|Year : 2022 | Volume
| Issue : 3 | Page : 354-360
Prevalence and risk factors associated with dry eye disease among adults in a population-based setting in South-West Nigeria
AO Betiku1, OO Oduyoye2, OO Jagun1, OS Olajide1, SO Adebusoye1, UO Aham-Onyebuchi1
1 Department of Surgery, Ben Carson School of Medicine, Babcock University, Ilishan-Remo, Ogun State, Nigeria
2 Department of Public Health, Babcock University, Ilishan-Remo, Ogun State, Nigeria
|Date of Submission||11-Jun-2021|
|Date of Acceptance||17-Dec-2021|
|Date of Web Publication||16-Mar-2022|
Dr. A O Betiku
Department of Surgery, Babcock University Teaching Hospital, Ilishan-Remo, Ogun State
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Dry eye disease (DED) occurs as a result of an abnormality in tear production, tear consistency, and tear evaporation. Aim: The aim of this study is to determine the prevalence and risk factors associated with dry eye disease in a population-based setting in Southwest Nigeria. Patient and Methods: A cross-sectional study was conducted at a medical outreach at Iperu Remo in Nigeria. A systematic random sampling technique was used to select 415 participants. Symptoms of dry eye were evaluated using the Ocular Surface Disease Index questionnaire. Tear film break-up time (TBUT), fluorescein staining, Schirmer test with anesthesia, and meibomian gland were evaluated. The diagnosis of DED was confirmed when the OSDI score is ≥13 and TBUT is less than 10 seconds. Data were analyzed using descriptive statistics, Chi-square, and logistic regression analyses at a 0.05 level of significance. Results: The overall prevalence of DED was 28.2%. Adults aged between 31 and 40 years were 23 times more likely to be diagnosed with dry eyes (aOR = 23.13; 95% CI: 1.32 – 405.99; P = 0.032) compared to those between 16 and 20 years. Female adults were about four times more likely to be diagnosed with dry eyes (aOR = 3.59; 95% CI: 1.44 – 8.94; P = 0.006). The use of drugs was also significantly associated with dry eyes. Conclusion: This study shows a fairly high prevalence of DED among adults in a semi-urban area in Southwest Nigeria. Ophthalmologists and other eye care workers need to be cautious about the DED and offer appropriate treatment options to patients.
Keywords: Dry eye disease, Ocular Surface Disease Index (OSDI), Schirmer test, Tear film break-up time (TBUT)
|How to cite this article:|
Betiku A O, Oduyoye O O, Jagun O O, Olajide O S, Adebusoye S O, Aham-Onyebuchi U O. Prevalence and risk factors associated with dry eye disease among adults in a population-based setting in South-West Nigeria. Niger J Clin Pract 2022;25:354-60
|How to cite this URL:|
Betiku A O, Oduyoye O O, Jagun O O, Olajide O S, Adebusoye S O, Aham-Onyebuchi U O. Prevalence and risk factors associated with dry eye disease among adults in a population-based setting in South-West Nigeria. Niger J Clin Pract [serial online] 2022 [cited 2022 Dec 10];25:354-60. Available from: https://www.njcponline.com/text.asp?2022/25/3/354/339720
| Introduction|| |
Dry eye disease (DED; also known as keratoconjunctivitis sicca) occurs as a result of an abnormality in tear production, tear consistency, and tear evaporation. Furthermore, the International Dry Eye Workshop in 2007 defined dry eye as a multifactorial 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. At the Tear Film and Ocular Surface Society (TFOS) Dry Eye Workshop II, a new definition for DED was a multifactorial disease of the ocular surface characterized by a loss of homeostasis of the tear film, and accompanied by ocular symptoms, in which tear film instability and hyperosmolarity, ocular surface inflammation and damage, and neurosensory abnormalities play etiological roles. Dry eye symptoms include pain and redness of the eye, burning or stinging, sandy or gritty feeling, and stringy discharge from the eye., These symptoms usually improve with treatment; however, the disease has no cure. Dry eye is one of the most frequent causes of ocular irritation in ophthalmology practice.,
Estimated reports of the prevalence of dry eye vary from 18.4% to 68.9% in hospital-based studies in adults aged 40 and above,,, while in population-based studies, the prevalence ranges from 14.4% to 50.1%.,, Systematic reviews and meta-analysis show a larger range between 9.5% and 87.5%.
