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Oman Journal of Ophthalmology, Vol. 8, No. 3, 2015 151

Correspondence:

Dr. Suchi Vinod Shah, F-4, Teaching Staff Quarters, MVJ Medical College, Dandupalya, 30th Km Milestone, National Highway 4, Kolathur P.O., Hoskote,

Bengaluru - 562 114, Karnataka, India. E-mail: [email protected]

Copyright: 2015 Shah S and Jani H. This is an open-access article distributed under the terms of the Creative Commons Attribution License, whichpermits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Context: Dry eye is a very common as well asunder-diagnosed ocular disorder. It is not onlytroublesome in terms of its symptoms but also imposesa great financial burden.

Aims: To determine the prevalence of dry eye inophthalmology out-patients at a Tertiary Care Hospitaland its association with various clinico-epidemiological

factors.

Settings and Design: A hospital-based study at aTertiary Care Center was conducted including 400out-patients of age 40 years and above.

Materials and Methods: Patients were consecutivelyselected and underwent a routine ophthalmologicalexamination along with tear film break-up time (TBUT)as a screening tool for detecting the presence of dry eye.

Statistical Analysis: We performed a descriptive,univariate and multivariable logistic regression analysis

to calculate odds ratios and 95% confidence interval.

Results: The mean age of the study population was

58.6 years. The overall prevalence of dry eye was found

to be 54.3%. An association was found between dry eye

prevalence and outdoor workers, participants working

indoor using air conditioners, housewives, diabetics,

patients who have undergone previous ocular surgery

and those with meibomian gland dysfunction.

Conclusions: Dry eye is a very common condition with

a high prevalence among the elderly. We recommend

the screening of all out-patients by TBUT, which is

a simple test to perform and examination of lids for

meibomian gland disease, which if present can be

treated. Further studies are needed to establish uniform

diagnostic criteria for dry eye, which will help to get

more concrete prevalence data, as well as its etiological

factors.

Keywords: Dry eye, meibomian gland dysfunction, tear

film breakup time

Introduction

In 2007, the International Dry Eye Workshop (DEWS) revised

the original definition and classification scheme of dry eye

disease (DED) and developed a new definition based on aetiology,

mechanism, and severity of the disease. The term dry-eye syndrome

according to DEWS has been defined as “a multifactorial disease of

the tears and ocular surface that results in symptoms of discomfort,

visual disturbance, and tear-film instability with potential damage

to the ocular surface. It is accompanied by increased osmolarity

of the tear film and inflammation of the ocular surface”.[1] Dry eye

refers to disorders of the tear film due to reduced tear production

and/or excessive tear evaporation associated with symptoms of

ocular discomfort.[2]

Patients with dry eye often complain of pain, heaviness, foreign

body sensation, redness, photophobia and reflex watering due

to corneal irritation. Because the tear film in dry eye patients is

Original Article

Prevalence and associated factors of dry eye: Our experience

in patients above 40 years of age at a Tertiary Care Center

Suchi Shah, Harsha Jani

Department of Ophthalmology, Pramukhswami Medical College and Shree Krishna Hospital, Karamsad, Gujarat, India

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Shah and Jani: Prevalence and associated factors of dry eye

152 Oman Journal of Ophthalmology, Vol. 8, No. 3, 2015

unstable and incapable of maintaining the protective qualities that

are necessary for its structure and function, patients experience

the symptoms of discomfort associated with dry eye, which are

burning, stinging, grittiness, foreign body sensation, tearing,

ocular fatigue, and dryness. Patients may complain of symptoms

of dry eye in the presence or absence of signs of the disease.[3]

A more recent area of study in dry eye is the implications for visualfunction and its quality.[4] The decreased blink rate experienced

during visual function tasks (for example extended computer use,

reading, watching TV, working on microscope) can exacerbate

dry eye and its signs and symptoms (like blurred vision, ocular

surface staining, short tear film break-up time [TBUT]), which in

turn, can limit patients’ visual functioning capabilities.[5]

Materials and Methods

We conducted a cross-sectional study involving 400 patients who

visited the Ophthalmology Outpatient Department at a 600-bed

Rural Teaching Tertiary Care Center, with various complaints

which may or may not involve dry eye symptoms. Our studysample includes mixed population of both rural and urban areas.

