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Citation information: Lee S-Y, Petznick A & Tong L. Associations of systemic diseases, smoking and contact lens wear with severity of dry eye.
Ophthalmic Physiol Opt 2012, 32, 518526. doi: 10.1111/j.1475-1313.2012.00931.x
518 Ophthalmic & Physiological Optics 32 (2012) 518526 2012 Singapore Eye Research Institute
S-Y Lee et al. Systemic conditions and associations with dry eye
performed ocular surgery is cataract surgery. The surgical having smoked within the previous 1 year, whereas a
incisions during cataract surgery may inadvertently damage patient was considered to be a current CL user if lenses
corneal nerves,17 and thus reducing corneal sensation.18 have been worn within the previous 1 month.
It has not been reported whether the presence of these
systemic or ocular conditions are associated with more
Clinical assessment
pronounced symptoms or more severe clinical signs of
dry eye or MGD in dry eye patients. This is relevant Assessment of dry eye symptoms was administered by a
because there is a wide range of severity in dry eye trained interviewer using three of eight questions
patients and the methods of treatment required are very described previously.33 The patients were interviewed with
different in mild and severe dry eye.19 the following questions: Did you have sensitivity to bright
The present study was a cross sectional study that used lights in the last month?, Did you have a feeling of ocu-
prospectively collected clinical data from a group of dry lar grittiness in the last month? and Did you have any
eye patients treated in a tertiary eye clinic. The aim of blurring of vision last month? The answer was coded into
this study was to evaluate symptoms and clinical signs in 0 (none at all), 1 (occasionally), 2 (once in the week), 3 (a
patients with dry eye and/or MGD to identify possible few times per week) and 4 (at least once a day).
associations between the presence of ocular and systemic Clinical examination was conducted by a single oph-
conditions and the severity of dry eye. thalmologist (LT) to avoid inter-examiner discrepancies.
Clinical examinations included Schirmers test (without
anaesthesia), TBUT, corneal fluorescein staining, and
Methods
evaluation of meibomian gland status. For TBUT and
Patients corneal staining evaluation, fluorescein was instilled with
Prospective recruitment of patients from the dry eye a fluorescein strip (Fluorets, http://www.Bernell.com)
clinic at the Singapore National Eye Center was per- moistened with non-preserved sodium chloride. TBUT
formed between August 2006 and October 2010. Consec- was measured with a stopwatch and determined as the
utive 510 patients visiting the clinic for the first time time taken (in seconds) for the first dark spot to appear
were enrolled in the study. on the cornea from the moment of eye opening. Corneal
The study protocol was part of a routine, on-going arm fluorescein staining was graded according to a previously
of a long term clinical audit and was approved by the reported corneal fluorescein staining scheme.34 The cor-
Institutional Review Board of the Singapore Eye Research nea was divided into five zones for evaluation superior,
Institute. All study procedures complied with the tenets of inferior, nasal, temporal and central. The number of fluo-
the Declaration of Helsinki on human research. As all pro- rescein spots in each zone was recorded; a greater number
cedures performed were essential for standard clinical care of spots were reflected by a higher score (ranging from 0
of these patients, written consent was not required, but to 5). One extra point was added to the grade if there
consent was taken by assent. Patients were informed of were filaments present in the zone, and another point if
the hospital privacy policy that required all patient identi- there was confluent fluorescein staining.
fiers to be removed for any publication. Anteriorization of Marxs line (mucocutaneous junc-
Patients with dry eye symptoms and at least one abnor- tion) relative to the meibomian gland orifices (Yamaguchi
mal finding out of the three objective clinical tests (Schir- grading)35 in the eyelid margins was assessed as in our
mers test without anaesthetic 10 mm at 5 min, tear previous report33 in temporal and nasal halves of each
break-up time (TBUT) 10 s, or significant corneal fluo- eyelid. A higher score indicated a greater severity of
rescein staining as evaluated by the referring physician) MGD.
were referred to the investigators (LT) clinic and
recruited on their first visit.
Statistical analysis
Statistical analysis was performed using SPSS version 17
Data collection
(http://www.ibm.com/SPSS_Statistics). To maintain inde-
Dry eye symptoms, ocular surface and eyelid assessments pendence of data points, only the data points obtained
were coded in a standardized form and analyzed. Patients from the right eyes were used in the analysis. The age and
were asked about the history of factors known to be asso- gender distribution of the medical and ocular factors were
ciated with dry eye, such as current smoking,8,9,2022 evaluated using either the Chi square tests (for ordinal
current contact lens (CL) wear,2329 previous ocular sur- variables) or MannWhitney U-test (for continuous vari-
geries,3,4,8,9,30 and diagnoses of RA,3,31 DM9,12,13,30,32 and ables). Where a cell number was < 7, the Fishers exact
thyroid disease.3,8,9,30 Current smoking was defined as probability test was used instead.
