|Year : 2016 | Volume
| Issue : 2 | Page : 42-45
A hospital-based study to estimate the proportion of dry eye cases among patients attending the Tertiary Care Hospital, Gangtok, Sikkim
Karma Loday Bhutia, Neiwete Lomi
Department of Ophthalmology, Sikkim Manipal Institute of Medical Sciences, Gangtok, Sikkim, India
|Date of Web Publication||17-Jan-2017|
Karma Loday Bhutia
Department of Ophthalmology, Sikkim Manipal Institute of Medical Sciences, Gangtok, Sikkim - 737 102
Purpose: Dry eye is major tear deficiency disorder affecting millions of people worldwide. Materials and Methods: A cross-sectional study was conducted in the Ophthalmology Department, Central Referral Hospital, Gangtok, Sikkim. Seven hundred random patients fulfilling the inclusion criteria were examined in the eye outpatient department after informed consent. Results: Eighty-nine patients (12.7%) were found to have dry eye based on McMonnies-HO questionnaire, Schirmer's test, and tear film breakup time. There were 62 females and 27 males with dry eye. Female to male ratio was 2.3:1. The age of patients with dry eye ranged from 31 to 79 years. Conclusion: On analysis of symptoms that the patients presented, most common symptoms seen were dryness and grittiness.
Keywords: Dry eye, keratoconjunctivitis sicca, McMonnies-HO questionnaire, Schirmer′s test, tear film break-up time
|How to cite this article:|
Bhutia KL, Lomi N. A hospital-based study to estimate the proportion of dry eye cases among patients attending the Tertiary Care Hospital, Gangtok, Sikkim. Sudanese J Ophthalmol 2016;8:42-5
|How to cite this URL:|
Bhutia KL, Lomi N. A hospital-based study to estimate the proportion of dry eye cases among patients attending the Tertiary Care Hospital, Gangtok, Sikkim. Sudanese J Ophthalmol [serial online] 2016 [cited 2017 Dec 13];8:42-5. Available from: http://www.sjopthal.net/text.asp?2016/8/2/42/198534
| Introduction|| |
Dry eye is a major tear deficiency disorder that affects millions of people worldwide.  It causes chronic ocular irritation and is significantly distressing for the patient and ophthalmologist which is often overlooked and remains underdiagnosed. Also known as keratoconjunctivitis sicca (KCS), it is a multifactorial disease of the tear film and the ocular surface, caused by reduced tear production or excessive tear evaporation resulting in discomfort, visual disturbance, and tear film instability with a potential damage to the ocular surface. The normal tear film consists of three layers. The outer superficial layer is the lipid layer, produced by the meibomian glands. Its function is to limit evaporation of the tear film, allow smooth frictionless movement of lids, prevent contamination of tears, and stabilize the tear film. The middle layer is the aqueous layer. It constitutes over 90% of the tear film and is produced by the lacrimal gland and accessory lacrimal glands of Wolfring and Krause. The innermost layer of the cornea is the mucin layer which is produced by the goblet cells. It lowers the surface tension and renders the corneal surfaces wet. Different diseases affect the different layers of tear film, clinically causing dry eye or KCS. Dry eye conditions have been classified into two main categories: (1) Aqueous tear-deficient dry eye (ATDDE) due to deficiency of lacrimal gland to produce tears and (2) evaporative dry eye (EDE) due to excessive evaporation of tears. ATDDE includes Sjogren's syndrome (SS) dry eye and non-SS dry eye. EDE includes ocular surface disorders, meibomian gland dysfunction, low blink rate. Dry eye is also significant in diabetes mellitus, due to decreased corneal sensitivity, neuropathy of lacrimal gland, and loss of goblet cells.  Dry eye syndrome can lead to vision-threatening complications; therefore, early diagnosis is important.  Symptom assessment plays a large role in the diagnosis of dry eye.  A number of diagnostic tests have been performed to establish the diagnosis of dry eye such as the. We selected McMonnies and HO questionnaire as our screening test as it is a well-balanced and focused test. It allowed us to pinpoint the source of aggravating environmental factors when the symptoms occur occasionally. It has sensitivity reportedly varying 87-98% and specificity 87-97%.  Still, the correlation between subjective complaints and objective symptoms is not satisfyingly reliable. A study done by Nichols KK showed that clinical tests such as Schirmer's test assist in the final diagnosis and make it more objective.  Tear film break-up time (TBUT) is a test, in which tear film is stained with sodium fluorescein 1% and is observed with a slit-lamp, and time is noted for the first appearance of a "dark" dry spot which is recorded as the TBUT. Thus, we used Schirmer's test and TBUT for diagnosis of dry eye and comparison with questionnaire-based results as our tool of investigation. Our study used McMonnies questionnaire along with Schirmer's test and TBUT to evaluate the proportion of dry eye patients in Gangtok and create awareness among people regarding its early prevention and treatment.