We recruited our participants over a period of 2 months. Patients

of age 40 years and above were consecutively selected on 2 fixed

days of a week and administered a structured questionnaire. [6]

Patients with ocular surface infections, foreign body, extensive

ocular surface pathologies and those who had undergone an

ocular surgery within 2 months were excluded from the study.

The questionnaire included demographic, medical, lifestyle

data and symptoms[7] of dry eye such as dryness, grittiness,

burning, stickiness, heaviness, itching and watering.[8] The above

symptoms were found to be some of the leading and troublesome

ones as reported by previous studies and other validated

questionnaires.[9] The questionnaire was administered by a single

trained ophthalmology resident in vernacular language while the

ocular examination was carried out by an ophthalmologist. We

obtained a written informed consent from all our participants.

All participants underwent a general ophthalmic assessment along

with slit lamp examination and TBUT. TBUT was performed in all

participants by a single observer.

Tear film break-up time was used to assess the stability of the

precorneal tear film. It is a global marker for DED, easy and rapid

to perform.[10] It is considered to be a reliable and repeatable

test for dry eye and is minimally invasive.[11]

It is also correlatedwith the tear meniscus during normal blinking.[12] TBUT has

been reported to be low in different types of dry eye, including

keratoconjunctivitis sicca, mucin deficiency and meibomian

gland disease.[13] It was measured by applying fluorescein dye in

the inferior cul-de-sac followed by evaluating the stability of the

precorneal tear film.[14] Test was conducted at room temperature

with fans switched off, and all readings were taken by a single

observer. We performed this test by moistening a fluorescein

strip (Contacare Ophthalmics and Diagnostics, Baroda, India)

with sterile normal saline and applying it to the inferior fornix.

After several blinks, patient was instructed not to blink further,

and the tear film was examined using a broad beam of the slit lamp

with a blue filter. The time lapse between the last blink and the

appearance of the first randomly distributed dark discontinuity

in the fluorescein stained tear film was taken as the TBUT. TBUT

was measured before instillation of any eye drops. Patients with

TBUT < 10 s were diagnosed as having dry eye.

Statistical analysisA descriptive analysis was performed first, followed by a univariate

and multivariable logistic regression analysis. For the purpose of

analysis, the average of TBUT of both the eyes was considered.

The association between demographic variables, addictions,

systemic diseases (diabetes, hypertension and arthritis), dry eye

symptoms and DED was evaluated using Pearson Chi-squared

tests. For statistical analyses, commercially available software SPSS

for Windows (version 14.0; SPSS, Inc., Chicago, Illinois, USA)

was used. Multivariable analysis was performed to determine

the strength of association between dry eye and its contributing

factors. Using the logistic regression model, odds ratios (OR) and

95% confidence intervals were calculated for the same.

Results

Of the 417 consecutive patients, 400 patients agreed to participate

in the study (4% drop out rate). Mean age of the study population

was 58.6 years. Sample consisted of 52% females, and the majority

of them were housewives. Tobacco chewing was found to be the

most prevalent addiction among the study population (9%).

Table 1 represents the baseline characteristics of the study

population.

The overall prevalence of dry eye was found to be 54.3% of the

sample size of 400 participants of age 40 years and above. The

prevalence of dry eye was found to be maximum in the elderly.

It was 67.3% in participants aged 71 years and above. Fifty-one

percent males and 57.2% of females had dry eye disorder. This

depicts a higher prevalence of dry eye disorder among the female

population.

We assessed the prevalence of dry eye among various occupation

groups. Farmers and those doing outdoor jobs have the highest

prevalence of dry eye, which is 59.3% while those doing indoor

jobs without the use of air conditioners have the least prevalence

of dry eye [Table 2].

