OCULAR SURFACE DISEASES IN DIABETES MELLITUSDR DHWANIT KHETWANIMBBS UNDER THE GUIDANCE OFOPHTHALMOLOGY J.R DR. V .H .KARAMBELKAR Associate Professor, Dept. of Ophthalmology

WHAT IS DIABETES?According to the WHO:The term diabetes mellitus describes a metabolic disorder of multiple aetiology characterized by chronic hyperglycaemia with disturbances of carbohydrate, fat and protein metabolism resulting from defects in insulin secretion, insulin action, or both.

MY STUDYMy study focusses on Evaluation of effects of Diabetes on the Ocular surfaces SAMPLE SIZE- 100 PatientsTYPE OF STUDY – Crossectional studyDURATION OF STUDY- 18 MonthsTIME OF STUDY- FROM OCT 2016 – MAY 2018

AIMS AND OBJECTIVESAIM: To Study the changes in Ocular Surface due to diabetesOBJECTIVES:• To study the effect of diabetes on Tear Secretion• To study the magnitude of Tear Film Dysfunction• To study the relation between the manifestations of diabetes and Tear Production.

PURPOSE OF THE STUDY It is well known that diabetic individuals are vulnerable to many sight threatening disorders, the most widely known of which is diabetic retinopathy. However, diabetic patients have also been found to have symptoms indicative of dry eye.

Numerous studies have been done to relate Diabetes with Diabetic Retinopathy and other associated conditions, but very few have been done to relate Dry Eye with Diabetes.

PREVIOUS STUDIES Risk factors for ocular surface disorders in patients with diabetes mellitus. By,

Ozdemir M1, Buyukbese MA, Cetinkaya A, Ozdemir G.(TURKEY)CONCLUSIONS:The results of the study indicate that poor metabolic control and proliferative diabetic retinopathy are high risk factors for ocular surface disorders in type 2 diabetes. Tear function and ocular surface changes in noninsulin-dependent diabetes

mellitus BY Dogru M, Katakami C, Inoue M.(JAPAN)CONCLUSIONS:The ocular surface disease in diabetes is characterized by a disorder of tear quantity and quality, squamous metaplasia, and goblet cell loss, all of which seem to evolve in close proximity to the status of metabolic control and peripheral neuropathy.

SELECTION CRITERIA INCLUSION CRITERIA:

Known Cases of Diabetes for more than 5 years

EXCLUSION CRITERIA Any congenital lacrimal dysfunction Patients on any drug treatment , Topical (Betaxolol, Olapatidine,

Naphazoline, Miotics or Mydriatics , Ketorolac) or Systemic (Beta blockers anti-hypertensives, anti-histaminics , Anti-psycotics) which produces dry eye.

Patient having under gone any ocular surgery (Cataract , Refractive surgery, pterygium excision)

Patients with any other ocular disorder known to produce dry eye (Allergic eye disease, Vit A deficiency, Post Steven Johnsons, Vernal keratoconjuctivitis, Post ocular chemical burns) .

Systemic diseases associated with dry eye other than diabetes mellitus (RA , SLE , CVD, Thyroid disordes)

WHAT EXACTLY DOES THE “OCULAR SURFACE” COMPRISE OF?

Surface and Glandular epithelia of the Cornea,

Conjunctiva, Lacrimal Gland, Accessory lacrimal glands, Meibomian gland, and their apical (tears) and basal (connective tissue) matrices,

Eyelashes with their associated glands of Moll and Zeis

The Nasolacrimal Duct.

A TEAR FILM COMPRISES OF… -Superficial thin lipid layer

-Middle bulk aqueous layer

-Innermost mucous layer

EACH LAYER HAS A DIFFERENT FUNCTION..

HOW DOES DIABETES AFFECT THE TEAR FILM DYNAMICS? Diabetes with the following associated factors affects the Tear film dynamics Peripheral neuropathy secondary to hyperglycaemia, Insulin insufficiency Inflammation.

PERIPHERAL NEUROPATHY SECONDARY TO HYPERGLYCEMIA,

In the eye, hyperglycemia and microvascular damage to the corneal nerves can block the feedback mechanism (or “loop”) that controls tear secretion.

When the innervation of the ocular surface is disrupted, the lacrimal gland does not secrete tears properly.

An almost neurotrophic-like condition may be the product of

significant nerve damage to the cornea.

INSULIN INSUFFICIENCY. In the eye, corneal and lacrimal gland metabolism, growth, epithelial cell proliferation and culture maintenance are influenced by insulin. A low insulin level generally disrupts the biomechanical balance of these tissues and results in ocular dryness.

Hyperglycemia triggers inflammatory alterations and is believed to impair normal events, such as tear secretion.

We know that inflammation is not only a cause, but also a consequence of dry eye. Aqueous deficient dry eye or lacrimal insufficiency usually results from lacrimal gland inflammation.

INFLAMMATION

SYMPTOMS

METHODS AND MATERIALSSOURCE OF DATA: All Patients attending OPD at OPHTHALMOLOGY DEPT. in KRISHNA HOSPITAL , KARAD from OCTOBER 2016 to MAY 2018.

METHODS OF COLLECTION OF DATA The Ocular surface will be studied by the following tests : (1) The Schirmer test

(2) Tear film Break Up Time (TBUT)

(3) Blink Rate (4) Lissamine Green staining test

(5) Tear Meniscus Height test

SCHIRMER’S TESTSCHIRMER'S TEST I Off the fan. A 5 mm x 30mm Whatman filter paper

strip is folded 5 mm from the end. The folded end is placed gently over the lower palpebral conjunctiva at its lateral one-third. The patient keeps the eye open and looks upward. Blinking is permissible. Check the results after 5 minutes.

Normal Measurements More than 15 mm in all age groups (15 - 30mm) -

Normal Less than 10 mm is suggestive of moderate dry eye Less than 5 mm is diagnostic of severe dry eye.

TEAR BREAK-UP TIME TEST Sterile Fluorescein 2% dye is instilled into

the lower fornix of the eye and the patient is asked to blink. The cornea is scanned under low slit lamp magnification using blue cobalt filtered light. The patient is instructed to blink once or twice and then stare straight ahead without blinking

Values of < 10s are considered abnormal Values of 5-9 are borderline dry eye Values of < 5s are clearly indicative of dry

eye

BLINK RATE TEST In this test the person is asked to sit relaxed on a chair and fix the gaze at one point. The number of times a person blinks in a span of 3 minutes is recorded.

On an average a person blinks 10-12 times a minute . In diabetes, the Blink rate is decreased due to Perepheral Neuropathy and hence this leads to Dry Eye

LISAMINE GREEN B TEST

TEAR MENISCOGRAPHYTechnique to quantify height and volume of lower lid meniscus

NORMAL VALUE : 1mm

IT BECOMES THIN OR ABSENT IN DRY EYE

PROFORMA PROFORMA FOR THESIS Sr. No: Date: Name of Patient:- Date of birth:- Age/Sex/Occupation:- Address/Contact no.:- OPD number:- IPD number:- Chief Complaints:

H/O Glasses: H/O redness/discharge/pain/photophobia H/O ocular surgery/trauma/ocular disease H/O any systemic illness:

PAST HISTORYPERSONAL HISTORYFAMILY HISTORY

GENERAL EXAMINATIONTemp : Pulse Rate: B.P Respiratory Rate

OCULAR EXAMINATIONHEAD POSTUREFACIAL SYMMETRYVISUAL AXIS R.E L.EVision- Distant Near

EyebrowsLids/Lashes:-Conjunctiva:- ScleraCornea:-