Sociodemographic factors associated with dry eye include age and sex. It is more common in women and older adults aged 40 years and above. Other factors include smoking, air pollution, excessive exposure to sunlight, drugs, and some ocular surface diseases such as pterygium, Meibomian gland More Details dysfunction.,,
Limited studies on the prevalence and risk factors associated with dry eye syndrome in population-based settings are available in Nigeria. Most of the studies available are usually hospital-based. This study is therefore designed to determine the prevalence and risk factors of DED in a population-based setting in a semi-urban area in South-Western Nigeria.
| Materials and Methods|| |
A population-based cross-sectional survey was conducted at the Kesington Adebukunola Adebutu Foundation medical outreach, Iperu Remo in Ikenne Local Government Area of Ogun State, Nigeria. Ikenne Local Government Area is a semi-urban area that consists of five towns namely: Ikenne, Iperu, Ilisan, Irolu, and Ogere. Residents of these towns usually converge at this outreach once every month for medical checkups. Four hundred and fifteen (415) patients were selected by systematic random sampling where every third patient presented at the outreach was included in the study once they met the inclusion criteria. All patients included in the study gave informed consent before participating in the study. Patients aged less than 16 years were excluded from the study including patients needing emergency eye surgery or those who have undergone an eye surgical procedure in the last 6 months. Symptoms of dry eyes were evaluated using the Ocular Surface Disease Index (OSDI) questionnaire. Patients underwent a comprehensive eye examination including slit lamp biomicroscopy. Dry eye tests conducted were, namely, tear film break-up time (TBUT), corneal fluorescein staining, Schirmer's test with anesthesia, and meibomian gland evaluation. Information regarding patients' sociodemographic characteristics, smoking status, and environmental exposures were collected. Moreover, information on previous ocular diagnoses, medical conditions, and systemic medications was also included. The measurement of tear break-up time was done by inserting a fluorescein strip soaked with non-preserved saline in the inferior conjunctival fornix. Using the cobalt blue light filter of the slit lamp, the tear film is examined and the time taken for the first black spots to appear on the cornea after the last blink is known as TBUT. The cornea was also examined for the presence of staining. A Schirmer test with anesthesia was done using a Schirmer strip. The topical anesthetic was instilled into the inferior conjunctival fornix and the excess was removed. The Schirmer strip was inserted at the junction of the outer third and middle third of the lower lid. The strip is removed after 5 min and the length of the strip wetted was measured in millimeters. Less than 6 mm of wetting was considered abnormal. The diagnosis of dry eye disease (DED) is made when the OSDI score is ≥13 and TBUT is less than 10 s. Data collected were entered, coded, cleaned, and analyzed using the Statistical Package for Social Sciences version 23. Descriptive statistics including frequencies and percentages; Chi-square test and correlation analyses were used to determine the relationship between sociodemographic characteristics and prevalence of DED. Logistic regression analyses will be used to determine the risk factors for DED. Level of statistical significance was considered at P values ≤ 0.05. Ethical approval for this study was sought from the Institution's Health Research Ethics Committee before it was conducted. The tenets of the Helsinki Declaration were strictly adhered to throughout the study.
| Results|| |
A total of 415 adults participated in the study. The majority of the respondents were aged between 41 – 50 years (29.4%) while more than half of them were females (75.2%). The majority of the respondents were married (71.8%), with at least secondary education (34.7%), and were Christians (76.9%). A high percentage of the respondents (94.9%) were Yorubas, which is the predominant ethnic group in the study area. One hundred and fifty-four (37.1%) participants had an ocular history of spectacles, 116 (28.0%) had a medical history of hypertension, 126 (30.4%) had a drug history of systemic drugs while 49 (11.8%) have had drug allergies before [See [Table 1]].