| Materials and Methods|| |
A cross-sectional study was conducted in the Department of Ophthalmology, Central Referral Hospital (CRH), Gangtok, Sikkim. The duration of the study was from February 2015 to February 2016 with approval from the Institutional Ethics Committee. Seven hundred patients attending the eye outpatient department (OPD) (CRH) fulfilling the inclusion criteria were selected for the study. Written informed consent was obtained from each subject before the study.
All patients of age 18 years and above were included in this study.
Patients with active ocular infection and those on topical medications or had undergone intra- or extra-ocular surgery in the previous 6 months were excluded from the study.
Procedures for assessing the dry eye
The subjects were asked to fill McMonnies and HO questionnaire.  The McMonnies and HO questionnaire had 12 questions that focused on the clinical risk factors for dry eye. These domains were derived from literature and included age, gender, dry eye symptoms (namely, itching, burning, foreign body sensation), feeling of dryness and tiredness, previous treatment for dry eye, secondary symptoms (associated with environmental stimuli), systemic diseases, dryness of mucous membranes, and systemic medications.
Scoring of the dry eye
A scoring system was used from 0 to 40. Scores above 20 were consistent with the diagnosis of dry eye. Scores between 10 and 20 indicated borderline dry eye problems. Scores below 10 indicated no dry eye. The maximum possible score was 40.
Procedure of Schirmer's test
All patients were then subjected to detailed slit-lamp examination and tear film assessment by Schirmer's basic secretion test using Schirmer's strips. Strips were placed in the lower fornix of both eyes at the junction of lateral one-third and medial two-third of the eyelid for a span of 5 min. After 5 min, the extent of wetting of the filter paper strip was recorded. A value of <10 mm wetting was taken as an indicator of dry eye.
Procedure of tear film break-up time
Tear film is stained by sodium fluorescein 1% and is observed with a slit-lamp under cobalt blue light, and time taken for the first appearance of a "dark" dry spot is recorded as the TBUT or TBUT. Time <10 s is suggestive of a dry eye.
Diagnosis of dry eye
It was done with positive Schirmer's test (wetting <10 mm) and TBUT of <10 s along with McMonnies score more than 20. Data were noted on a standardized pro forma.
| Results|| |
[Figure 1] and [Figure 2] represent the number of patients with dry eye cases. It was found that out of 700 patients, 89 patients (12.7%) were classified to have dry eye based according to dry eye diagnosis criteria and a majority of 87.3% were normal. The age of patients with dry eye ranged from 31 to 79 years, with a peak above 50 years. [Figure 3] represents the distribution of genders among the patients with dry eye and it was seen that there were 62 females and 27 males with dry eye with the ratio of 2:3 (female:male).
[Table 1] represents the list of symptoms reported by patients with dry eye. On analysis of symptoms that the patient presented, most common symptoms seen were dryness and grittiness.
| Discussion|| |
Dry eye tends to be ignored as a disease entity because of the vast array and nonspecificity of symptoms. The prevalence of dry eye in the general population is still not precisely known.  The prevalence of dry eye has a wide variation. It is due to the use of different dry eye diagnostic methods and tests. The proportion of dry eye patients diagnosed in our study is well below the expected range of the previous studies. This may be probably due to the climate and geographical factor in this region. The cool and dust-free environment may be the reason for low proportion of dry eye patients in this region.