Our area of study is one of the key places for tobacco production

and the study population thus comprises of tobacco addicts either

in the form of chewing, snuffing or smoking. About 8.8% of the

population comprised of tobacco smokers while 11.3% consumed

tobacco in the form of chewing or snuffing. Sixty percent of the

smokers and tobacco chewers had dry eye.

The effect of systemic disorders like diabetes mellitus (mainly

type 2), hypertension and arthritis with dry eye was studied.



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Sixty-seven percent of the diabetic patients suffered from dry

eye. This is quite high as compared to the dry eye prevalence

in hypertensive patients (51%) and those suffering from

arthritis (55%).

We estimated the prevalence of dry eye among patients having

meibomian gland disease. Eighteen percent of the study population

had blocked meibomian glands, which were diagnosed on slitlamp examination. We found 95.1% prevalence of dry eye among

these patients. This highlights the importance of examination of

meibomian glands and associated lid disorders in routine patients.

Sample consisted of 6.3% glaucoma patients who were on various

topical antiglaucoma medications, out of which 72% had dry eye.

There were 23.5% patients who had undergone a previous

intraocular surgery (mostly cataract extraction). Out of them,

60.4% suffered from dry eye. Patients who had undergone surgery

within the last 2 months were excluded from the study.

Only two patients were soft contact lens users and both of them

had dry eye disorder.

The participants were asked if they had one or more of the dry

eye symptoms such as dryness, grittiness, burning, excess mucus,stickiness, heaviness, itching and watering. These symptoms were

compared with TBUT readings. Among the various symptoms

for which patients visited our Outpatient Department watering

was the most common complaint (33.5%) followed by itching

sensation (15%). Of the total study population, patients who

complained of dryness and excessive mucoid discharge had the

maximum prevalence of dry eye (82.6% and 87.5% respectively).

Of the patients who had dry eye, watering (41%) and

itching (19.8%) were the most common symptoms [Table 3].

Among the asymptomatic patients, 24.1% had dry eye. This

reflects the subclinical dry eye patients who later on may comeback with one or more of the dry eye symptoms.

A multivariable logistic regression analysis showed an association

between dry eye prevalence and outdoor workers, participants

Table 2: Prevalence of dry eye among various

occupation groups

Occupation Frequency

(n)

Percentage Dry eye

prevalence (%)

Indoor table work

without air conditioner

94 23.5 42.6

Indoor table work with

air conditioner

29 7.3 58.6

Outdoor jobs/

laborer/farmer

81 20.3 59.3

Housewife* 196 49.0 57

Total 400 100.0 54.3

*Females staying at home and performing various household chores

Table 1: Sociodemographic and clinical profile of

study population (n =400)

Variable Number ofsubjects

Percentageof total

Age distribution

40-50 years 103 25.8

51-60 years 130 32.5

61-70 years 122 30.5

71-80 years 38 9.5

81-90 years 7 1.8

Sex

Male 192 48

Female 208 52

Occupation

Indoor table work without air conditioner 94 23.5

Indoor table work with air conditioner 29 7.3

Outdoor jobs/laborer/farmer 81 20.3Housewife* 196 49

Systemic diseases

Diabetes 97 24.3

Hypertension 156 39

Arthritis 11 2.8

Addictions

Smoking 26 6.5

Tobacco chewing/snuffing 36 9

Smoking+tobacco chewing/snuffing 9 2.3

*Females staying at home and performing various household chores

Table 3: Presenting symptoms among dry eye

patients (n =217)

Symptom Number of patients Percentage

Watering 89 41

Itching 43 19.8

Heaviness 33 15.2

Burning 32 14.7

Stickiness 20 9.2Dryness 19 8.8

Grittiness 19 8.8

Excess mucus 7 3.2

Table 4: Multivariable logistic regression analysis

showing association of dry eye

Variable P OR 95% CI

Lower Upper

Occupation 0.067

Indoor work without

air conditioner

[Reference category]

