Frequency and Risk Factors Associated with Dry Eye Disease


Dry eye disease is curable when diagnosed appropriately and correct measures taken. However, it evidence that many of the risk factors associated with it can easily be controlled. As we know from the English proverb, “prevention is always better than curative”. This paper aims at identifying and analyzing the risk factors related to dry eye diseases in the patients attending Tertiary care Ophthalmology center in Mexico City.

The method s that will be used includes studying population and use of questionnaires. The population visiting Ophthalmology Center will actually undergo a comprehensive examination test. The information on populations, past ocular and medical medication, and history was also collected. The results would be used infer to the risk and factors related to Dry eyes in patience in Mexico.

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Dry eye refers to a condition whereby there are inadequate tears to nourish and lubricate the eye. Tears are essential for maintaining health of the eye’s front surface and providing clear vision. Individuals with dry eyes have poor quality of tears or they do not produce adequate tears. This problem is popular particularly in adults. With every blink of eyelids, tears usually spread across the eye’s front face. Tears have several functions including reducing risks of eye infections, they provide lubrication, wash away strange particles in the eye, and maintain the eye’s surface smooth and clear. The excess tears in eyes usually flow into tiny drainage ducts, in inner corner of eyelids, which drain behind the nose.dry eyes makes somebody to feel very uncomfortable.

For people with dry eyes, their eyes may burn or sting. Dry eyes are experienced in certain situations including while riding bicycle, on an airplane, after staring computer for few hours, and in air-conditioned room. The dry eye treatment makes somebody feel more comfortable. These treatments may include eye drops and lifestyle changes. For extreme cases, eye surgery is the only option.

The Mexico ophthalmology care is actually trained to monitor, diagnose, surgical and medical treat of all orbital and eyelid problems affecting the visual pathway and the eye. In addition, to monitor, diagnose, and cure all visual and eye disorders. They frequently prescribe vision services in addition to serve as consultants to doctors and other professionals.

Given the suggestion that the disease may be more common and severe in Hispanic patients, we undertook this study to evaluate the epidemiology of dry eye disease in our hospital based population. It is important to understand the burden of disease in different populations in order to stratify material and human resources, in order to diagnose dry eyes disease ahead of time to prevent complications, and also importantly to have a good quality of life with a good treatment.

Background Information

Over the past years, many cases of dry eyes disease have been witnessed in the patients attending tertiary care center. However, the specific number of infected people has not yet been established thus difficult to establish the risk factor related with the disease. A need to establish this number is very important since it will help to identify and control the risk factors connected with the eye disease. For achieving these objective, there is need to identify the frequency of the patients attending Tertiary Care Ophthalmology Center (Uchino, 2011).

This is achievable through carrying out some examination test to the entire patient attending Care Ophthalmology. The patients will be interrogated concerning the dry eye disease. General questions. More information will be collected by use of questionnaire. I believe through identification of these frequency and risks factors, will be able to come up with appropriate method of completely solving the problem or reduce the chances of attack.

The last Dry Eye Workshop subcommittee (DEWS) in 2007 defined dry eye disease (DED) as a multi-factorial disease of the tears and ocular surface that results in symptoms of discomfort, visual disturbance, and tear film instability with potential damage to the ocular surface (Lin, 2003). It is accompanied by increased osmolality of the tear film and inflammation of the ocular surface. Based on data from large dry eye studies, such as the Women’s Health Study (WHS) and the Physicians Health Study (PHS), it has been estimated that approximately 3.23 million women and 1.68 million men, amounting to 4.91 million Americans over 50 years of age, have symptomatic dry eye disease (Schaumberg, 2013). Several worldwide epidemiological published studies have approximated the dry eye prevalence according to symptoms from 7 – 93% and by signs 20 – 85%.

Data from the WHS suggest that the prevalence of severe symptoms and/or clinical diagnosis of dry eye may be greater in Hispanic and Asian populations, compared to Caucasian populations (Acquadro, 2012). Presently, only two studies have investigated dry eye prevalence in Hispanic populations, and these studies found an 11% and 25% prevalence in Spanish and Hispanic American populations, respectively (Schein, 1999). No studies have focused on Hispanic populations in South America. Similarly, many studies have focused on population-based epidemiology and fewer have ascertained the frequency and epidemiology of dry eye in hospital based populations.