Sikkim is a small Himalayan state in the Northwest India, bordered by Bhutan, Tibet, and Nepal. Part of the Himalayas has a dramatic landscape including India's highest mountain, 8586 m, Kanchenjunga. Sikkim has been awarded as one of the cleanest states in India. 
In our study, there is a relative peak in dry eye cases in patients of age group of 45 years and above which reflects dry eye induced due to exposure to environmental factors in this group which is most active occupationally. The proportion of patients diagnosed with dry eye disease in our study was 12.7%, which in comparison to study done by Sahai and Malik from Jaipur in western part of India was found to be 18.4%.  Higher proportion of dry eye was seen in elderly females, probably may be due to deficient tear secretion due to estrogen deficiency in menopausal women as reported in previous literature. Meibomian gland dysfunction and EDE frequently occur during menopause. As menopause sets in, an imbalance between estrogen and androgens, due to decrease in androgen levels, occurs.  The most common complaints of dry eye patients are foreign body sensation, burning, redness, itching, blurred vision, and light sensitivity.  In our study, the common complaints were dryness and grittiness. The study used McMonnies and HO questionnaire to evaluate symptoms of dry eye along with Schirmer's test and TBUT to confirm the diagnosis of dry eye in subjects. Hence, the questionnaire and clinical tests are correlated in diagnosing dry eye. This study gave us the proportion of patients diagnosed with dry eye, out of 700 patients which attended the eye OPD in CRH, Gangtok, in a period of 1 year. The procedure can be considered safe since no side effect was seen while performing the Schirmer's test and TBUT. The limitations of our study include the small sample size since the study was completed in a short period of only 1 year.
The results obtained from this study enabled early detection of dry eye syndrome and helped to caution the individual about any vision impairment and disturbance in quality of life, related to it. Early detection and timely management helped to prevent long-term sequelae and vision-threatening complications.
In conclusion, dry eye is a common disease presenting with different symptoms which can be easily confirmed using simple and low-cost tests such as McMonnies-HO questionnaire and clinically by Schirmer's test and TBUT so that disease can be graded according to severity and appropriate treatment can be started.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Goto E, Yagi Y, Matsumoto Y, Tsubota K. Impaired functional visual acuity of dry eye patients. Am J Ophthalmol 2002;133:181-6.
Dogru M, Katakami C, Inoue M. Tear function and ocular surface changes in non insulin-dependent diabetes mellitus. Am Acad Ophthalmol 2001;108:586-91.
Rahman A, Yahya K, Ahmed T, Sharif-ul-Hasan K. Validity of symptoms as screening tool for dry eye. Pak J Ophthalmol 2007;23:198-9.
McCarty CA, Bansal AK, Livingston PM, Stanislavsky YL, Taylor HR. The epidemiology of dry eye in Melbourne, Australia. Ophthalmology 1998;105:1114-9.
Nichols KK, Nichols JJ, Zadnik K. Frequency of dry eye diagnostic test procedures used in various modes of ophthalmic practice. Cornea 2000;19:477-82.
McMonnies C, Ho A, Wakefield D. Optimum dry eye classification using questionnaire responses. Adv Exp Med Biol 1998;438:835-8.
Stephen PC, Roger BW, Michael SE, editors. Dry Eye and Ocular Surface Disorders. 1 st
ed, Ch. 1, Newyork: CRC press; 2004. p. 5-7.
Clean India Journal. Sikkim the cleanest state. Daily News; 12 February, 2014.
Sahai A, Malik P. Dry Eye: Prevalence and attributable risk Factors in a Hospital-Based Population. Indian J Ophthalmol 2005;53:87-91.
Garg A, Sheppard JD, Donnenfeld ED, Meyer D, Cyres MK, editors. Clinical Diagnosis and Management of Dry Eye and Ocular Surface Disorders. 1 st
ed, Ch. 3 & 5. India: Jaypee publisher; 2006. p. 49-50, 69-70.
Lemp MA. Report of the National Eye Institute/ Industry Workshop on Clinical Trials in Dry Eye. CLAO 1995;21:221-32.
[Figure 1], [Figure 2], [Figure 3]