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 55.6ꢀ± 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  
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.  
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  
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.  
Correspondence to: Munir Amjad Baig  
Azad Jammu Kashmir Medical College, Muzaffar Abad  
E-mail: drmuniramjad@gmail.com  
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  
Received: February 9, 2020  
Accepted: May 4, 2020  
Revised: May 4, 2020  
Pakistan Journal of Ophthalmology, 2020, Vol. 36 (3): 221-225  
221  
Munir Amjad Baig, et al  
dysfunction.  
Human  
cornea  
contains  
both  
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.  
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.  
Suspected dry eyes based on symptoms like ocular  
A review of the literature showed that DED was  
present in more than half of diabetic patients.  
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.  
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.  
RESULTS  
A total of 400 type 2 Diabetic patients of varying  
duration, age ranging from 38-78 years, mean age  
55.6ꢀ± 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.  
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.  
Table 1: Baseline characteristics (n = 400) 38 – 78 years.  
Demographics  
Age group (years)  
38 – 47  
Respondents  
(%)  
98  
127  
104  
71  
24.5%  
31.7%  
26%  
17.8%  
100%  
48 – 57  
58 – 6 7  
68 or above  
Total  
400  
Sex  
Male  
Female  
Urban  
Rural  
Family history  
Smokers >5 years  
Glasses  
246  
154  
281  
119  
136  
111  
82  
61.5%  
38.5%  
70.2%  
29.8%  
34%  
28%  
20.5%  
35.2%  
Computer users  
141  
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%  
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  
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Pakistan Journal of Ophthalmology, 2020, Vol. 36 (3): 221-225  
Dry Eye Disease and Diabetes Mellitus  
Table 2: Dry eye symptoms after smoking.  
were on insulin and 16.5%  
were on both. 34% 136  
patients had positive family  
history of diabetes.  
Symptoms  
Burning/dryness  
F.B. sensations  
Redness  
Never  
89  
92  
108  
122  
120  
Rarely  
54  
90  
Sometimes  
Often All the Time  
% age  
51%  
40.5%  
33.5%  
28.2%  
23%  
53  
56  
67  
61  
56  
75  
69  
58  
68  
53  
129  
93  
76  
45  
91  
The most common  
Watering  
Discharge  
104  
132  
39  
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  
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%)  
Normal  
(n=168) 21 (12.5%) 48 (28.5%)  
77 (33.1%)  
33 (19.6%)  
86 (37%)  
8 (5%)  
117 (50.4%)  
20 (11.1%)  
Table 4: DED related to duration of diabetes.  
Duration  
Total No.  
89  
Dry Eyes  
% Frequency  
38.2%  
1 – 5 years  
6 – 10 years  
11 – 15 years  
16 – 20 years  
Total  
34  
63  
81  
54  
232  
117  
(50.4%)  
had  
110  
130  
71  
400  
57.2%  
62.3%  
76%  
58%  
telengiectasias and plugging  
of Meibomian openings  
and/or mucous threads.  
Decreased tear film function  
was found in patients with  
DR than in those with non-DR.  
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.  
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.  
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.  
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.  
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  
Majority of our subjects were in the age group of  
Pakistan Journal of Ophthalmology, 2020, Vol. 36 (3): 221-225  
223  
Munir Amjad Baig, et al  
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.  
Conflict of Interest  
Authors declared no conflict of interest  
Author’s Designation and Contribution  
Munir Amjad Baig; Associate professor: Study design,  
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.  
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. Am J Ophthalmol. 2007; 143 (3): 409–  
415.  
3. Cheema A, Aziz T, Mirza SA, Siddiqi A,  
Maheshwary N, Khan MA. Sodium Hyaluronate eye  
drops in the treatment of dry eye disease: An open  
label, uncontrolled, multicentre trial. J Ayub Med Coll  
Abbottabad, 2012; 24 (3-4).  
4. Le Q, Zhou X, Ge L, Wu L, Hong J, Xu J. Impact of  
dry eye syndrome on vision-related quality of life in a  
non-clinic-based general population. BMC Ophthalmol.  
2012; 12: 22.  
5. Ahmed AM. History of diabetes mellitus. Saudi Med J  
2002; 23: 373-8.  
6. Liu H., Sheng M., Liu Y., et al. Expression of SIRT1  
and oxidative stress in diabetic dry eye. International  
Journal of Clinical and Experimental Pathology, 2015;  
8 (6): 7644–7653.  
7. Fuerst N, Langelier N, Massaro-Giordano M, Pistilli  
M, Stasi K, Burns C, et al. Tear osmolarity and dry  
eye symptoms in diabetics. Clin Ophthalmol. 2014; 8:  
507–515.  
8. Manaviat MR, Rashidi M, Afkhami-Ardekani M,  
Shoja MR. Prevalence of dry eye syndrome and  
diabetic retinopathy in type 2 diabetic patients. BMC  
Ophthalmol. 2008; 8: 10. Doi: 10.1186/1471-2415-8-  
10.  