The main purpose of this research is to determine frequency and risk factors for the dry eye disease among Mexican patients attending the tertiary care ophthalmology center.

Key Words

1. dry eye disease
2. meibomian gland dysfunction,
3. ocular surface disease


I. Dry Eye Disease (DED).
II. Tear Film Break-up Time (TBUT).
III. Meibomian Gland Dysfunction (MGD).
IV. Ocular Surface Disease Index (OSDI).
V. Dry Eye Questionnaire (DEQ-5).
VI. Dry Eye Workshop Subcommittee (DEWS).
VII. Association Para Evictor la Cagier (APEC)..
VIII. Second-hand Smoke (SHM).
IX. Continuous Positive Airway Pressure (CPAP).


The methodology used in the research includes study of population and comprehensive examination method. Each method and the procedure followed will be discussed below. After analysis, the two results are compared to see how frequency and risk factors associated with the Dry Eye Disease affects the patients attending Tertiary care Ophthalmology Center in Mexico City.

Study Population

In this method, all the patients from outpatient’s clinic of the Ophthalmology center, who were observed between November and December 2012, and May and June 2013 in the Mexico City, was integrated in this cross-sectional study. In November and December 2012, the overall patients were 1600 while in May and June 2013, the overall patients were 1200. Insertion criteria were patients for first time who were sixteen years and above (Schiffman, 2000).

Decision criteria included patients who failed to sign the informed consent or who were incapable of following instructions. The Institutional Review Board and the Ethics Committee approval were accessed. The research work followed the belief of Helsinki Declaration based on the approval by Institutional Review Board of the hospital and was conducted after getting the informed consent of the patients in accordance with the institutional guidelines. 600 patients met the criteria. 200 patients participated in filling the dry eye questionnaires; they needed emergency care such as mental disabilities or eye surgery.


I. Symptom based dry eye assessment:
Symptoms of dry eye were evaluated using two questionnaires that had been validated for the Spanish language based on MAPI Institute guidelines

  • Dry Eye Questionnaire.
  • 5 (DEQ-5) Ocular Surface Disease Index.
  • Symptomatic Dry Eye Disease defined as having a DEQ.
  • -5 score 12, or.
  • OSDI score 23.

II. DED was graded based on the DEQ-5 score as follows:

  • Normal (0-5).
  • Mild to moderate (6-11).
  • Severe (12).

III. Based on the OSDI score as follows:

  • Normal (0-12).
  • Mild (13-22).
  • Moderate (23-32).
  • Severe (33-100).

Objective dry eye assessment:

The Patients underwent a comprehensive examination test sequence following the DEWS Diagnostic Methodology steps. The measurements included, in the order that they were performed, tear-film breakup time. (4 µl of sterile fluorescein placed in conjunctival sac), fluorescein staining (classified by Oxford protocol), Schirmer test with anesthesia, and meibum quality was rated on a scale of 0 to 4 (0-clear; 1-cloudy; 2-granular; 3-toothpaste type; 4- no meibum extracted).

The patients were considered positive for meibomian gland dysfunction if the score was one and above. Clinical dry eye was defined as having TBUT scores greater than or equal to five, Schirmer 5 or staining >=5 mm. in every participant, the eye with the worst sings was actually used for the Analysis.

Other information:

Information was obtained by patient report on demographics, including age, gender, occupation (outdoors or Indoors), contact lens use (none, soft or hard contact lenses), smoking (current smoker or not), second-hand smoke (current hand smoke or not), the use of continuous positive airway pressure, and exposure to air conditioning. Information on ocular and medical diagnoses (diabetes mellitus, arthritis, thyroid problems, Jorgen’s Syndrome, human immunodeficiency virus, hepatitis, rosaceous, acne, and previous ocular surgery) and the use of topical or systemic medications (artificial tears, lowering-IOP eye drop medication, antihypertensive drugs, diuretics, antihistamines, sleeping pills, tranquilizers, oral contraceptives, and medication for gastritis) was also collected (Chalmers, 2010).