Ophthalmic & Physiological Optics 32 (2012) 518526 2012 Singapore Eye Research Institute 519
Systemic conditions and associations with dry eye S-Y Lee et al.
The presence of systemic disease, smoking, ocular sur- vs non-smokers) using the MannWhitney U-test since
gery and CL wear were analysed as independent variables the data were not normally distributed.
against the outcome measures (dry eye tests) as depen- Spearman correlation analysis was first performed to
dent variables. Outcome variables such as TBUT were determine any correlation between severity of clinical
compared between dichotomous groups (such as smokers signs and symptoms with age. In logistic regression
Demographics
N 510 130 (25) 380 (75)
Age (mean S.D.) in years 53 14 51 16 54 13
40 95 35 (36.8) 63 (66.3) < 0.001*
4160 244 53 (21.7) 191 (8.3)
61 171 42 (24.6) 129 (75.4)
p-value < 0.001*
Medical history
Rheumatoid arthritis Total 25 (4.9) 1 (0.8) 24 (6.3) 0.008
40 2 (2.1) 1 (2.9) 1 (1.6)
4160 15 (6.1) 0 (0.0) 15 (7.9)
61 8 (4.7) 0 (0.0) 8 (6.2)
p-value 0.28
Diabetes mellitus Total 30 (5.9) 11 (8.5) 19 (5.0) 0.19
40 0 (0.0) 0 (0.0) 0 (0.0)
4160 9 (3.7) 3 (5.7) 6 (3.1)
61 21 (12.3) 7 (16.7) 14 (10.9)
p-value < 0.001*
Thyroid disease Total 41 (8.0) 3 (2.3) 38 (10) 0.004#
40 1 (1.1) 0 (9.0) 1 (1.6)
4160 24 (9.8) 0 (0.0) 24 (12.6)
61 16 (9.4) 3 (7.1) 13 (10.1)
p-value 0.032
Current smoking Total 33 (6.5) 26 (20) 7 (1.8) < 0.001*
40 7 (7.4) 5 (14.3) 2 (3.2)
4160 10 (4.1) 8 (15.1) 2 (1.0)
61 12 (7.0) 10 (23.8) 2 (1.6)
p-value 0.33
Ocular history
LASIK Total 23 (4.5) 5 (6.4) 17 (5.8) 0.81
40 7 (7.4) 0 (0.0) 7 (11.1)
4160 13 (5.3) 3 (5.7) 10 (5.2)
61 4 (2.3) 2 (4.8) 2 (1.6)
p-value 0.17
Cataract surgery Total 41 (8.0) 12 (9.2) 29 (7.6) 0.58
40 0 (0.0) 0 (0.0) 0 (0.0)
4160 9 (3.7) 2 (3.8) 7 (3.7)
61 32 (18.7) 10 (23.8) 22 (17.1)
p-value < 0.001*
CL wear Total 90 (17.6) 12 (9.2) 78 (20.5) 0.005#
1030 41 (43.2) 8 (22.9) 33 (52.4)
4150 33 (13.5) 4 (7.5) 39 (20.4)
6170 7 (4.1) 2 (4.8) 7 (5.4)
p-value^ < 0.001*
RA, rheumatoid arthritis; DM, diabetes mellitus; TD, thyroid disease; CL, contact lens.
*p < 0.001.
#
p < 0.005.
p-value for significant inclination towards a gender.
^p-value for significant association of condition with age.
