Makkah Ophthalmic Technical

College

Prevalence of Dry Eye Syndrome among Patients with Diabetes

Mellitus at Makkah Eye Complex Khartoum – 2021

A Research Submitted in Fulfillment for Requirement for Bachelor Degree in

Ophthalmic Assistance

Prepared by:
Abdallah Mohamed
Ahmed Habib
Asmaa Abdulhakim
Eman Makki
Mohammed Abubakr
Rabha Abkar
Sherain Omer

Supervisor:
Dr.Shihab Hamadnlla
 Acknowledgment

We thanks God firstly, we express grateful thanks to the Makkah Ophthalmic Technical College
for offering us this favorable opportunity in a modern academic environment. We would like to
express us deep sincere appreciation and thanks to supervisor Dr. Shihab Hamadnalla for his
technical support which added a valuable academic to this study for kind follow-up and
supervision as well as encouragement Thank are extended to all those who helped us during this
study.

I
 Abstract
Background: Dry Eye Syndrome also known as Keratoconjutivitis Sicca. It is Diseases of ocular
surface that result due to tear deficiency excessive evaporative. Dry eye is condition produced by
the inadequate inter-relation between lacrimal film and ocular surface epithelium. Objective: To
determine the risk factors of dry eye syndrome among diabetic patients attending Makkah Eye
Complex and to determine the prevalence of dry eye syndrome. Methodology: retrospective cross
sectional hospital based study to estimate the prevalence of the dry eye syndrome at Makkah Eye
Complex in 2021. Analysis: Statistical data were analyzed using the Statistical Package for Social
Sciences (SPSS) version 22. Results: 80 patients were included in this study suffering from
different levels of dry eye syndrome. The majority of the sample were between the ages of 57-66
years old (25%) indicating that age is a factor when it comes to dry eye syndrome. The majority
of the sample were females (55%). 100% of the sample are diabetic. The majority (59%) use tabs
and (21%) use insulin injection as a way of controlling their glucose levels. Discussion: The
majority of the sample were between the ages of 57-66 years old (25%) indicating that age is a
factor when it comes to dry eye syndrome. The majority of the sample were females (55%) leading
the researchers to deduce that women are more likely to develop dry eyes. Previous studies showed
that hormonal changes caused by menopause, pregnancy and the use of oral contraceptives are a
factor in increasing dry eye syndrome. 100% of the sample are diabetic. The majority (59%) use
tabs and (21%) use insulin injection as a way of controlling their glucose levels. Conclusion:
Based on the study performed, dry eye syndrome is prevalent in the community of Makka Eye
Hospital where the majority of the participants suffered from a certain degree of dry eye syndrome.
The majority of the participants suffered from diabetes. The majority of the participants suffering
from DES were women also in accordance to previous studies. Recommendations: Researchers
recommend creating workshops to increase knowledge regarding the prevalence of dry eye
syndrome and establishing an environment that fosters training and creates programs for
individuals to easily and cheaply test for dry eye syndrome. In addition, further research should be
done due to the visible prevalence of dry eye syndrome in Makkah Eye Hospital

II
 Table of Contents
Title Page No.
Acknowledgement I
Abstract II
Table of Contents III
List of Figures IV
List Abbreviations V
Objective VI
Justification VII
CHAPTER ONE
Introduction 1
CHAPTER TWO
Literature Review 3
CHAPTER THREE
Methodology 6
CHAPTER FOUR
Results 7
CHAPTER FIVE
Discussion 12
CHAPTER SIX
Conclusion 13
Recommendations 13
References 14

III
 List of Figure
Title Page No.
Figure (1). Age 7
Figure (2). Sex 8
Figure (3). Type of medication 9
Figure (4). Right Eye Visual Acuity 10
Figure (5). Left Eye Visual Acuity 11

