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Dry eye syndrome: undiagnosed entity.

INTRODUCTION: The preocular tear film is a hydrated mucus gel that contains soluble antimicrobial proteins and growth factors that protect and support the ocular surface. The final common pathway in dry eye is a perturbation of the integrated ocular surface/lacrimal gland reflex unit. [2]

Reported prevalence of dry eye is diverse, with questionnaire based surveys documenting rates ranging from 14.4% to 33% of the population sampled. [3-6] Studies which also involve tests of tear function including Schirmer's test, tear break up time, fluorescein staining, or rose bengal staining for determination of dry eye have found generally lower prevalence rates. [3-7]

There are only threepublished reports on prevalence of dry eye among hospital-based.

Population from North and Eastern India and the prevalence variesbetween 18.4% and 40.8%. [8-11] One small study from high altitudeshowed a higher prevalence of 54%. [12]

It can be caused by deficiency of any one or more of the tear film components, or can be a component of systemic diseases, including Sjogren's syndrome, lupus and Stevens-Johnson syndrome. Additionally, factors such as contact lens wear and adverse environmental exposures such as arid environments, windy conditions or visual tasking can exacerbate the symptoms of dry eye.

AIMS OF THE STUDY: To determine the prevalence of dry eye in symptomatic patients attending the Ophthalmology OPD in Santhiram Medical College, Nandyal.

To evaluate the clinical features, diagnostic tests and treatment of dry eye disease.

PATIENT AND METHODS: The study was conducted on 70 patients who presented with symptoms suggestive of dry eye. It was a one year cross sectional study with the study period ranging from December 2011 to November 2012.

INCLUSION CRITERIA: Patients equal to and above 20yrs presenting with following symptoms and signs--Burning sensation, Sandy grity feeling, Foreign body reaction, Photophobia, Heavy lids. The above symptoms increase in conditions of low humidity and wind.

EXCLUSION CRITERIA: Patients less than 20yrs with h/0 Increased mucoid discharge and watery secretion suggestive of vernal keratoconjunctivitis, Alkali burns, Trachoma, Acute ocular infections, Ocular surgery within last 6 months, Impaired ectropion, Contact lens users, eyelid function like in bell's palsy, nocturnal lagophthalmos,

Of the 70 subjects who were included in the study, 4 had undergone cataract surgery in one the eyes. That eye was excluded and the other eye was considered for the study.

Written informed consent was taken before enrolling the patients in the study. An OSDI questionnaire was administered to all participants to assess the symptoms of dry eye and correlate them with the signs.

* A complete slit-lamp examination of the lid margins, tear meniscus, conjunctiva, and cornea and tear film was done. Relevant examination of other important ocular structures was done. Following this, tests to diagnose dry eye were performed. These are tear break up time(TBUT), Rose Bengal staining, Schirmer's tests 1 and 2.

* Participants were labeled as having dry eye if at least two out of these four diagnostic tests were positive. This criterion of two diagnostic tests to diagnose dry eye was adopted in order to increase the detection rate of dry eye and hence arrive at an accurate prevalence.

Table 1: Characteristics of the study population

Characteristics                                     Number

Total number of patients                            70(136)
Age group                                          >20 years
Schirmer test positive                              56 eyes
Tear film break up time positive                    26 eyes
Rose Bengal test positive                           51 eyes
Dry eye present (2 or more tests positive)   34 patients (56 eyes)
Dry eye absent                               36 patients (80eyes)

The total number of patients examined in our study was 70. The eyes included in the study were 136. The age group was between 21 to 70 years, with the mean age of the patients being 47.92 years. Of the total number of patients, 57 were females and 13 were males with a female to male ratio of 4.38:1. Among the entire group, 34 patients (56 eyes) were diagnosed to have dry eye based on the tests.

The entire study population was divided decade wise into subgroups and the relationship of age with dry eye prevalence was studied. The youngest patient was of 21 years and the oldest was 65 years. Mean age was 47.96[+ or -]11.55 years.

