The Change of Tear Film in Classification of Diabetic Retinopathy

Wan Seok Kang; Hyun Tae Choi; Min Ahn; In Cheon You

doi:10.3341/jkos.2014.55.4.486

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Kang, Choi, Ahn, and You: The Change of Tear Film in Classification of Diabetic Retinopathy

Original Article

J Korean Ophthalmol Soc 2014;55(4):486-492.

Published online: 7 September 2014

DOI: https://doi.org/10.3341/jkos.2014.55.4.486

The Change of Tear Film in Classification of Diabetic Retinopathy

Wan Seok Kang, MD, Hyun Tae Choi, MD, Min Ahn, MD, In Cheon You, MD

Department of Ophthalmology, Chonbuk National University College of Medicine, Jeonju, Korea

Address reprint requests to In Cheon You, MD Department of Ophthalmology, Chonbuk National University Hospital, #20 Geonji-ro, Deokjin-gu, Jeonju 561-712, Korea, Tel: 82-63-250-1996, Fax: 82-63-250-1960 E-mail: you2ic@hanmail.net

Received 20 October 201228 September 2013 Accepted 1 March 2014

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

To determine the relationship between changes in the tear film according to the classification of diabetic retinopathy in patients with diabetes.

Methods

A total of 117 newly detected diabetic patients were included in this study. The classification of diabetic retinopathy was performed based on the Early Treatment Diabetic Retinopathy Study (ETDRS). The duration of diabetes and HbA1c were also investigated in patients who had undergone panretinal photocoagulation or insulin treatment. To examine the tear film function, we performed the tear break-up time test, the Schirmer I test, and the diagnostic fluorescein staining test of the ocular surface. The Cochet-Bonnet esthesiometer was also employed to examine the corneal sensitivity.

Results

As the severity of diabetic retinopathy progressed, the degree of ocular surface fluorescein staining increased significantly. There was no relationship between the duration of diabetes and the results of the tear film function test. Patients who had high blood HgA1c levels showed significant increases in tear break-up time and degree of ocular surface fluorescein staining. The patients who had undergone panretinal photocoagulation showed significant differences in tear break-up time and degree of ocular surface fluorescein staining.

Conclusions

The diabetic patients with progressed diabetic retinopathy, uncontrolled blood HgA1c levels and who had previously undergone panretinal photocoagulation should be managed more carefully since those patients are more susceptible to ocular surface disorder with aggravation of tear film function.

Keywords: Corneal sensitivity, Diabetic retinopathy, Tear film

References

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Table 1.

Demographic features and baseline characteristics

	No DR (n = 30)	Mild NPDR (n = 27)	Moderate NPDR (n = 23)	Severe NPDR (n = 22)	PDR (n = 15)	p-value
Sex Male	24 (80.0)	15 (55.6)	11 (47.8)	15 (68.2)	10 (66.7)	0.134
Female	6 (20.0)	12 (44.4)	12 (52.5)	7 (31.8)	5 (33.3)
Mean ages (years)	43.0 ± 16.8	55.0 ± 13.1	56.1 ± 12.5	60.8 ± 14.3	57.6 ± 9.3	<0.001
Duration of diabetes (years)	5.8 ± 8.1	7.6 ± 6.6	10.4 ± 10.0	15.4 ± 14.2	8.6 ± 8.4	0.010
HbA1c (%)	5.9 ± 0.2	6.4 ± 0.1	7.3 ± 0.1	8.5 ± 0.2	11.4 ± 0.8	<0.001
Previous PRP	0 (0)	0 (0)	6 (26.1)	12 (54.5)	13 (86.7)	<0.001
Insulin treatment	26 (86.7)	18 (66.7)	9 (39.1)	13 (59.1)	7 (46.7)	0.004
Hypertension	10 (33.3)	7 (25.9)	12 (52.2)	13 (59.1)	10 (66.7)	0.030

Values are presented as mean ± SD; Analyzed by Fisher’s exact test and ANOVA.

DR = diabetic retinopathy; NPDR = non-proliferative diabetic retinopathy; PDR = proliferative diabetic retinopathy; PRP = panretinal photocoagulation.

Table 2.

Tear film function tests according to diabetic retinopathy classifications

	No DR	Mild NPDR	Moderate NPDR	Severe NPDR	PDR	p-value^*	p-value^†
BUT (s)	11.5 ± 2.5	9.8 ± 2.0	9.3 ± 2.4	7.8 ± 2.2	7.1 ± 2.4	<0.001	0.412
SchirmerⅠ test (mm)	16.0 ± 7.6	13.6 ± 6.3	12.9 ± 4.9	13.6 ± 7.0	11.5 ± 2.6	0.188	0.552
Fluorescein stain	0.57 ± 0.68	0.74 ± 0.66	1.22 ± 1.38	2.64 ± 0.95	3.46 ± 1.77	<0.001	<0.001

Values are presented as mean ± SD.

BUT = tear break-up time; DR = diabetic retinopathy; NPDR = non-proliferative diabetic retinopathy; PDR = proliferative diabetic retinopathy.

^* Analyzed by ANOVA adjusted for age, DM duration (year) and HbA1c

^† Analyzed by ANCOVA adjusted for age, DM duration (year) and HbA1c.

Table 3.

Corneal sensitivity according to of diabetic retinopathy classifications

	No DR	Mild NPDR	Moderate NPDR	Severe NPDR	PDR	p-value
Sensitivity threshold (mm)	58.7 ± 1.3	55.1 ± 2.6	52.2 ± 2.1	45.5 ± 3.3	39.7 ± 2.3	0.116

Values are presented as mean ± SD; Analyzed by ANOVA.

DR = diabetic retinopathy; NPDR = non-proliferative diabetic retinopathy; PDR = proliferative diabetic retinopathy.

Table 4.

The relationship between tear function tests and other parameters in type 2 diabetes mellitus

		BUT (s)	SchirmerⅠ test (mm)	Fluorescein stain
Duration of diabetes (years)^*	R partial	-0.146	-0.113	0.059
	p	0.120	0.229	0.529
HbA1c (%)^†	R partial	-0.457	0.080	0.497
	p	<0.001	0.394	<0.001
Previous PRP	Yes (n = 31)	7.3 ± 2.6	11.7 ± 5.8	3.03 ± 1.70
	No (n = 86)	10.2 ± 2.4	14.6 ± 6.4	0.94 ± 0.92
	p by ANCOVA	0.006	0.288	<0.001
Insulin treatment	Yes (n = 73)	9.7 ± 2.8	14.1 ± 7.3	1.34 ± 1.47
	No (n = 44)	8.9 ± 2.5	13.3 ± 4.2	1.75 ± 1.51
	p by ANCOVA	0.788	0.678	0.753

Values are presented as mean ± SD.

BUT = tear break-up time; PRP = panretinal photocoagulation.

^* ANCOVA adjusted for age, HbA1c

^† Age, DM duration (year).

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