Loss of Tear Glands Linked to Suboptimal Diabetes Control

Miriam E. Tucker

April 01, 2020

Loss of meibomian glands in the eye, which contribute to producing tears, appears to be associated with high rates of dry eye in individuals with diabetes and may serve as a biomarker for suboptimal glycemic control, new research suggests.

Gloria Wu, MD, an ophthalmologist at the University of California, San Francisco, presented the findings from a small study using infrared imaging of the eyelids in 120 patients with dry eye during a virtual press briefing held March 30, originally scheduled for the ENDO 2020 meeting.

The meibomian glands are the vertical striations that line the margins of the lower eyelids. They produce the lipid that combines with aqueous fluid from the lacrimal gland to create the tear film. Absence of meibomian glands can lead to dry eyes, eye pain, discomfort, and blurred vision.

Dry eye affects about 7% of the US population, compared to 57% of people with type 1 diabetes and 70% with type 2 diabetes. Two proposed mechanisms for the phenomenon in diabetes are microischemia and inflammation, Wu said.  

In her study, loss of meibomian glands was far more common among the 60 participants with dry eye and diabetes than among the 60 participants with dry eye but without diabetes, and the amount of gland loss was directly linked to A1c level.  

The findings suggest that loss of meibomian glands could serve as a diabetes biomarker, particularly in underserved areas where A1c testing might not be readily available.

Wu noted many newer smartphones, including the Samsung Galaxy 10S and iPhone 10, Xs, and 11, have infrared cameras that could potentially help characterize dry eye in patients with diabetes.

"In the future, we hope patients can use [smartphones] and flip their own eyelids and take a picture. We hope that in rural health clinics and community health centers we can use this device that people have...When people complain of dry eye and they have diabetes we can consider [closer diabetes monitoring]," said Wu.

Asked to comment, endocrinologist David C. Lieb, MD, told Medscape Medical News, "It's important for providers who care for people with diabetes to know that diabetes is associated with a high incidence of meibomian gland dysfunction leading to dry eye. That's another reason people with diabetes need to make sure they see their eye care specialist on a regular basis."

"When I ask patients if they've seen their eye specialist I may add dry eye to my list of questions rather than just asking them when was the last time they went," added Lieb, who is associate professor of medicine at Eastern Virginia Medical School in Norfolk.

"I may ask them if they have symptoms of dry eye, and if they do, it's something they need to talk about with that individual."

Meibomian Gland Disappearance Correlated With Glycemic Control

Wu and colleagues retrospectively reviewed electronic health records for 120 patients diagnosed with dry eye, including 60 patients with and 60 patients without type 2 diabetes.

Those with diabetes were a mean age of 65 years, split evenly between men and women. The controls were younger, averaging 54 years, and comprised 37 men and 23 women.

Researchers performed infrared imaging (820 nm) of the lid; percentage loss of meibomian glands was calculated for each eye, then averaged per patient.

They found that 51.5% of patients in the diabetes group had lost meibomian glands, compared with just 11.3% of controls, a highly significant difference (P = .0001).

When A1c was also assessed, only four of 60 participants with A1c ≤ 5.9% lost ≥ 25% of the glands, compared with 55 of 60 participants with A1c ≥ 6.0%.

And specifically among those with diabetes, 35 of 37 with A1c > 6.6% lost > 40% of the glands, compared with just 12 of 23 participants with A1c < 6.5% (all P < .0001).

"In patients with dry eye and diabetes, loss of meibomian glands is associated with elevated A1c...[and] may suggest a need for...further monitoring of the patient's diabetic condition," say the researchers.

Asked whether the glands could re-grow with improved glycemic control, Wu said she has not looked at that in people with diabetes, but in some patients who receive intensive treatment for dry eye with artificial tears or cyclosporine, the glands do grow back after about 6 months.

Lieb said he found the smartphone diagnostic idea "fascinating, especially in an area where you might not be able to easily measure an A1c. Most people have access to point-of-care A1c testing but not everybody can make it to a doctor's office."

And, he added, "anything that's noninvasive has some potential benefit."

Wu and Lieb have reported no relevant financial relationships.

ENDO 2020. Abstract MON-704. Presented March 30, 2020.

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