IV
 List of Abbreviations
DCR Dacryocystorhtinostomy
DES Dry eye syndrome
DM Diabetes mellitus
DMDES Diabetes Mellitus Associated Dry Eye Syndrome
DR Diabetic Retinopathy
LFU Lacrimal function unit
NPDR Non Proliferative Diabetic Retinopathy
OSDI Ocular Surface Disease Index
PDR Proliferative Diabetic Retinopathy
SLB Slit- Lamp Bio microscopy
TBUT Tear Break Up Time

V
Objective:
To study the prevalence of dry eye syndrome among diabetic patients at Makkah Eye
Complex Khartoum 2021

VI
Justification:

• High prevalence of dry eye syndrome was recognized among patients presented Makkah
Eye Complex Khartoum, should be estimated scientifically

VII
Chapter One
 Introduction

Dry Eye Syndrome also known as Keratoconjutivitis Sicca. It is Diseases of ocular surface that
result due to tear deficiency excessive evaporative.[1]
Dry eye is condition produced by the inadequate inter-relation between lacrimal film and ocular
surface epithelium.[2]
Dry eye is a common seen with increased prevalence in patients with autoimmune disease and in
the elderly [3].

• Causes of Decreased tear production:

1. Aging is directly associated with a reduction in lipid production, resulting in evaporative

dry eye.
2. Excessive use of contact lens absorb the tear film, and rub against the conjunctive in the
eyelids.
3. Medication many medications can cause or exacerbate dry eye symptoms.
e.g. (antihistamines, antidepressant, beta-blockers, diuretics).
4. corneal nerves sensitivity caused by neurotropic changes has been documented in patients
with herpes simplex keratitis, diabetes and after refractive surgery.[4]

Dry eye symptoms may be a manifestation of a systemic disease, therefore timely detection
may lead to recognition of a life-threatening condition. Additionally, patients with dry eye are
prone to potentially blinding infections, such as bacterial keratitis. In addition, at an increased risk
of complications following common procedures such as laser refractive surgery. [5]

• Increase tear evaporative:

1. Posterior Belphraitis
2. Blinking less often
3. Eye lid problem
4. Radiation (orbit) therapy.
5. Smoking.[6]

Major causes of dry eye syndrome

Dry eyes can develop for many reasons, including:

1
Age: Dry eyes are a part of natural aging process. The majority of people over age 65 experience
some symptoms of dry eye.
. Gender. Women are more likely to develop dry eyes due to hormonal changes caused by
pregnancy, the use of oral contraceptives and menopause.
. Medications: Certain medicines including antihistamines, decongestants, blood pressure
medications, and antidepressants can reduce tear production.
. Medical conditions: People with rheumatoid arthritis, diabetes, and thyroid problems are more
likely to have symptoms of dry eyes also. Problems with inflammation of the eyelids (blepharitis),
inflammation of the surfaces of the eye, or the inward or outward turning of eyelids can cause dry
eyes to develop.
. Environmental conditions: Exposure to smoke, wind and dry climates can increase tear
evaporation resulting in dry eye symptoms. Failure to blink regularly, such as when staring at a
computer screen for long periods, ca also contribute to drying of the eyes.
. Other factors: Long-term use of contact lenses can be a factor in the development of dry eyes.
Refractive eye surgeries, such as LASIK, can decrease tear production and contribute to dry eyes[6]

Classification of Dry Eye Syndrome:

DES was recognized as a lacrimal function unit (LFU) dysfunction disease by the International
Dry Eye Workshop in 2007. The LFU, which protects and maintains the tear film and normal
function of the ocular surface, is composed of “the cornea, conjunctiva, lacrimal gland, meibomian
gland. Lids, and the sensory and motor nerves that connect them"[7]
Human tear film comprises three layers: lapid (secreted by the meibomian gland), aqueous
(secreted by the lacrimal gland), and mucin (secreted by conjunctiva, cornea, lacrimal gland, and
other structures). These three layers contain enzymes, signaling molecules, and metabolites and
are essential in maintaining the physiological function of the ocular surface. The 1995
NEI/Industry Dry Eye Workshop identified two types of DES: aqueous tear-deficient (tear-
deficient, lacrimal tear deficiency) and evaporative dry eye. Aqueous-deficient dry eye has two
major subgroups. Sjögren and non-Sjögren syndrome. Evaporative dry eye may be intrinsic (e.g.
due to meibomian gland dysfunction, eyelid problems, or low blink rate) or extrinsic (e.g. due to
vitamin A deficiency, preservatives in topical medications, contact lens wear. or diseases of the
ocular surface) DM associated dry eye may be tear-deficient or evaporative dry eye [8]