Statistical Analysis

After the data collection, it was merged together for the purpose of analysis. Some specialized software was used to analyze data. The software included Statistical Package for Social Sciences (SPSS). The relationship between eye metrics (objective and subjective) and the risk factors (demographic) were analyzed using the regression analysis. P<=0.05 was considered to be the level of statistical significance.


Out of 350 eligible patients, 338 consecutive patients were recruited for dry eye disease examination. Their mean (SD) age was 44.96 (16.3) years (age range, 16-85 years), and 187 (55%) were women (Table 1). The frequency of dry-eye diagnosed by OSDI: 23 was 59% (95% confidence Interval, 54%-65%). The frequency for dry-eye by DEQ-5 score: 12 was 30% (95% Confidence Interval, 25%-35%).

Dry eye disease classified by severity score can be found in Table 2. Of the patients diagnosed with DED according to OSDI questionnaire, 96% (192/200) had positive TBUT scores: 5 seconds, 34% (68/200) had staining: 2, and 21% (42/200) had Schirmer score: 5 mm. No statistically significant associations were found between the symptoms and clinical signs (p=0.09, p=0.1, p=0.3,). The frequency of the dry eye by signs was 94% (314/338), including 93.5% (314/338) with TBUT scores: 5 seconds, 31% (101/338) with staining: 2, and 22% (74/338) with Schirmer: 5 mm.

Meibomian Gland Dysfunction (MGD) was found in 228 of 338 (68%) patients. In those diagnosed with DED by OSDI, 142 of 200 (71%) had MGD. However, this association was not statistically significant between MGD and the dry eye symptoms by OSDI questionnaire (95% 1.4 CI, 0.9-2.3 p 0.09). In this group of patients, 96.1% (219/338) had positive TBUT (p=<0.05). Risk factors associated with increased DED symptoms included symptoms of dry mouth. Interestingly, patients using over the counter lubricant eye drops were as likely to have OSDI: 23. Over the counter GI ulcer medications use (omeprazole and antihistamine 2 medications) imparted a 3-fold increase of DED symptoms. Patients spending most of their time indoors had less DED symptoms by OSDI, compared to their counterparts (37.5% vs. 62.5%, P=0.04) (Table 3).

Risk factors associated with DEQ5 symptoms included the use of lubricant eye drops and dry mucosa symptoms, both of which imparted a twofold increased of symptoms (95% 2.0 CI, 1.0-3.5 p 0.03 and 95% 2.0 CI, 1.1-3.5 p 0.01. When considering all signs of DED including TBUT, staining, schemers, and meibum quality, we found that 3% of the variability in DEQ-5 scores and 5% of the variability in OSDI scores was explained by tear film parameters (highest Schirmer, TBUT, Oxford, and MGD) (Nichols, 2012).

Comprehensive Patients Examination Three hundred and thirty eight consecutive patients who had been observed in an ophthalmologic center in Mexico City between November and December went through a comprehensive examination, including measurement of tear film break time, Fluorescence staining classified by the Oxford scheme, Schemer test type 1, and the evaluation of Meibomian Gland Dysfunction. The symptoms of OSD were evaluated by the Ocular Surface Disease index and Dry eye questionnaire (Francisco, 2012). Information on Demographics, exposure, past ocular and medical history, and medications was also collected.

I. Symptomatic OSD was defined by OSDI score >=23.

II. Symptomatic OSD was defined as having an OSDI score : 23

III. Clinical OSD was defined as having a Schirmer test: 5, or staining: 2.

Meibum quality was rated on a scale of 0 to 4 (0-clear; 1-cloudy; 2-granular; 3-toothpaste type; 4- no meibum extracted). Patients were considered positive for meibomian gland dysfunction (MGD) if the score was one and above.


From the analysis, the mean patient age was 44.96 (±16.3) years (range, 16-85) and 151 (44.7%) patients were male. The frequency of symptomatic DED based on the OSDI score was 59.2%, with those aged 36-55 years being most likely to have a positive OSDI (42%). The frequency of symptomatic DED based on DEQ-5 was 29.6%, with those aged 36-55 years being most likely to have a positive score (compared to 27.5% and 23% for those >55 years). DED based on any of the clinical signs was observed at a frequency of 91%, and 67.5% of patients had an MGD score: 2. Female gender have a higher risk factor of the dry eye disease by 56.5% according to OSDI score and 62% to DEQ-5 (P=0.04 and 0.1).