9. Najafi L, Malek M, Valojerdi AE, Aghili R,  
Khamseh ME, Fallah AE, et al. Dry eye and its  
correlation to diabetes microvascular complications in  
people with type 2 diabetes mellitus. J Diabetes  
Complicat. 2013; 27: 459–462.  
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.  
10. WHO Diabetes Geneva Switzerland: World Health  
Organization, 2016. [cited 2016 January 14]. 1--  
Available. --from:  
Ethical Approval  
The study was approved by the Institutional review  
board/Ethical review board.  
http://www.who.int/diabetes/facts/world_figures/en/ind  
ex2.html  
224  
Pakistan Journal of Ophthalmology, 2020, Vol. 36 (3): 221-225  
Dry Eye Disease and Diabetes Mellitus  
11. Meo SA, Zia I, Bokhari IA, Arain SA. Type 2  
diabetes mellitus in Pakistan: Current prevalence and  
future forecast. J Pak Med Assoc. 2016; 66 (12): 1637-  
1642.  
12. Beckman K. A. Characterization of dry eye disease in  
diabetic patients versus non-diabetic patients. Cornea,  
2014; 33 (8): 851–854.  
13. Misra SL, Craig JP, Patel DV, McGhee CN,  
Pradhan M, Ellyett K, Kilfoyle D, Braatvedt GD. In  
vivo confocal microscopy of corneal nerves: an ocular  
biomarker for peripheral and cardiac autonomic  
18. Zhang X, Zhao L, Shijing Deng S, Xuguang Sun X,  
and Ningli Wang N. Dry Eye Syndrome in Patients  
with Diabetes Mellitus: Prevalence, Etiology, and  
Clinical Characteristics. J Ophthalmol. 2016: Article ID  
8201053, 7 pages.  
19. Gupta P. K. Vickers L. A. The future of dry eye  
treatment: a glance into the therapeutic pipeline.  
Ophthalmology and Therapy, 2015; 4 (2): 69–78.  
20. Messmer EM, von Lindenfels V, Garbe A, Kampik  
A. Matrix metalloproteinase 9 testing in dry eye disease  
using  
a
commercially available point-of-care  
immunoassay. Ophthalmology, 2016; 123: 2300–2308.  
21. Ang L, Jaiswal M, Martin C, Pop-Busui R. Glucose  
control and diabetic neuropathy: lessons from recent  
large clinical trials. Curr Diab Rep. 2014; 14: 528.  
22. Rema M, Premkumar S, Anitha B, Deepa R,  
Pradeepa R, Mohan V. Prevalence of Diabetic  
Retinopathy in Urban India: The Chennai Urban Rural  
Epidemiology Study (CURES) Eye Study. Invest  
Ophthalmol Vis Sci. 2005; 46: 2328–2333.  
23. Imam S, Elagin RB, Jaume JC. Diabetes-associated  
dry eye syndrome in a new humanized transgenic  
model of type 1 diabetes. Molecular Vision, 2013; 19:  
1259–1267.  
24. Nakata M., Okada Y., Kobata H, Shigematsu T,  
Reinach PS, Tomoyose K, Saika S. Diabetes mellitus  
suppresses hemodialysis-induced increases in tear fluid  
secretion. BMC Research Notes, 2014; 7 (1): 78.  
25. Zia A, Bhatti A. Prevalence of type 2 diabetes–  
associated complications in Pakistan. Int J Diabetes  
Dev C. 2016; 36 (2): 179–188.  
neuropathy in type  
1 diabetes mellitus. Invest  
Ophthalmol Vis Sci. 2015; 56 (9): 5060–5065.  
14. Achtsidis V, Eleftheriadou I, Kozanidou E,  
Voumvourakis K, Stamboulis E, Theodosiadis PG,  
et al. Dry eye syndrome in subjects with diabetes and  
association with neuropathy. Diabetes Care, 2014; 37  
(10): e210–e211.  
15. Chia EM, Mitchell P, Rochtchina E, Lee AJ,  
Maroun R, Wang JJ. Prevalence and associations of  
dry eye syndrome in an older population: the Blue  
Mountains Eye Study. Clin Exper Ophthalmol. 2013;  
31 (3): 229-232.  
16. Liu NN, Liu L, Li J, Sun YZ. Prevalence of and risk  
factors for dry eye symptom in mainland china: a  
systematic review and meta analysis. J Ophthalmol.  
2014; 2014: 748654.  
17. Chen L, Magliano DJ, Zimmet PZ. The worldwide  
epidemiology of type 2 diabetes mellitus–present and  
future perspectives. Nat Rev Endocrinol. 2012; 8: 228–  
236. Doi: 10.1038/nrendo.2011.183.  
.…….  
DEQ 6  
1. Do your eyes ever feel dry?  
2. Do you ever feel a gritty or sandy sensation in your eye?  
3. Do your eyes ever have a burning sensation?  
4. Are your eyes ever red?  
5. Do you notice much crusting on your lashes?  
6. Do your eyes ever get stuck shut in the morning?  
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'.  
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