2
Diagnosis:

Diagnosing the DES starts with a good clinical history and proceeds to an applicable systemic
physical examination, a complete ocular and slit-lamp tests.

Prevention of Dry Eye Syndrome:

Besides using eye drops or ointment, there are several simple ways to help prevent dry eyes.
These include:
Avoid places with a lot of air movement: This means limiting your exposure to fans and hair
dryers and by wearing wraparound sunglasses when outside on windy days to protect your eyes
from drying out [9].

3
Chapter Two
 Literature review
In a population- based prevalence study of individuals 65 years of age or older, 14.6 percent
of 2.482 patients reported symptoms suggestive of dry eye. Extrapolating these numbers to the US
population suggests there are 4.3 million Americans with dry eye Yet, the condition remains
remarkably under diagnosed [10]
Diabetes mellitus (DM) has been identified as one of the leading systemic risk factors for
DES. The reported prevalence of DES in diabetics is 15-33% in those over 65 years of age and
increases with ageandis 50% more common in women than in men [11]
The incidence of dry eye is correlated with the level of glycated hemoglobin: the higher
the level of glycated hemoglobin, the higher the incidence of dry eye [12]
The Beaver Dam Eye Study reported that approximately 20% of dry eyes occurred in
individuals with Type 2 diabetes aged between 43 and 86 years. Hom and De Land reported that
53% of patients with either diabetes or borderline diabetes had self –reported, clinically relevant
dry eyes [13]
Significant association have been identified between diabetic retinopathy (DR) and DES.
In a hospital-based study, 17.1% DES in patients with DM was found to have mild non
proliferative diabetic retinopathy (NPDR), 17.1% had moderate NPDR, 11.1% had severe non
proliferative diabetic retinopathy (NPDR) and 25.1% had proliferative diabetic retinopathy
(PDR)[13]
DR is also associated with a decrease in tear film function. Tear break-up time (TBUT)and
Schimer’s test values were significantly decreased in the PDR group compared to the non-DR
group while corneal fluorescein staining scores positive rate of rose Bengal staining the surface
regularity index ,and the surface asymmetry index were increased .The concentrations of
lactoferrin and tear-specific Prealbumin were decreased in the DR group [14]

Another hospital –based study showed that DES is more prevalent in individuals with DR
and/or clinically significant macular edema (P=0.006) compared to the non-DR group .the odds
of DR in DES were 2.29(Cl=1.16-4.52=0.016) and both DES and retinopathy were associated with
HbA 1c[15]
DM has been identified as one of the leading systemic risk factors for DES type 2 diabetes;
which accounts for nearly 90% of diabetes worldwide increasing in both developed and developing
counties .Ocular surface disease in diabetes is characterized by reduced corneal sensitivity and by

4
alteration in tear quantity and quality. Diabetic patients might exhibit dry eye symptoms probably
due to neuropathy, metabolic dysfunction, or abnormal lacimal secretions
Damage to the microvasculature of the lacrimation in persons who suffer 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 keratoconjuntivitis sicca [16]
In a recent natural history, study of dry eye, blurred vision was reported as moderate to very severe
in 58% of dry eye patients compared with only 10.5% in normal controls. Although there are many
reports of decreased visual quality of life and symptoms in dry eye patients compared to controls,
7, 12 there is little information surrounding which specific dry eye signs contribute to diminished
visual functions [17]
In WESDR, the incidence of macular edema after 10 years of development is of 20% in patients
with diabetes mellitus Type I, 25.4% in patients with Type II diabetes insulin resistant and 13.9%
of the patients with diabetes mellitus Type II without insulin requirements.
This study showed that the incidence of macular edema also increased with the severity of
retinopathy in both Type I diabetes and in Type II [18]

