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35]

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

Context: Dry eye is a very common as well as

underdiagnosed ocular disorder. It is not only
troublesome in terms of its symptoms but also imposes
a great financial burden.
Aims: To determine the prevalence of dry eye in
ophthalmology outpatients at a Tertiary Care Hospital
and its association with various clinicoepidemiological
factors.
Settings and Design: Ahospitalbased study at a
Tertiary Care Center was conducted including 400
outpatients of age 40years and above.
Materials and Methods: Patients were consecutively
selected and underwent a routine ophthalmological
examination along with tear film breakup 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.

Introduction
In 2007, the International Dry Eye Workshop(DEWS) revised
the original definition and classification scheme of dry eye

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DOI:
10.4103/0974-620X.169910

Results: The mean age of the study population was

58.6years. 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 outpatients 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

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

mechanism, and severity of the disease. The term dryeye 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 tearfilm 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

Copyright: 2015 Shah S and Jani H. This is an openaccess article distributed under the terms of the Creative Commons Attribution License, which
permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Correspondence:
Dr. Suchi Vinod Shah, F4, Teaching Staff Quarters, MVJ Medical College, Dandupalya, 30th Km Milestone, National Highway 4, Kolathur P.O., Hoskote,
Bengaluru562114, Karnataka, India. Email:suchi.shah.87@gmail.com

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Shah and Jani: Prevalence and associated factors of dry eye

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 visual
function 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 breakup time[TBUT]), which in
turn, can limit patients visual functioning capabilities.[5]

Materials and Methods

We conducted a crosssectional study involving 400patients who
visited the Ophthalmology Outpatient Department at a 600bed
Rural Teaching Tertiary Care Center, with various complaints
which may or may not involve dry eye symptoms. Our study
sample includes mixed population of both rural and urban areas.
We recruited our participants over a period of 2 months. Patients
of age 40years 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 breakup 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 correlated
with 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 culdesac 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.
152

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 analysis
A 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 Chisquared
tests. For statistical analyses, commercially available software SPSS
for Windows(version14.0; 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, 400patients agreed to participate
in the study(4% drop out rate). Mean age of the study population
was 58.6years. 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%).
Table1 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 40years and above. The
prevalence of dry eye was found to be maximum in the elderly.
It was 67.3% in participants aged 71years and above. Fiftyone
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[Table2].
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
type2), hypertension and arthritis with dry eye was studied.
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Shah and Jani: Prevalence and associated factors of dry eye

Sixtyseven 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 slit
lamp 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,

Table1: Sociodemographic and clinical profile of

study population(n=400)
Variable

Number of Percentage
subjects
of total

Age distribution
40-50years
51-60years
61-70years
71-80years
81-90years
Sex
Male
Female
Occupation
Indoor table work without air conditioner
Indoor table work with air conditioner
Outdoor jobs/laborer/farmer
Housewife*
Systemic diseases
Diabetes
Hypertension
Arthritis
Addictions
Smoking
Tobacco chewing/snuffing
Smoking+tobacco chewing/snuffing

103
130
122
38
7

25.8
32.5
30.5
9.5
1.8

192
208

48
52

94
29
81
196

23.5
7.3
20.3
49

97
156
11

24.3
39
2.8

26
36
9

6.5
9
2.3

*Females staying at home and performing various household chores

Table2: Prevalence of dry eye among various

occupation groups
Occupation
Indoor table work
without air conditioner
Indoor table work with
air conditioner
Outdoor jobs/
laborer/farmer
Housewife*
Total

Frequency
(n)
94

Percentage
23.5

Dry eye
prevalence(%)
42.6

29

7.3

58.6

81

20.3

59.3

196
400

49.0
100.0

57
54.3

*Females staying at home and performing various household chores

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

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[Table3].
Among the asymptomatic patients, 24.1% had dry eye. This
reflects the subclinical dry eye patients who later on may come
back 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

Table3: Presenting symptoms among dry eye

patients(n=217)
Symptom
Watering
Itching
Heaviness
Burning
Stickiness
Dryness
Grittiness
Excess mucus

Number of patients
89
43
33
32
20
19
19
7

Percentage
41
19.8
15.2
14.7
9.2
8.8
8.8
3.2

Table4: Multivariable logistic regression analysis

showing association of dry eye
Variable

OR

95% CI
Lower

Occupation
Indoor work without
air conditioner
Farmers/laborers/outdoors
Indoor table work with
air conditioner
Housewife
Diabetes(no/yes)*
Previous ocular surgery
(no/yes)*
Meibomian gland dysfunction
(no/yes)*
Constant

Upper

0.067
[Reference category]
0.026
0.179

2.087
1.876

1.093
0.750

3.985
4.697

0.014
0.001
0.080

1.950
2.272
1.565

1.147
1.369
0.948

3.314
3.771
2.582

0.000

20.282

4.789 85.900

0.001

0.434

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

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Shah and Jani: Prevalence and associated factors of dry eye

working indoor using air conditioner, housewives, diabetics,
patients who have undergone previous ocular surgery and those
with meibomian gland dysfunction(MGD)[Table4].

Discussion
Dry eye prevalence as estimated in this study is around 54% in
patients visiting the Outpatient Department at a Tertiary Care
Center. Guillon etal.[15] have shown in a study in United Kingdom
that the tear film evaporation is significantly higher in subjects
above the age of 45years. 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
etal.[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 hospitalbased
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 study
conducted in Korea reported a prevalence of 33.2%.[24] The overall
prevalence of dry eye among patients of age 40years 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. Apoor 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 etal.[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
154

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
etal. in Iran where 54.3% of the type2 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]
Seventytwo 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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Shah and Jani: Prevalence and associated factors of dry eye

found to have dry eyes. We found the prevalence of dry eye to be
24.1% in asymptomatic patients. Nichols etal.[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.

6.
7.

8.

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

for TBUT instead of noninvasive BUT. Fluorescein itself can
sometimes be irritating and lead to reflex tearing. Another
drawback is that our study is a hospitalbased 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, female
gender, 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. Asurvey reported that American consumers spend
over100 million dollars per year toward lubricating eye drops.[34]
Le etal.[35] in a populationbased crosssectional study in China
reported an adverse impact on the visionrelated quality of life as
well as an impairment on mental health in patients having various
dry eye symptoms. Agood history and clinical examination can
help us to bring out this underdiagnosed condition and deal
with 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

9.

10.

11.
12.

13.

14.

15.
16.
17.

18.
19.

20.

21.

22.

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, Conflict of Interest: None declared.

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