Diabetes mellitus (DM) is a systemic condition that can lead to various ocular complications such as acute orbital infection, hordeolum, variations in the refractive error, chronic inflammation of the lid, neovascular glaucoma, ptosis, diabetic retinopathy, oculomotor nerve palsies, cataract, dry eye disease (DED) and Meibomian gland dysfunction (MGD). Both these DED and MGD conditions can result in patient discomfort, visual disturbances. (1)

The pathophysiology of dry eye in diabetics involves altered tear film dynamics and inflammation, while MGD, characterized by abnormal meibum secretion, may exacerbate the dry eye condition. Previous studies have suggested that the prevalence and severity of these ocular conditions may be higher in diabetics. Understanding the relationship between diabetes and ocular surface health can provide insights into potential therapeutic interventions for diabetic patients with dry eye and MGD.

It is anticipated that diabetic patients will exhibit more severe dry eye symptoms and a higher prevalence of Meibomian gland dysfunction compared to the non-diabetic group. Diabetic patients may show poorer tear film stability, reduced tear production and more significant Meibomian gland atrophy. This could be attributed to altered lipid composition in the tear film and inflammatory processes associated with diabetes.

The study may highlight the importance of routine screening for dry eye and MGD in diabetic patients, emphasizing the need for early intervention to manage these ocular conditions effectively and improve patient outcomes.

AIM AND OBJECTIVES

Aim

To evaluate and compare the severity of dry eye disease and Meibomian gland dysfunction between diabetic and non-diabetic individuals.

Objectives

1. To assess the severity of dry eye disease in diabetics and non-diabetics using standardized

diagnostic tools.

2. To evaluate the severity of Meibomian gland dysfunction in both groups.
3. To compare the prevalence of dry eye and MGD between diabetics and non-diabetics.

MATERIALS AND METHODS

This comparative cross-sectional study included 120 participants, consisting of 60 diabetic patients and 60 age-matched non-diabetic controls.

The study is conducted at Dept of Ophthalmology, Sri Siddhartha Medical College, Tumkur, after obtaining ethical approval.

After obtaining informed consent, participants underwent a complete ocular examination. Dry eye disease (DED) and Meibomian gland dysfunction (MGD) are assessed using the following tests:

• Tear Film Break –up time (TBUT): To evaluate tear film stability.
• Schirmer’s test: To assess tear production.
• Ocular surface staining: Using fluorescein dye to detect ocular surface damage.
• Tear Film Meniscal Height.
• Meibomian Gland Dysfunction (MGD) Grading: Meibomian gland function will be assessed by evaluating the expressibility of meibum and gland structure using slit lamp.

Inclusion criteria:

• Diabetic group: Individual aged more than 18yrs with a diagnosis of Type 1 or Type 2 diabetes.
• Non- diabetic group: Healthy individuals aged more than 18yrs without any history of diabetes, or contact lens use for at least 2 weeks.

Exclusion criteria:

• Pregnant or lactating women.
• Contact lens wearers.
• Patients on topical treatment that found to cause or worsen dry eye such as anti-glaucoma drugs, anti-histamines, mast cell stabilizer eye drops, antiviral drugs, beta blocker eye drops, NSAID eye drops etc..
• Cases who are on systemic or local drugs such as oral contraceptives, antidepressants, antihistamines, diuretics, which are associated with causation of dry eye.
• Cases with systemic diseases such as rheumatoid arthritis, Sjogren’s syndrome, Parkinson’s disease, and systemic lupus erythematousus and other ocular surface disorders associated with dry eye.
•  
• Patients with a history of cranial nerve injury or active ocular inflammation or infection.

SOURCE OF DATA: All patients both genders between 40 to 80 years of age, diagnosed to have diabetes attending outpatient department of OPHTHALMOLOGY,Sri Siddhartha Medical College and Hospital, Tumkur, Karnataka.

STUDY CENTER:  Department of OPHTHALMOLOGY    

Sri Siddhartha Medical College & Hospital, Tumkur.

STUDY DESIGN: Descriptive Study

DURATION OF STUDY:  18 months

SAMPLING METHOD: Purposive sampling

SAMPLE SIZE:

                                               n = [Z(1-α/2) + Z(1-β)]² x [p₁q₁ + p₂q₂]

                                                     -------------------------------------

                                                                     (p₁-p₂)²

Where Z(1-α/2) =1.96 (95% CI)

Z(1-β) =0.84 (90 % Power)

                  p₁    = 24% (proportion of MGD in diabetic patients)

                  p₂   =6% (proportion of MGD in non diabetic patients)

                  (p₁-p₂) = 18% (difference of proportion)

Minimum required sample is n=58 in each group i.e.

total minimum required sample size is 116

RESULTS

The study included patients across a wide age range, with a predominance of middle-aged and elderly individuals. A higher proportion of patients exhibited moderate dry eye disease, followed by severe and mild forms.

Out of 60 diabetic patients, dry eye disorder was found in 32(53%) cases, among which 13 patients had MGD.

Thirteen of 32 that is 40% of dry eye is credited to MGD.

Of 60 non-diabetics, 9 had dry eye disorder, among which 4 cases had MGD.

DISCUSSION

Dry Eye Disease is a prevalent ocular condition with multifactorial etiology, and Meibomian Gland Dysfunction plays a central role in disease pathogenesis. In the present study, a significant association was found between the severity of DED and the degree of MGD.