Prevalence of Dry Eye disease according to the Schirmer's test, Tear film break-up time (TBUT), Meibum quality, and the OSDI scores
[Table 2] shows the prevalence of DED according to the various tests conducted. Schirmer's test results revealed that 113 (27.2%) participants had dry eyes (≤ 5 mm); 158 (38.1%) had DED (TBUT <10 seconds), 65 (15.7%) were diagnosed of cloudy, granular, or toothpaste-like meibum quality, 343 (82.7%) had mild (20.5%), moderate (31.3%), or severe (30.8%) OSDI scores while 30 (7.3%) had abnormal corneal staining. The overall prevalence of DED was 28.2% as a result of being diagnosed with dry eyes according to a combination of OSDI and TBUT.
|Table 2: Prevalence of dry eye according to the Schirmer's test, tear film break-up time (TBUT), Meibum quality, and the OSDI scores|
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Association between the prevalence of Dry Eye disease (according to the OSDI scores) and sociodemographic characteristics
[Table 3] shows the association between DED prevalence and sociodemographic factors. Results showed that DED varied significantly (p < 0.05) according to the age, sex, educational status, and religion of the respondents. The prevalence of dry eye was significantly higher among adults aged 60 years and above (29.7%), females (77.8%), among those who had secondary education (33.2%), and Christians (74.6%).
|Table 3: Association between prevalence of dry eye (according to OSDI scores) and sociodemographic characteristics|
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Association between prevalence of Dry Eye disease (combination of OSDI scores and TBUT) and sociodemographic characteristics
[Table 4] shows the association between DED prevalence (combination of OSDI scores and TBUT) and sociodemographic factors. Results showed that there was no significant association between DED and sociodemographic characteristics. The prevalence of dry eyes increased with age with the highest prevalence occurring in adults above 60 years (33.3%) [χ2 = 3.569, P = 0.613]. Also, the prevalence of dry eyes was higher in females (71.8%) compared to their male counterparts (28.2%), higher among the married (68.4%), those who had primary education (30.8%), the Yorubas (92.3%), and those who were Christians (76.1%). These relationships were, however, not statistically significant.
|Table 4: Association between prevalence of dry eye (combination of OSDI and TBUT) and sociodemographic characteristics|
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Association between environmental factors and dry eye
[Table 5] shows the association between environmental factors and dry eye. The results revealed that air pollution (χ2 = 4.329; P = 0.040) and drugs (χ2 = 4.710; P = 0.030) were positively associated with dry eyes among the respondents.
|Table 5: Association between environmental factors and prevalence of dry eye according to the OSDI scores|
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Logistic Regression of the factors associated with dry eye
Results showed that middle age, sex, level of education, and drugs were significantly associated with dry eye prevalence [Table 6].
|Table 6: Logistic regression analysis of the factors associated with dry eye disease|
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Adults between 31 and 40 years were 23 times more likely to be diagnosed with dry eye (aOR = 23.13; 95% CI: 1.32 – 405.99; P = 0.032) compared to those between 16 and 20 years. This was statistically significant. Adults between 21 and 30 years were about 24 times more likely to be diagnosed with dry eye (aOR: 24.38; 95% CI: 0.61 – 975.99; P = 0.090) compared to those between 16 and 20 years. However, it was not statistically significant. Furthermore, female adults were about four times more likely to be diagnosed with dry eyes (aOR = 3.59; 95% CI: 1.44 – 8.94; P = 0.006) compared to their male counterparts. This was statistically significant. Moreover, those who had secondary and tertiary education were 4% (aOR: 0.04; 95% CI: 0.00 – 0.93; P = 0.045) and 3% (aOR: 0.03; 95% CI: 0.00 – 0.86; P = 0.040) less likely to be diagnosed with dry eyes compared to those who had no formal education, respectively. The use of drugs was also significantly associated with dry eyes. Those who reported having been on drugs prior to the study were 4% less likely to be diagnosed with dry eye (aOR: 0.04; 95% CI: 0.00 – 0.54; P = 0.016) compared to those who were not.
| Discussion|| |
DED is one of the most frequent ophthalmic disorders and may have a significant impact on the quality of life of individuals. It causes various disabling symptoms and comprises the results of corneal, cataract, and refractive surgical procedures.