Farmers/laborers/outdoors 0.026 2.087 1.093 3.985

Indoor table work with

air conditioner

0.179 1.876 0.750 4.697

Housewife 0.014 1.950 1.147 3.314

Diabetes (no/yes)* 0.001 2.272 1.369 3.771

Previous ocular surgery

(no/yes)*

0.080 1.565 0.948 2.582

Meibomian gland dysfunction

(no/yes)*

0.000 20.282 4.789 85.900

Constant 0.001 0.434

*First variable in parenthesis refers to the reference category. OR: Odds ratio,

CI: Confidence interval



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working indoor using air conditioner, housewives, diabetics,

patients who have undergone previous ocular surgery and those

with meibomian gland dysfunction (MGD) [Table 4].

Discussion

Dry eye prevalence as estimated in this study is around 54% in

patients visiting the Outpatient Department at a Tertiary CareCenter. Guillon et al.[15] have shown in a study in United Kingdom

that the tear film evaporation is significantly higher in subjects

above the age of 45 years. An intact and efficient lipid layer in

the tear film is required to prevent the evaporative loss of tear

film. This lipid layer is thinner and less efficient in older subjects

and particularly females. There is destabilization associated with

significant changes in the tear lipid layer leading to less protection

from evaporation in the older population.[16] These findings are

consistent with the previous studies by Shaumberg,[17] Moss

et al.[18] which emphasize an increased prevalence of dry eye in

the elderly, particularly women.

The prevalence of dry eye disorder had been very variable as found

from the previous population based as well as hospital-based

studies. Studies have reported the prevalence of dry eye to be

varying from 5% to as high as 73.5%.[19,20] In a survey conducted

by the American Academy of Ophthalmology, respondents

reported that around 30% of patients seeking treatment from

an ophthalmologist have symptoms consistent with DED.[21]

Another update from the international DEWS stated that the

global prevalence of dry eye is about 17% while several other

studies show a higher prevalence of approximately 30% in people

of Asian descent.[22] A retrospective study conducted at Miami

and Broward Veterans Affairs eye clinics estimated a prevalence

of 22% DED in females compared to 12% in males.[23] A studyconducted in Korea reported a prevalence of 33.2%.[24] The overall

prevalence of dry eye among patients of age 40 years and above

in our study population is 54.3% which is quite higher than that

found in other similar studies. This may reflect the effect of tropical

whether conditions in our area of study and other population

characteristics of the study population. Another reason for this

disparity among the reported prevalence among various studies

may be a lack of standardized diagnostic definition.

About 20% of our study population consisted of farmers and

laborers working in adverse environmental conditions for long

hours. They are exposed to excessive heat, sunlight, dust and

wind. Further, their exposure to fertilizers and insecticides

cannot be ignored. A poor economic condition as well as lack of

awareness in this group of people prevents them from adopting

protective equipment during work. We found the prevalence of

dry eye to be 59.3% in this study population. Khurana et al.[25]

too reported an increased risk of dry eye among farmers and

laborers (32% and 28% respectively of the dry eye patients)

probably due to excessive exposure to adverse environment. This

emphasizes the need for creating awareness among the farmers

to adopt protective measures during work. This might not

altogether prevent the incidence of dry eye, but this is will help

in delaying this condition and decreasing its severity. This also

generates a need for regular screening for dry eye in this group of

people who carry an immense burden of dry eye and are probably

underreported due to their ignorance toward health.