There were 57 females and 13 males in the study group with the females to male ratio being 4.38:1

The ocular surface disease index (OSDI) was administered to the patients before subjecting them to examination or tests. Of the entire study group, 27.1% responded with symptoms of moderate to severe dry eye.

[chi square] - 10.174 p = 0.006(S).

The eyes of the patients showing positive symptoms were then analysed and the symptoms were compared with the signs to look for correlation between symptoms and signs.

An OSDI scoring of 67-100 which corresponds to severe dry eye, was found to correlate significantly with objective tests of dry eye(p=0.006). Similar findings were noted by Ozcura et al [13] who evaluated the OSDI questionaire for diagnosis of dry eye and found a significant inverse correlation between OSDI and TBUT scores. Simpson TL et al [14] scoring system is highly sensitive in have found that this symptomatic and differentiating asymptomatic subjects of dry eye. Srinivasan et al [15] used the OSDI scoring system to detect dry eye in postmenopausal women and concluded that OSDI could be effectively used to separate post-menopausal women who demonstrate clinical signs of ocular dryness.

The patients were asked for history dry mouth during recruitment into the study. This data was used to assess the number of people presenting with both dry mouth and dry eye. 12 patients (17.14%) were found to have evidence of both dry mouth and dry eye. 5 patients (7.1%) had a history of dry mouth but no evidence of dry eye.

[chi square] - 10.327 p = 0.001(VS)

[chi square] - 4.880 p = 0.27(S)

Study by Jie et al [16] has shown that there was significantly higher incidence of dry eye among people with under corrected refractive errors. It has been postulated that persons with refractive errors have an increased tendency to rub their eyes which apart from introduction of infective material,sebum and sweat could cause the lodgement of particulate foreign substances into the eye that predispose to tear film instability. Also, people with uncorrected refractive errors have more tendency to squeeze the eye, causing instability of tear film, predisposing to dry eye.

A total of 56(41.17%) eyes gave a wetting of less than 10mm on performing the Schirmer test. Among these, 51 were proved to be positive for dry eye based on pre-determined diagnostic criteria. The Schirmer test showed a sensitivity of 91.1% and specificity of 93.7%. The positive predictive value of the test was found to be 91.07% and the negative predictive value was 93.7%.

Among the 31 patients who gave a positive result for dry eye based on the schirmer test in one or both eyes, 20 patients (28.6%) had a wetting of less than or equal to 5mm. The rest i.e. 11 patients(15.7%) had wetting of between 6 to 10mm in one or both eyes, which is indicative of mild moderate dry eye.

TBUT was the second test to be performed. It was found to be positive (<10 seconds) in 26 eyes (19.11%). All the eyes which gave a positive result showed objective evidence of dry eye. This test was found to have a sensitivity of 46.4% and specificity of 100%. Its positive predictive value was 100% and negative predictive value was 72.7%.

A total of 51 eyes (37.5%), showed positive staining. Among these, 48 eyes(94.1%) were positive for dry eye. The test was found to have a sensitivity of 85.7% and specificity of 96.2%. The positive predictive value of the test was 94.1% and negative predictive value was 90.6%

Out of 56 eyes 46 were treated with artificial tears. 10 eyes with meibomian gland disease were treated with only Doxycyxline 100 mg twice daily for 3 weeks and then at follow up the dose was titrated depending on the response.

In a study by Aragona et al [17] has shown that long term treatment with sodium hyaluronate containing artificial tears improves rose bengal stains with dry eye, suggesting that treatment with this agent promotes corneal and conjunctival epithelial healing. This effect was noted after 3 months of starting the treatment.