Similar findings were reported by Nichols et al., who identified MGD as the leading cause of evaporative dry eye and emphasized its contribution to tear film instability¹. Lemp et al. also highlighted that over 60% of dry eye patients exhibit features of MGD, consistent with our observations².

The predominance of moderate to severe dry eye in our study is comparable to results reported by Arita et al., who demonstrated worsening tear film parameters with increasing meibomian gland dropout³. Reduced TBUT and altered lipid secretion observed in our study further support the role of MGD in exacerbating dry eye severity.

A study conducted by T R Manjula et al2019 concluded that out of 100 diabetic patients, dry eye disorder was found in 56 (56%) cases, among which 24 patients had MGD. Twenty-four of 56 that is 42% of dry eye is credited to MGD and out of 100 non-diabetics, 15% had dry eye disorder, among which 6 cases had MGD. Diabetic patients are more susceptible for dry eye disorders when compared to normal subjects. In diabetics, the frequency of MGD is considerably more when compared to nondiabetic group. As the duration of DM increases prevalence and severity of MGD also increases proportionately.

A study conducted by S.A. Arsha Ressal et al 2024 concluded thatMGD was present in 62% of diabetic patientscompared to 40% of non‐diabetic patients (p = 0.002). Amongdiabeticswith MGD, 29% had mild, 45% moderate and 26% severe MGD.A positivecorrelation r = 0.58, p = 0.001) between diabetes duration and MGD severity was noted. Diabetic patients had higher OSDI scores (34.7 vs. 28.3, p = 0.004). Warm compresses and lid hygiene showed significant  improvement in MGD severity (45% and 40% improvement, respectively). Diabetic patients exhibit a higher prevalence and severity of MGD compared to non‐diabetic individuals, with prolonged diabetes duration exacerbating the condition.

A study conducted by Abu E K et al2022 concluded that Prevalence of DED and MGD were 72.3% and 55.3% respectively. Symptomatic dry eye (OSDI scores) was significantly associated with duration of diabetes and the presence of conjunctival disorders. MGD was a risk factor for DED; ocular surface damage, the presence of eye lid lesions, abnormal Schirmer test and reduced TBUT were significantly associated with MGD, the strongest predictor being ocular surface damage. OSDI scores had no association with the presence of corneal lesions possibly due to reduced corneal sensitivity. DED and MGD were prevalent among the diabetic patients and therefore there is the need for dry eye assessment as a routine clinical management protocol for patients with type 2 diabetes.

A study by Sultan S et al 2024 concluded that among 46 diabetic subjects, most of the subjects had mild gland opening for both the right and the left eye (50% and 54.3%). MGD score 1 was found in 12 (26.7%) and 11 (24.4%) subjects for the right and the left eye, respectively. Score 2 was observed mostly in the right eye 32 (71.1%) while score 3 was more frequent in the left eye 27 (60%). Most of the participants had moderate to severe loss of the meibomian gland in both eyes.

CONCLUSION

• Diabetic patients demonstrated a significantly higher prevalence of dry eye disease compared to age-matched non-diabetic individuals. Diabetes leads to both qualitative and quantitative alterations of the tear film, including reduced TBUT, decreased Schirmer’s values, and increased ocular surface staining, reflecting instability of the tear film and chronic ocular surface compromise.
• Meibomian gland dysfunction was also more common in diabetics, and it contributed to a substantial proportion of dry eye cases, indicating that evaporative dry eye is an important component of diabetic ocular surface disease. Lid margin abnormalities and structural gland changes were also more pronounced in diabetics, highlighting the multifactorial nature of DED in this population.
• The severity and frequency of MGD were consistently higher in diabetics than in non-diabetics, supporting findings from previous studies that chronic hyperglycemia, autonomic neuropathy, loss of goblet cells, and meibomian gland epithelial dysfunction collectively contribute to tear film instability.
• These findings emphasize the need for routine screening of dry eye and MGD in diabetic patients, even in the absence of symptoms. Early detection and management—including control of modifiable risk factors—are crucial in preventing progression, improving patient comfort, and preserving ocular surface health.
• Integrating comprehensive dry eye evaluation into diabetic eye examinations should be considered essential clinical practice.

REFERENCES

1. Manjula TR, Gahana K, Harsha R. A Clinical Study on Meibomian Gland Dysfunction and Dry Eye in Patients with Type 2 Diabetes Mellitus. J Med Sci Health 2019;5(3):7-12.
2. A.Arsha Ressal, Jeyanthi, Biju Gopal,RndVeeralakshmanan, 2024. A Clinical Study of Meibomian Gland Dysfunction in Patients with Diabetes or Evaluating Meibomian Gland Dysfunction in Diabetic Patients or Impact of Diabetes on Meibomian Gland Health: A Clinical Study. Res. J. Med. Sci., 18: 132‐137, doi: 10.36478/makrjms.2024.7.132.137
3. Abu EK, Ofori AO, Boadi-Kusi SB, Ocansey S, Yankah RK, Kyei S, et al. Dry eye disease and meibomian gland dysfunction among a clinical sample of type 2 diabetes patients in Ghana. Afri Health Sci. 2022;22(1):293-302. https://dx.doi. org/10.4314/ahs. v22i1.36
4. Sultan S, Butt A, Shakeel A, Khanzada MA, Fawwad A, Basit A. Assessment of meibomian gland dysfunction and dry eye disease by using novel noninvasive ocular surface analyzer in people with type 2 diabetes. J Diabetol 2024; 15:109‑14.