We found a prevalence of 67% dry eye among the diabetic

patients. This is consistent with a study conducted by Manaviat

et al. in Iran where 54.3% of the type 2 diabetic patients suffered

from dry eye syndrome.[26] Possible reason for this may be the

diabetic sensory or autonomic neuropathy or the occurrence of

microvascular changes in the lacrimal gland.[27]

Two patients of the sample were soft contact lens users and both of

them had dry eye. Both of these patients were regular contact users

with >10 h of lens usage every day. It has been found previously

that prelens tear film thinning time was most strongly associated

with dry eye followed by nominal contact lens water content and

refractive index. This, together with poor lens wettability, could be

a basis for a higher evaporative loss during contact lens wear and

was attributed to potential changes in tear film lipid composition.[28]

Seventy-two percent of the patients on topical antiglaucoma

medications (6.3%) had dry eye. Many components of eye

drop formulations can induce a toxic response from the ocular

surface. The most common offenders are preservatives such as

benzalkonium chloride, which causes surface epithelial cell

damage and punctuate epithelial keratitis. This interferes with

ocular surface wetting.[1] Thus, the use of preserved drops is an

important cause of dry eye in glaucoma patients. Possible solutions

to this problem would be shifting to nonpreserved antiglaucoma

drugs or simultaneous prescription of preservative free lubricants

in this group of patients.

We found the prevalence of dry eye to be as high as 95% in

patients with blocked meibomian glands (10.3%). As defined by

the international workshop on MGD, MGD is a chronic, diffuse

abnormality of the meibomian glands, commonly characterized by

terminal duct obstruction and/or qualitative/quantitative changes

in the glandular secretion. This may result in alteration of the tear

film, symptoms of eye irritation, clinically apparent inflammation,

and ocular surface disease.[29] Another study has found MGD as

the most common cause of evaporative dry eye.[30] Further, aging

is associated with the development of MGD, which in turn leads

to tear film instability and evaporative dry eye.

The prevalence of dry eye was found to be 60% among the smokers.

Previous studies have also related an increased prevalence of dry

eye among smokers.[31] The reason for this is not clearly known,

but smoking is indeed a suggested risk factor,[19] which needs to

be further verified and quantified.

Symptoms of burning sensation, dryness, and stickiness are

the most prevalent among dry eye patients. There have been a

few cases where the symptoms did not match our findings.

Asymptomatic patients or patients with very few symptoms were



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found to have dry eyes. We found the prevalence of dry eye to be

24.1% in asymptomatic patients. Nichols et al.[32] have reported

this problem too where there was a lack of correlation between

signs and symptoms of dry eye. This probably varies with patients’

awareness and sensitivity toward the symptoms.

The main limitation of this study is the use of fluorescein stain

for TBUT instead of noninvasive BUT. Fluorescein itself cansometimes be irritating and lead to reflex tearing. Another

drawback is that our study is a hospital-based study at a Tertiary

Care Center, which itself could increase the prevalence of any

disease condition compared to that conducted in the community.

This study reflects a major burden of DED among the routine

outpatients. Further, there is lack of data for the same in our region

of practice. Although a similar study was conducted in the state of

Rajasthan, it had a major drawback as its results were based purely

on univariate analysis.[33] This accounts for the need to gather more

data in this field to know the exact extent of DED in our country.

Thus, various contributing factors for dry eye are age, femalegender, outdoor jobs, tobacco consumption, diabetes mellitus,

meibomian gland disease, antiglaucoma medications and contact

lens use. These results should give motivation toward building up

a more systematic and targeted approach toward this issue as dry

eye is not just a burden on ocular health, but it is great economic

burden too. A survey reported that American consumers spend

over 100 million dollars per year toward lubricating eye drops.[34]

Le et al.[35] in a population-based cross-sectional study in China

reported an adverse impact on the vision-related quality of life as

well as an impairment on mental health in patients having various

dry eye symptoms. A good history and clinical examination can

help us to bring out this under-diagnosed condition and dealwith this situation more aggressively. Further studies need to be

undertaken to establish a universal diagnostic criterion, concrete

etiologic association and options to deal with the same.

Acknowledgment

We acknowledge Mr. Ajay Phatak and Mrs. Jaishree Ganjiwale for their

help in statistical analyses of the data.

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Cite this article as: Shah S, Jani H. Prevalence and associated factors of

dry eye: Our experience in patients above 40 years of age at a Tertiary Care

Center. Oman J Ophthalmol 2015;8:151-6.Source of Support: Nil, Conict of Interest: None declared.

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