In a study conducted by Horwarth-Winter et al, to evaluate the clinical course of dry eye syndrome, during follow-up subjective symptoms improved in 68% of the patients who received treatment. Subjective symptoms were unchanged in 30% of patients and increased in 2%

Out of the 56 dry eye cases, 5 cases did not report for first follow-up. Out of the remaining 51 dry eye cases, 3 did not report for the 2 follow-up. Table shows a rise in OSDI score in 1-33 i.e. mildly symptomatic cases (74.5% during 3rd week of follow up and 81.2% during 6th week). Patients who were moderate to severely symptomatic reported a fall in OSDI scores. 2.08% of the cases were totally symptom free at the end of 6 weeks

Patients with schirmer < 5mm remained about 58.8% during first follow-up and 58.3% during second follow-up. Schirmer more than 10 was noted in 1.9%during first follow-up and 6.25% during second follow-up.

Rose Bengal test was positive in 82.35% during first follow-up and 81.25% during second follow-up. It was negative in 9 eyes during both first and second follow-up.

CONCLUSION: Dry Eye Syndrome itself cannot be prevented, notably because most of the cases are due to the aging process. However, these guide lines are helpful to ease the discomfort and further complications.

To avoid excessive air movement: To avoid hot, dry environments and to add moisture to the air. To wear glasses on windy days and goggles while swimming: To take frequent breaks: To position the computer screen below eye level: To stop smoking and avoid passive smoking: To use hot compresses and eye massage [18]: To instill artificial tears/lubricating gels:

Dry eye is an under-diagnosed ocular disorder. This is because diagnosis and assessment of dry eye are complicated by the considerable variation in disease symptoms and signs and lack of definitive diagnostic tests.

GOAL--To treat and manage patients of dry eye disease at any level. To find out etiological factors responsible. To treat any complications--in patients with severe dry eye. To train comprehensive ophthalmologists.

Dry eye evaluation with an appropriate and standard questionnaire along with standard tests for dry eye helps in diagnosis and treatment. This will go a long way in the effective and successful management of patients with dry eye, specially so as the disease is chronic and needs long term treatment. Early and appropriate management will provide ocular comfort and satisfaction with a better quality of life.

Among the 70 patients studied, prevalence of dry eye was found to be as high as 48.5%.

The prevalence of dry eye increased with increase in age and significantly higher among people more than 40 years of age was prevalence was higher among females when compared to males. Conjunctival congestion was found to be reliable sign of dry eye with a strong positive association.

People with refractive errors, with or without history of spectacle use, had a higher incidence of dry eye compared to emmetropes. OSDI was found to be reliable measure of dry eye symptoms. Higher, scores of OSDI, indicating severe dry eye, correlated well with diagnostic tests for dry eye.

Schirmer test showed a high sensitivity and specificity, followed by rose bengal tests and impression cytology. TBUT was significantly decreased in cases with meibomian gland disease.

46 dry eye cases were treated with artificial tears.10 cases who showed evidence of meibomian gland disease were treated with doxycycline.


[1.] International Dry Eye Workshop Subcommittee. The definition and classification of dry eye disease: report of the definition and classification subcommittee of the International Dry Eye Work Shop (DEWS-2007). Ocul Surf 2007; 5: 75-92.

[2.] The Diagnosis and Management of Dry Eye: A Twenty-five-Year Review P flug felder, Stephen C. M.D.; Solomon, Abraham M.D.; Stern, Michael E. Ph.D.Cornea: September 2000;19(5):644-649.

[3.] Caffrey BE, Richter D, Simpson T, et al. The Canadian dry eye epidemiology study. In: Sullivan DA, et al, ed. Lacrimal gland, tear film and dry eye syndromes 2. New York: Plenum Press, 1998:805-6.

[4.] Shimmura S, Shimazaki J, Tsubota K. Results of a population-based questionnaire on the symptoms and lifestyles associated with dry eyes. Cornea 1999; 4: 408-11.

[5.] Moss SE, Klein R, Klein BEK. Prevalence of and risk factors for dry eye syndrome. Arch Ophthalmol 2000; 118: 1264-8.[CrossRef][Medline][Web of Science].