520 Ophthalmic & Physiological Optics 32 (2012) 518526 2012 Singapore Eye Research Institute
S-Y Lee et al. Systemic conditions and associations with dry eye
models the significant medical\ocular factors were evalu- Table 2. Dry eye symptom grading stratified by the presence of the
ated as independent variables and the associated clinical various systemic conditions and history of ocular surgery
features of dry eye as the dependent variable. The regres- Light Burning
sion results were presented as crude and adjusted odds Condition sensitivity Grittiness sensation
ratios (OR). The measurements for the dependent vari-
Overall median 0.0 (0.03.0) 1.0 (0.03.0) 0.0 (0.02.0)
able were dichotomised into values above or below the
(interquartile
mean of the variable values into 1 and 0 respectively in range)
logistic regression analyses. RA 2.0 (0.04.0) 2.0 (0.04.0) 2.0 (0.03.0)
Since multiple statistical tests have been performed in No RA 0.0 (0.03.0) 1.0 (0.03.0) 0.0 (0.02.0)
this study, the level of statistical significance (p < 0.05) p-value 0.020 0.081 0.052
for the crude analysis was adjusted using the Bonferroni DM 0.0 (0.02.0) 1.0 (0.02.5) 0.0 (0.02.0)
correction. For the analysis for associations between No DM 0.0 (0.03.0) 1.0 (0.03.0) 0.0 (0.02.0)
p-value 0.45 0.44 0.39
symptoms and various conditions a significant p-value
TD 0.0 (0.03.0) 2.0 (0.04.0) 1.0 (0.02.0)
0.002 was used. For the analysis for associations between No TD 0.0 (0.03.0) 1.0 (0.03.0) 0.0 (0.02.0)
clinical signs and various conditions, a Bonferroni adjust- p-value 0.93 0.26 0.53
ment would provide a p-value of 0.0006, but as SPSS can Smoking 1.0 (0.03.3) 2.0 (0.04.0) 0.0 (0.01.0)
only provide a level of significance up to three decimal No smoking 0.0 (0.03.0) 1.0 (0.030) 0.0 (0.02.0)
places, this value was rounded up to p < 0.001. p-value 0.39 0.12 0.19
LASIK 0.0 (0.03.5) 2.0 (0.04.0) 1.0 (0.04.0)
No LASIK 0.0 (0.03.0) 1.0 (0.03.0) 0.0 (0.02.0)
Results p-value 0.93 0.68 0.14
Cataract 0.0 (0.04.0) 2.0 (0.04.0) 1.0 (0.02.5)
Patient demographics surgery
The mean S.D. age of the patients was 53.0 No cataract 0.0 (0.03.0) 1.0 (0.03.0) 0.0 (0.02.0)
14.1 years, with 130 men (25%) (Table 1). 87.8% of the surgery
study population was Chinese, 1.8% Malay, 3.9% Indian p-value 0.67 0.81 0.87
and 6.5% were of other races. We recognise that this was CL wear 0.0 (0.03.0) 0.0 (0.02.0) 0.0 (0.02.0)
No CL wear 0.0 (0.03.0) 0.0 (0.04.0) 0.0 (0.02.0)
primarily a Chinese population and therefore we reanaly-
p-value 0.86 0.002* 0.92
sed the data using Chinese participants only. This reanal-
ysis however essentially produced the same conclusions RA, rheumatoid arthritis; DM, diabetes mellitus; TD, thyroid disease;
(data not shown). CL, contact lens.
In this study, 4.9%, 5.9% and 8.0% of the patients had MannWhitney U-test.
*p 0.002.
a previous diagnosis of RA, DM, and thyroid disease
respectively, and 6.5% were current smokers. 17.6% of
the patients wore CLs, 4.5% and 8.0% had previously had
LASIK and cataract surgery respectively. only two significant findings remained which were RA
The mean Schirmers test value, TBUT, corneal fluores- and superior corneal staining (p < 0.001), and CL wear
cein staining grades, Yamaguchi scores and symptom and ocular grittiness (p = 0.002).
scores in the factors of interest are shown in Tables 2 On further adjustments for age, sex and other ocular/
and 3. systemic factors using crude analysis, we found that a
Severity of most dry eye clinical signs increased with previous diagnosis of RA was associated with greater fluo-
age, including TBUT (p = 0.03), Schirmers test values (p rescein staining in the superior zone of the cornea com-
< 0.001), corneal fluorescein staining (p < 0.05) and pared to dry eye patients without RA (OR = 11.2, 95%
Yamaguchi scores (p < 0.001) (Table 4). On the other CI 4.6, 27.4) (Table 5).
hand, the severity of symptoms was not associated with Additionally, dry eye patients who wore CLs experi-
age. enced less ocular grittiness than other dry eye patients,
Using crude analysis, significant associations were using crude analysis (p = 0.002) (Table 2) and multivari-
found between RA and corneal fluorescein staining (supe- ate analysis (adjusted OR = 0.48, 95% CI 0.26, 0.88)
rior and inferior zones), previous cataract surgery and (Table 5).