5
Chapter Three
 Methodology
 Study Type:

Retrospective cross-sectional study

 Sample size:

A convenient participants size was found to be 80 cases

 Study area:

Makkah Eye Complex Khartoum

 Population:

All diabetic patients attending retina clinic at Mekka Eye Complex

 Sampling technique:

Simple random selection

 Statistical Analysis:
The data was organized into a master sheet, and entered into a computer running the Statistical
Package for Social Sciences (SPSS) Version 22. Cross tabulation and descriptive analysis was
used to form relationships between variables.

 Study duration :

25th November to 30 st December

 Data collection:

From patient’s medical records.

6
Chapter Four
 Results

Age Distribution

25%

21.25%

15%
12.5%
11.25%
8.75%
6.25%

17.00-26.00 27.00-36.00 37.00-46.00 47.00-56.00 57.00-66.00 67.00-76.00 77.00-86.00

Figure (1). Age

Figure (1) shows the distribution of the participants according to their age where (12.5%) were
between the ages of 17-26, (6.25%) were between the ages of 27-36, (11.25%) were between the
ages of 37-46, (21.25%) were between the ages of 47-56, (45%) were between the ages of 57-66,
(15%) were between the ages of 67-76 and (8.75%) were between the ages of 77-86

7
 Gender
55%

45%

Male Female

Figure (2). Gender

Figure (2) shows the distribution of the participants according to gender. 45% of the participants
were male and 55% of the participants were female.

8
 Distribution of the participants according to the type of
medication they are taking
73.8%

26.3%

Insulin Tab

Figure (3). Type of Medication

Figure (3) shows the distribution of the participants according to the type of medication they are
taking. 73.8% of the participants identified as taking tabs as a medication for their diabetes and
26.3% of the participants identified as taking insulin

9
 Distribution of the Participants According to the Vision
Acuity of the Right Eye
22.5%

18.8%

15% 15% 15%

10%

3.8%

6 9 12 18 24 36 60

Figure (4). Right Vision Acuity

Figure (4) show the distribution of the participants according to their vision acuity of the right eye.
22.5% of the participants had a vision acute of 6/6, 10% of the participants had a vision acute of
6/9, 18.8% of the participants had a vison acute of 6/12, 3.8% of the participants had a vison acute
of 6/18, 15% of the participants had a vison acute of 6/24, 15% of the participants had a vison acute
of 6/36, 15% of the participants had a vison acute of 6/60

10
 Distribution of the participants According to the Vision
Acuity of the Right Eye

21.3%
20%
17.5% 17.5%

13.8%

7.5%

2.5%

6 9 12 18 24 36 60

Figure (5). Left Eye Vision Acuity

Figure (5) shows the distribution of the participants according to the vision acute of the left eye
where 13.8% of the participants had a vision acute of 6/6, 21.3% of the participants had a vision
acute of 6/9, 17.5% of the participants had a vison acute of 6/12, 2.5% of the participants had a
vision acute of 6/18, 20% of the participants had a vison acute of 6/24, 17.5% of the participants
had a vison acute of 6/36, 7.5% of the participants had a vison acute of 6/60

