Journal List > J Korean Ophthalmol Soc > v.55(4) > 1009929

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

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.

References

1. Dogru M, Kaltakami C, Inoue M. Tear function and ocular surface changes in noninsulin-dependent diabetes mellitus. Ophthalmology. 2001; 108:586–92.
crossref
2. Saini JS, Khandalavla B. Corneal epithelial fragility in diabetes mellitus. Can J Ophthalmol. 1995; 30:142–6.
3. Foulks GN, Thoft RA, Perry HD, Tolentino FI. Factors related to corneal epithelial complications after closed vitrectomy in diabetes. Arch Ophthalmol. 1979; 97:1076–8.
4. Hyndiuk RA, Kazarian EL, Schultz RO, Seideman S. Neurotrophic corneal ulcers in diabetes mellitus. Arch Ophthalmol. 1977; 95:2193–6.
crossref
5. Sánchez-Thorin JC. The cornea in diabetes mellitus. Int Ophthalmol Clin. 1998; 38:19–36.
crossref
6. Henkind P, Wise GN. Descemet's wrinkles in diabetes. Am J Ophthalmol. 1961; 52:371–4.
crossref
7. Ozdemir M, Buyukbese MA, Cetinkaya A, Ozdemir G. Risk factors for ocular surface disorders in patients with diabetes mellitus. Diabetes Res Clin Pract. 2003; 59:195–9.
crossref
8. Yu L, Chen X, Qin G, et al. Tear film function in type 2 diabetic patients with retinopathy. Ophthalmologica. 2008; 222:284–91.
crossref
9. Kim JS, Hyun GW, Moon NJ, et al. The study for relationship of ocular surface abnormalities, corneal sensitivity and diabetic retinopathy in DM. J Korean Ophthalmol Soc. 2004; 45:383–9.
10. Li HY, Pang GX, Xu ZZ. Tear film function of patients with type 2 diabetes. Zhongguo Yi Xue Ke Xue Yuan Xue Bao. 2004; 26:682–6.
11. Seifart U, Strempel I. The dry eye and diabetes mellitus. Ophthalmologe. 1994; 91:235–9.
12. Jin J, Chen LH, Liu XL, et al. Tear film function in non-insulin de-pendent diabetics. Zhonghua Yan Ke Za Zhi. 2003; 39:10–3.
13. Rahman A, Yahya K, Ahmed T, Sharif-UI-Hasan K. Diagnostic value of tear films tests in type 2 diabetes. J Pak Med Assoc. 2007; 57:577–81.
14. Tabatabay CA, Bumbacher M, Baumgartner B, Leuenberger PM. Reduced number of hemidesmosomes in the corneal epithelium of diabetics with proliferative vitreoretinopathy. Graefes Arch Clin Exp Ophthalmol. 1988; 226:389–92.
crossref
15. Azar DT, Spurr-Michaud SJ, Tisdale AS, Gipson IK. Decreased penetration of anchoring fibrils into the diabetic stroma. A morphometric analysis. Arch Ophthalmol. 1989; 107:1520–3.
16. Taylor HR, Kimsey RA. Corneal epithelial basement membrane changes in diabetes. Invest Ophthalmol Vis Sci. 1981; 20:548–53.
17. Graham CR Jr, Richards RD, Varma SD. Oxygen consumption by normal and diabetic rat and human corneas. Ophthalmic Res. 1981; 13:65–71.
crossref
18. Tsubota K, Chiba K, Shimazaki J. Corneal epithelium in diabetic patients. Cornea. 1991; 10:156–60.
crossref
19. Shimazaki J, Tsubota K, Yoshida A, et al. Changes of corneal redox state in diabetic animal models. Cornea. 1995; 14:196–201.
crossref
20. Friend J, Ishii Y, Thoft RA. Corneal epithelial changes in diabetic rats. Ophthalmic Res. 1982; 14:269–78.
crossref
21. Chang SW, Hsu HC, Hu FR, Chen MS. Corneal autofluorescence and epithelial barrier function in diabetic patients. Ophthalmic Res. 1995; 27:74–9.
crossref
22. Göbbels M, Spitznas M, Oldendoep J. Impairment of corneal epithelial barrier function in diabetics. Graefes Arch Clin Exp Ophthalmol. 1989; 227:142–4.
crossref
23. Goebbels M. Tear secretion and tear film function in insulin de-pendent diabetics. Br J Ophthalmol. 2000; 84:19–21.
crossref
24. Yoon KC, Im SK, Seo MS. Changes of tear film and ocular surface in diabetes mellitus. Korean J Ophthalmol. 2004; 18:168–74.
crossref
25. Nielsen NV. Corneal sensitivity and vibratory perception in diabetes mellitus. Acta Ophthalmol. 1978; 56:406–11.
crossref
26. Resenberg ME, Tervo TM, Immonen IJ, et al. Corneal structure and sensitivity in type 1 diabetes mellitus. Invest Ophthalmol Vis Sci. 2000; 41:2915–21.
27. Murphy PJ, Patel S, Kong N, et al. Noninvasive assessment of corneal sensitivity in young and elderly diabetic and nondiabetic subjects. Invest Ophthalmol Vis Sci. 2004; 45:1737–42.
crossref
28. Rogell GD. Corneal hypesthesia and retinopathy in diabetes mellitus. Ophthalmology. 1980; 87:229–33.
crossref
29. Wang F, Gao N, Yin J, Yu FS. Reduced innervation and delayed re-innervation after epithelial wounding in type 2 diabetic Goto- Kakizaki rats. Am J Pathol. 2012; 181:2058–66.
30. Schultz RO, Peters MA, Sobocinski K, et al. Diabetic keratopathy as a manifestation of peripheral neuropathy. Am J Ophthalmol. 1983; 96:368–71.
crossref
31. Verrotti A, Giuva PT, Morgese G, Chiarelli F. New trends in the etiopathogenesis of diabetic peripheral neuropathy. J Child Neurol. 2001; 16:389–94.
crossref
32. Dyck PJ, Davies JL, Wilson DM, et al. Risk factors for severity of diabetic polyneuropathy: intensive longitudinal assessment of the Rochester Diabetic Neuropathy Study Cohort. Diabetes Care. 1999; 22:1479–86.
crossref

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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