Various objective tests have been developed to diagnose DED and its severity. However, many of the procedures used are largely unrepeatable and show poor correlation with patient symptoms and quality of life. In this study, five diagnostic tests including one validated test were used to screen and diagnose DED and its severity among adults in a population-based setting in South-Western Nigeria. They included: Schirmer's test, TBUT, Corneal staining, meibum quality, and OSDI.
This study revealed that the prevalence of dry eye varied according to the tests conducted including corneal staining (7.3%), meibum quality (15.7%), Schirmer's test (27.2%), TBUT (38.1%), and OSDI (82.7%). The overall prevalence of dry eye was 28.2% as a result of being diagnosed with DED on a combination of OSDI and TBUT scores as recommended by TFOS Dry Eye Workshop II. Prevalence of dry eyes reported in this study in relation to corneal staining score, Schirmer's test score of ≤5 mm and TBUT of <10 seconds was higher than what was reported by Guo et al. in the Henan Eye study. Furthermore, the Beaver Dam Eye Study, studies in Singapore and Japan showed a prevalence of dry eye between 4.5% and 15%. Onwubiko et al. reported a prevalence of 19.2%. However, studies conducted in India, Mexico City, China, and Indonesia showed a prevalence between 23% and 43%. A plausible explanation for variations in the prevalence of dry eye across the globe is the rural–urban differences. Some studies were conducted in rural areas while some were conducted in urban areas. The sample size of the populations tested could be another possible explanation for these variations. The larger the sample size, there is increased likelihood of a higher prevalence of dry eye and validity of results. Lack of uniformity in the definition of DED, questionnaires, study designs used, study populations and sampling methods used, and set of diagnostic tests to confirm or rule out the disease are probable factors for the wide range of the prevalence of DED.,
Sociodemographic factors that were significantly associated with dry eye were age, female sex, level of education, and religion. Prevalence of dry eye increased with age with more cases above 60 years and was greater in females than males according to the OSDI scores. Females were about four times more likely to be diagnosed with DED compared to their male counterparts. Those who had secondary education were more affected. These findings are similar to what was reported in studies conducted in Taiwan, Singapore, and Smith. These relationships were statistically significant.
Environmental factors that were significantly associated with the prevalence of dry eyes in this study were air pollution and drugs. In Nigeria, air pollution is one of the major environmental hazards that negatively affect ocular health as a result of industrial emission of toxic gases into the environment, fumes from car exhaust pipes, smoking, and bush burning. In rural and semi-urban areas, where this study was conducted, the usage of firewood and bush burning for cooking food is a common norm, which can increase the likelihood of developing dry eye caused by fumes/smoke. Tan et al. reported a significant association between medication history and prevalence of DED. However, there was no significant association between smoking and DED in the same study. This could be a result of the population-sex difference. The males tend to smoke more than females in an average African society.
Furthermore, the multivariate analysis showed that adults aged less than 40 years were more likely to be diagnosed with DED. This finding is similar to the findings of Schaumberg who reported that the prevalence of DED increases among adults aged less than 50 years. However, some studies showed that adults above 60 years of age are more likely to be diagnosed with DED compared to the younger generation.,, Other independent risk factors for DED include the level of education (especially those who had secondary and tertiary educations) and those who were taking medications. These relationships were seen to be statistically significant.
| Conclusion|| |
This study demonstrates a fairly high prevalence of DED among adults in a semi-urban area in South-Western Nigeria. This condition causes a considerable impact on daily tasks further making it an important public health problem that requires utmost attention and preventive measures against future occurrences. Ophthalmologists and other eye care workers need to be cautious against DED and offer appropriate treatment options to patients. Independent categories under DED risk are age, female sex, level of education, air pollution, and those taking medications. There is a need for further studies in the prevalence and risk factors of DED in rural and urban settings that will aid preventive measures to be put in place and adequate attention paid to diagnosis and management of DED.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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