11
Chapter Five
 Discussion

The DES is a disorder of tear film, which could cause tear deficiency of excessive tear evaporation,
which in turn causes damage to the ocular surface and leads to symptom of ocular discomfort.
Various studies had previously reported an increase in incidences of DES in diabetics. The study
was done on 80 patients using patient’s record data. 31.25 % of all diabetic patients complained of
mild DES, 37.5% complained of moderate DES and 31.25% complained of severe DES. In
accordance with previous studies, the research deduced that Dry Eye Syndrome is more prevalent
in women where this research deduced that 55% of the participants were women suffering from
Dry Eye Syndrome in comparison to only 45% of men, which was in accordance with the NICECK
study. In accordance with the NICECK study, DES in diabetics was 25% higher in patients over
65 years of age. 73.8% of the participants used tabs and 26.3% of the participants used insulin
injections to control their diabetes. The American Academy of Ophthalmology stated that the
incidence of macular edema increased with the severity of retinopathy in both Type I and Type II
diabetes which was in line with the results of this study where the majority of the sample was over
65 years of age and have been suffering with diabetes for well over 10 years. In the study: “The
Progression of Ocular Findings, Natural History of Dry Eye” 58% of the sample exhibited
moderate to severe forms of blurred vision which was not in accordance with this study where the
majority of the sample exhibited mild forms of dry eye (52.6%) for the Right eye and (51.3%) for
the left eye.

12
Chapter Six
 Conclusion

Based on the study performed, dry eye syndrome is prevalent in the community of Makkah
Eye Hospital where the majority of the participants suffered from a certain degree of dry
eye syndrome. The majority of the participants suffered from diabetes. The majority of the
participants suffering from DES were women also in accordance to previous studies.

 Recommendations:

o Workshops to increase knowledge regarding the prevalence of dry eye syndrome

o Further research should be conducted on the prevalence of dry eye syndrome in

Makkah Eye Complex - Khartoum

13
 References:

1. Dalton .K.N(2010) the investigation of tear film osmolality as a clinical instrument used in
Assessments of the tear film and Dry Eye Disease (master’s thesis University of Waterloo)
2. Murube J. Benitez del Castillo JM, ChenZhuo L Bena A, Rolando M. The Madrid triple
classification of dry eye. Arch Soc ESpan Oftalmol 2003; 78:587-94
3. Fox RI, Howell FV. Bone RC, Michelson P. Primary Sjogren’s syndrome: Clinical and
immunopathologic features. Sem Arth Rheumatol 1984;14:77-105.
4. Schein OD, Munoz B. Tielsch JM, et al. Prevalence of dry eye among the elderly.Am J
ophthalmol 1997; 124:723-80.
5. Rolando . Refojo .M fKenyon K.R(1983) Increased tearevaporation in eyes with
keratoconjunctivits sicca Archives of ophthalmology. 101(4) 557-558.
6. Mohammad Ali Javadi, MD and Sepehr Feizi, MD, Dry Eye Syndrome, 2011 Jul; 6 (3) :
192-198.
7. G. Rieger, The importance of the precorneal tear film for the quality of optical imaging,
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WorkShop (2007), The Ocular Surface, vol. 5, no. 2, pp. 179193, 2007.M. Gekka,
K.Miyata, Y. Nagai et al., “Corneal epithelial barrier function in diabetic patients,” Cornea,
vol. 23, no. 1, pp. 35–37, 2004.
9. Lemp MA, Baudouin C, BaumJ, DogruM, Foulks GN, Kinoshits S et al. The difinition and
classification of dry eye disease:report of the definition and classification Subcommittee
of the International Dry Eye Workshop. Ocul Surf 2007;5(2) :75-92.
10. Schein OD, Munoz B. Tielsch JM, et al. Prevalence of dry eye among the elderly.Am J
ophthalmol 1997; 124:723-80.
11. Rolando . Refojo .M fKenyon K.R(1983) Increased tearevaporation in eyes with
keratoconjunctivits sicca Archives of ophthalmology. 101(4) 557-558.
12. Mohammad Ali Javadi, MD and Sepehr Feizi, MD, Dry Eye Syndrome, 2011 Jul; 6 (3) :
192-198.

14
13. Dry eye syndrome , NICECK,September 2012(UKaccess only ).
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