[6.] Schein OD, Munoz B, Tielsch JM, et al. Prevalence of dry eye among the elderly. Am J Ophthalmol 1997; 124: 723-8. [Medline][Web of Science]

[7.] McCarty CA, Bansal AK, Livingstone PM, et al. The epidemiology of dry eye in Melbourne, Australia. Ophthalmology 1998; 105: 1114-19.

[8.] Gupta SK, Gupta V, Joshi S, Tandon R. Subclinically dry eyes in urban Delhi: an impact of air pollution? Ophthalmologica 2002; 216: 368-71.

[9.] Sahai A, Malik P. Dry Eye: Prevalence and attributable risk factors in a hospital based population. Ind J Ophthalmol 2005; 53: 87-91.

[10.] Gupta N, Prasad I, Jain R, D'Souza P. Estimating the prevalence of dry eye among Indian patients attending a tertiary ophthalmology clinic. Ann Trop Med Parasitol 2010; 104: 247-55.

[11.] Basak SK, Pal PP, Basak S, Bandyopadhyay A, Choudhury S, Sar S. Prevalenceof Dry Eye Diseases in hospital-based population in West Bengal, Eastern India. J Indian Med Assoc. 2012; 110: 789- 94.

[12.] Gupta N, Prasad I, Himashree G, D' Souza P. Prevalence of dry eye at high altitude: a case controlled comparative study. High Alt Med Biol 2008; 9: 327-34.

[13.] Ozcura F, Aydin S, Helvaci MR. Ocular surface disease index for the diagnosis of dry eye syndrome. Ocul Immunol Inflamm 2007; 15 (5): 389-393.66.

[14.] Simpson TL et al. Dry eye symptoms assessed by 4 questionnnaires. Opt & VisSc 2008; 85 (8): 692-699.67.

[15.] Srinivasan S, Joyce E, Senchyma M, Simpson T, Jones L. Clinical signs & symptoms in post- menopausal females with symptoms of dry eye. Ophthalmic Physiol Opt 2008; 28 (4): 365 -372.

[16.] Van Bijsterveld OP. Diagnostic tests in the sicca syndrome. Arch Ophthalmol1969; 82: 10-14.

[17.] Aragona P, Papa V, Micali A, Santocona M, Milazzo G. Long term treatment with sodium hyaluronate containing artificial tears reduces ocular surface damage in patients with dry eye. Br J Ophthalmol 2002; 86: 181-184.

[18.] Sahlin S, Linderoth R. Eyelid botulinum toxin injections for the dry eye. Dev Ophthalmol 2008; 41: 187-92.

M. Ramesh Chandra (1), Govardhan Reddy (2), P. Kishore Kumar (3), D. V. Giddaiah (4), P. Sanjeeva Kumar (5)


(1.) M. Ramesh Chandra

(2.) Govardhan Reddy

(3.) P. Kishore Kumar

(4.) D. V. Giddaiah

(5.) P. Sanjeeva Kumar


(1.) Assistant Professor, Department of Ophthalmology, SRMC.

(2.) Professor, Department of Ophthalmology, SRMC.

(3.) Assistant Professor, Department of Ophthalmology, SRMC.

(4.) Professor, Department of Ophthalmology, SRMC.

(5.) Assistant Professor, Department of Ophthalmology, SRMC.


Dr. M. Ramesh Chandra, Assistant Professor, Department of Ophthalmology, Santhiram Medical College & General Hospital, Nandyal-518501. E-mail:

Date of Submission: 27/12/2014.

Date of Peer Review: 29/12/2014.

Date of Acceptance: 30/12/2014.

