Dry Eye Burden Runs High in Adults With Diabetes Across Amhara Hospitals
Symptomatic dry eye disease affected a large share of adults with diabetes receiving care at five comprehensive specialised hospitals in Ethiopia’s Amhara Region, with a prevalence of 40.4% among 1,134 participants. The finding places an everyday ocular complaint squarely inside the chronic complication burden of diabetes, where surface discomfort, tear-film instability, and corneal nerve dysfunction can accumulate in parallel with retinopathy and neuropathy.
The study enrolled adults older than 18 years who had lived in the region for more than six months and were selected by systematic random sampling between 8 May 2023 and 8 June 2023. A total of 1,199 patients were targeted, and 1,134 completed participation, yielding a response rate of 94.5%. The multicentre design adds breadth to the estimate, drawing from the University of Gondar, Debretabor, Tibebe Gion, Felege Hiwot and Debre Markos comprehensive specialised hospitals.
Dry eye in diabetes is not a cosmetic complaint or a minor nuisance. Hyperglycaemia can disrupt the lacrimal functional unit, alter ocular surface inflammation, and damage small nerves that help regulate blink and tear secretion. Once neuropathic injury and microvascular disease begin to affect the eye, symptoms can persist even when vision tests appear relatively stable.
Poor Glycaemic Control and Long Disease Duration Drove the Odds Up
The strongest clinical signal in the analysis came from glycaemic status. Poor glycaemic control was associated with more than doubled odds of symptomatic dry eye, with an adjusted odds ratio of 2.58 and a 95% confidence interval of 1.86 to 3.58. A long duration of diabetes also carried a similar pattern, with patients living with diabetes for 10 years or longer showing an adjusted odds ratio of 2.77, 95% confidence interval 1.95 to 3.95.
These associations fit the biology of chronic metabolic injury. Persistent glucose exposure accelerates oxidative stress, weakens epithelial integrity and promotes inflammatory changes across the ocular surface. Over time, the cumulative effect of diabetes appears to move beyond retinal disease alone and into the tissues responsible for lubrication, sensation and tear production.
Proliferative diabetic retinopathy showed the strongest association in the model, with an adjusted odds ratio of 5.58 and a wide confidence interval of 2.1 to 14.39. The size of that effect suggests that advanced microvascular disease in the eye may travel with a broader burden of surface damage, not just posterior segment pathology. For clinicians, the presence of proliferative retinopathy should prompt attention to symptoms that may otherwise remain hidden beneath the larger concern of retinal threat.
Neuropathy and Eye Care Gaps Point to a Shared Complication Pathway
Peripheral diabetic neuropathy was also strongly linked to symptomatic dry eye, with an adjusted odds ratio of 3.76 and a 95% confidence interval of 2.58 to 5.48. The connection is biologically plausible. Diabetic neuropathy can impair corneal sensory input, and reduced sensory drive can blunt reflex tearing and blink dynamics. Once that feedback loop fails, the ocular surface becomes increasingly vulnerable to dryness, irritation and epithelial damage.
Poor eye check-up practice emerged as another independent factor, with an adjusted odds ratio of 1.98 and a 95% confidence interval of 1.49 to 2.62. In practical terms, this means the patients least engaged in routine ocular assessment were nearly twice as likely to have symptomatic dry eye. The result speaks to a missed opportunity in diabetes care: symptoms and surface disease can progress while attention remains concentrated on glucose readings, medications and retinal screening alone.
Clinical care in diabetes often separates retinal disease, neuropathy and metabolic control into different lanes. The data argue for treating them as parts of the same complication network, because surface symptoms may be one of the earliest signals that the eye is already under chronic diabetic stress.
Why This Matters at the Bedside
Dry eye symptoms can reduce reading comfort, impair concentration and interfere with adherence to treatment routines. In diabetes clinics, patients may not volunteer ocular discomfort unless directly asked, especially when vision loss is absent. A structured symptom review and a routine eye history can reveal a problem that otherwise stays unrecorded.
The prevalence estimate of 40.4% is high enough to justify proactive screening in routine diabetes follow-up, particularly for patients with long-standing disease, poor glycaemic control, peripheral neuropathy or established retinopathy. Simple questioning about burning, grittiness, foreign body sensation and tearing variability can help identify patients who need further ophthalmic evaluation. This is especially relevant in settings where patients may present infrequently and ophthalmology access may be limited.
The study also reinforces a more integrated model of diabetes care. Maintaining glycaemic control is not only about preventing macrovascular events or nephropathy; it also appears to influence the integrity of the ocular surface. As diabetes duration lengthens, the risk profile expands, and dry eye should be viewed as part of that broader burden rather than an isolated complaint.
Cross-Sectional Data Define the Signal, Not the Timeline
Because the work used a cross-sectional design, it cannot determine the sequence in which dry eye symptoms, neuropathy and retinopathy developed. The associations are strong, but the direction of causality remains unmeasured. A patient with more advanced diabetes may simply be more likely to accumulate all three complications at once.
Even with that limitation, the pattern is clinically coherent. The eye surface, corneal nerves and retinal microvasculature all respond to chronic metabolic injury, and the study captures how often those pathways converge in routine hospital practice. The response rate of 94.5% strengthens confidence in the hospital-based estimate, but the findings still reflect a specialised care setting rather than the general community.
For clinicians managing adults with diabetes, the practical message is direct: ask about dry eye, look for it in patients with poor control or long disease duration, and do not wait for severe visual complaints before considering ophthalmic assessment. The combination of retinopathy, neuropathy and poor follow-up marks a group in which ocular surface disease is likely to be present and easily missed.