Patients spending most of their time indoors had less OSD by OSDI definition, compared to their counterparts (P=0.04). The use of duodenal ulcer modification was found to be at a risk factor for dry eye disease using the OSDI definitions (Viso, 2009). The patients using lubricants eye drops had more dry eye disease by DEQ5 and OSDI definitions, as compared to those who did not use lubricant eye drop (1.0 and 1.1 respectively, p-value<0.05).


This is the first study to demonstrate the frequency of symptomatic and clinical DED in a tertiary care ophthalmology center in Mexico. The frequency of DED in our population ranged from 29.6% using a symptomatic definition to 91% using objective measures.


To our knowledge, no studies have been published regarding the frequency of DED and associated risk factors in patients attending a tertiary care Ophthalmology Center in Mexico. This study was conducted to fill a gap regarding dry eye symptoms and signs in Hispanic Mexican populations (Schiffman,2000). We found that dry eye symptoms was common in patients attending a tertiary care Ophthalmology Center, with frequencies of 59% using OSDI and 30% using the DEQ-5 questionnaire.

Uchino (2012) studied the prevalence of dry eye in Indian patients attending a tertiary ophthalmology clinic. With 400 subjects above 40 years old, they found that 55% had DED based on OSDI. Similar prevalence of DED to our study, interestingly, they reported a higher DED prevalence in patients above 80 years old, with a rate of 41.2% compared to our population, which reported a rate of 27.5% in individuals above 56 years old and a higher frequency in patients aged 36 to 55 with Table 1. The current population had a higher range of age.

Another DED research study in veteran men above 50 years old reported a prevalence of 48% according to DEQ-5 severe symptoms, having a higher percentage than our population. Our results differ between DED diagnosed with DEQ-5 and OSDI questionnaire. An appropriate reason could be explained as the one published by (Chalmers, 2010). OSDI questionnaire considers visual function and includes questions related to difficulty with reading, driving at night, working with a computer, and watching TV, many of our patients seek eye care treatment for visual dysfunction, which could have a higher score for other reasons other than DED (Fiebiger, 2001).

Regarding data from his panic populations, a study based on Hispanic patients in Southern California with 463 subjects reported a DED frequency of 25%, as diagnosed by self-assessed ocular dryness (Chalmers, 2012). The higher frequency of DED in our population, compared to this previous study, may be due to different population ages with a higher range from four to 84 compare to our population from 16 to 85 years old or environmental conditions in the two locations. For example: Mexico City has an altitude of 7,380 ft (2,250 mts) to 12,890 ft (3,930 mts) above sea level compared to 612 ft (186 mts) in Southern California (Nelson, 2001).

More interestingly, no symptom or sign correlated with gender and age correlation with dry eye disease as it was observed in the study. Meibomian Gland dysfunction can lead to abnormalities of tear film composition and functioning, resulting in evaporative dry eye (Kim, 2009). In our study, it was observed that a high frequency of meibomian gland, dysfunction with a 68%. (Bukhari et al) reported similar results. With a prevalence of dry eye of 76.1% reported among patients with meibomian gland dysfunction and 64% by (Acquadro, 2012).

It is known that different medications can cause dry eye as a side effect. In our patients, the intake of gastric ulcer medication was found to have a positive correlation with dry eye. One potential explanation is that ranitidine one of the most common gastric ulcer medications use in Mexico, works as a histamine receptor-specific antagonist. Other risk factors for developing dry eye were evident in our study, as well as other studies, but we did not find any statistically significant association between them and dry eye among our cases (Table 2).

Our study must be considered in the setting of its limitations which included hospital based, patients seen in our Ophthalmology center for the first time, information cannot be extrapolated to general population, or to private clinical practice. Despite these limitations, our study is important because understanding the risk factors that are associated with DES are important because this information can increase our understanding of disease pathogenesis and thus, lead to the development of better therapeutic and treatment options. In conclusion, this study demonstrates a high frequency of DED in patients attending a tertiary care ophthalmology center in Mexico City.

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