Date of Publishing: 06/01/2015.
Table 2: Dry eye in relation to Age distribution

Age (years)   Dry eye present   Dry eye absent      Total
                  No. of            No. of         No. of
               patients (%)      patients (%)    patients (%)

21-30                0             5(100%)            5
31-40            6(31.5%)         13(68.42%)          19
41-50            8(53.53%)        7(46.66%)           15
51-60             12(60%)           8(40%)            20
61-70            8(72.72%)        3(27.27%)           11
Total               34                36              70

Table 3: Dry eye in relation to sex distribution

  Sex      Dry eye present   Dry eye absent   Total

Females        29(85%)             28          57
 Males         5(15%)              8           13
 Total           34                36          70

Table 4: OSDI Scores

  OSDI     No. Of patients

   0              6
  1-33           45
 34-66           12
 67-100           6
 Total           70

Table 5: OSDI scores and correlation with dry eye

 OSDI scores    Dry eye present   Dry eye absent   Total no. Of eyes

      0                0                12                12
    1-33              39                50                89
    34-66              7                16                23
   67-100             10                2                 12
    Total             56                80                136

Table 6: Presence of dry mouth

 Dry mouth    Dry eye present   Dry eye absent   Total

  Present           12                5           17
  Absent            22                31          53
   Total            34                36          70

Table 7: Signs of dry eye

         Signs            Dry eye present   Dry eye absent   Total

Conjunctival congestion         21                11          32
    Corneal dryness             15                0           15

Table 8: Relationship between refractive error & dry eye

 Refractive error    Dry eye present   Dry eye absent   Total

     Present               24                16          40
      Absent               10                20          30
      Total                34                36          70

Table 9: Results of Schirmer test

Schirmer test    Dry eye present   Dry eye absent   Total

   Positive            51                5           56
   Negative             5                75          80
    Total              56                80          136

Table 10: Distribution of patients according to Schirmer test

  Schirmer(mm)      0-5      6-10     >10      Total

No. Of patients      20       11       39        70
 % of patients      28.6     15.7     55.7      100

Table 11: Results of tear film break up time(TBUT) test

  TBUT      Dry eye present   Dry eye absent   Total

Positive          26                0           26
Negative          30                80          110
  Total           56                80          136

Table 12: Results of Rose Bengal test

Rose Bengal test    Dry eye present   Dry eye absent   Total

    Positive              48                3           51
    Negative               8                77          85
      Total               56                80          136

Table 14: Treatment in patients diagnosed with dry eye

      Drugs         Dry Eyes treated (%)

Artificial tears      46 eyes (82.14%)
   Doxycycline        10 eyes (17.85%)

Table 15: Comparision of OSDI Score during follow up:

  OSDI Score      1 week      3 week       6 week

      0              0           0       1 (2.08%)
     1-33        39(69.6%)   38(74.5%)   39 (81.2%)
    34-66        7(12.5%)     5(9.8%)     4 (8.3%)
    67-100       10(17.8%)   8(15.6%)     4 (8.3%)
    Total         56 eyes     51 eyes     48 eyes

Table 16: Comparision of Schirmer test during follow-up

Schirmer (in mm)   1st week    3rd week    6th week

      0-5          34(60.7%)   30(58.8%)   28(58.3%)
      6-10         22(39.2%)   20(39.2%)   17(35.4%)
      >10              0        1(1.9%)    3(6.25%)
     Total          56 eyes     51 eyes     48 eyes

Table 17: Comparision of rose bengal test during follow-up

Rose Bengal test    1st week     3rd week     6th week

    Positive        48(85.7%)   42(82.35%)   39(81.25%)
    Negative        8(14.2%)     9(17.6%)    9(18.75%)
      Total          56eyes       51eyes       48eyes
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Author:Chandra, M. Ramesh; Reddy, Govardhan; Kumar, P. Kishore; Giddaiah, D.V.; Kumar, P. Sanjeeva
Publication:Journal of Evolution of Medical and Dental Sciences
Article Type:Report
Geographic Code:9INDI
Date:Jan 8, 2015
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