) Lissamine green strip: detecting areas of mucin deficiency in the ocular surface.iii) Rose Bengal staining: staining dead or degenerating cells.

RESULTS:• Two hundred eyes of hundred patients were examined in this non randomized prospective study. The

participants were divided into two groups, Group A comprising of 50 non diabetic individuals and the other group (Group B), comprised of 50 known diabetics participants. Group A was taken as the control group.

• Reduced corneal sensation was detected in 14(73.1%) eyes of 7 individuals with DED in group B.

• TBUT test was positive in 9 eyes(9%) belonging to the non-diabetic group and 19 eyes (19%) in the diabetic group.

• Positive Schirmer’s tests were seen in 7 eyes (7%) of non diabetics and 24 eyes(24%) eyes of diabetics

• Fluorescein staining was positive in 19 eyes (19%) of diabetic

• patients as compared to 4 (4 %) eyes of non-diabetics. NEI grading of the corneal staining is taken to be positive if the score is 3 or more. All the eyes showed NEI grading of 3

• Rose Bengal staining of grade 3was seen in 3 eyes (3%) of non diabetic group (Group A) as well as 19 eyes (19%) in group B.

• Lissamine green staining showed grade 3 positive results in 19 eyes (19%) of Group B individuals.

RESULTS:• Corneal sensation abnormality in both Groups

NormalAbnormal

0

10

20

30

40

50

60

70

80

Diabetes

Non DM

46

73

53

27 DiabetesNon DM

RESULTS:• Comparison of the positive tests

• All these findings strongly suggest that dry eye is a significant feature of the diabetic ocular surface disease. Schirmer’s test results were significantly positive in diabetic individuals. These results are suggestive of a neuropathy involving the lacrimal gland.

TBUTSchirmer I

Fluroscein Staining Rose Bengal

Staning Lissamine Green

05

10152025

Group A

Group B

97

43

3

1924

9 9 9 Group AGroup B

CONCLUSION:

• This study shows that dry eye syndrome is an important manifestation of diabetes mellitus DED is easily detected and monitored by performing simple non invasive testing of the tear film and should be a part of routine check up at each ophthalmic visit, even if the patient is asymptomatic. Early diagnosis and timely treatment are important for preventing development of DED and its subsequent progression to vision threatening complications and to improve the quality of life.

REFERENCES:• S.E. Moss, R. Klein and B.E. Klein, Prevalence of and risk factors for dry eye syndrome,

Arch Ophthalmol 118 (2000), pp. 1264–1268.