Yamaguchi scores (in 3 out of 4 sectors), CL wear and
Schirmers test, and lastly, CL wear and frequency of ocu-
Discussion
lar grittiness (Tables 2 and 3). To exclude findings that
are confounded by age, we repeated the analyses for these This study investigated associations between the presence
associations and adjusted for age. After these analyses, of ocular and systemic conditions and the severity of dry
Ophthalmic & Physiological Optics 32 (2012) 518526 2012 Singapore Eye Research Institute 521
Systemic conditions and associations with dry eye S-Y Lee et al.
Table 3. (a) Dry eye clinical signs, (b) Yamaguchi score and MG plaques in the presence of the various systemic conditions and history of ocular surgery
Condition TBUT (secs) Schirmers (mm) Superior Inferior Temporal Nasal Central
(a)
Overall median 3.0 (2.03.3) 9.0 (5.015.0) 0.0 (0.03.0) 1.0 (0.03.0) 0.0 (0.03.0) 1.0 (0.02.0) 0.0 (0.02.0)
(interquartile range)
RA 2.0 (2.03.0) 9.0 (3.016.0) 2.0 (0.02.0) 3.0 (2.04.0) 0.0 (0.03.0) 2.0 (0.03.0) 0.0 (0.01.0)
No RA 3.0 (2.04.0) 9.0 (5.015.0) 0.0 (0.00.0) 1.0 (0.03.0) 0.0 (0.01.0) 1.0 (0.02.0) 0.0 (0.02.0)
p-value 0.37 0.89 < 0.001* 0.001* 0.19 0.16 0.65
DM 3.0 (2.04.0) 7.0 (4.812.3) 0.0 (0.01.0) 3.0 (1.04.0) 0.0 (0.03.0) 1.0 (0.03.0) 0.0 (0.01.5)
No DM 3.0 (2.03.0) 9.0 (5.015.0) 0.0 (0.01.0) 1.0 (0.03.0) 0.0 (0.01.0) 1.0 (0.02.0) 0.0 (0.02.0)
p-value 0.37 0.95 0.71 0.015 0.59 0.82 0.66
TD 3.0 (2.03) 7.0 (4.013.0) 0.0 (0.01.0) 2.0 (0.03.0) 1.0 (0.02.0) 1.0 (0.02.0) 1.0 (0.02.0)
No TD 3.0 (2.04.0) 9.0 (5.015.0) 0.0 (0.01.0) 1.0 (0.03.0) 0.0 (0.01.0) 1.0 (0.0520) 0.0 (0.02.0)
p-value 0.56 0.16 0.82 0.29 0.078 0.23 0.26
Smoking 3.0 (2.04.0) 15.0 (5.817.8) 0.0 (0.02.0) 1.0 (0.03.0) 0.0 (0.03.0) 1.0 (0.03.0) 1.0 (0.03.0)
No smoking 3.0 (2.03.0) 9.0 (5.015.0) 0.0 (0.01.0) 1.0 (0.03.0) 0.0 (0.01.0) 0.0 (0.02.0) 1.0 (0.02.0)
p-value 0.49 0.18 0.028 0.72 0.20 0.23 0.20
LASIK 3.0 (2.54.0) 11.0 (0.035.0) 0.0 (0.00.5) 1.5 (1.03.0) 0.5 (0.01.0) 1.0 (0.02.0) 1.0 (0.02.5)
No LASIK 3.0 (2.03.0) 9.0 (0.035.0) 0.0 (0.01.0) 1.0 (0.03.0) 0.0 (0.01.3) 1.0 (0.02.0) 0.0 (0.02.0)
p-value 0.036 0. 056 0.89 0.69 0.52 0.86 0.22
Cataract surgery 3.0 (2.03.5) 7.0 (3.010.0) 0.0 (0.00.0) 2.0 (0.03.0) 1.0 (0.02.0) 0.0 (0.02.5) 0.0 (0.02.0)
No cataract surgery 3.0 (2.03.0) 9.0 (5.016.0) 0.0 (0.01.0) 1.0 (0.03.0) 0.0 (0.01.0) 1.0 (0.02.0) 1.0 (0.02.0)
p-value 0.78 0.015 0.11 0.57 0.041 0.81 0.054
CL wear 3.0 (2.04.0) 13.5 (6.020.0) 0.0 (0.01.0) 1.0 (0.03.0) 0.0 (0.02.0) 1.0 (0.03.0) 0.0 (0.01.0)
No CL wear 3.0 (2.03.0) 9.0 (5.014.0) 0.0 (0.00.0) 1.0 (0.03.0) 0.0 (0.01.0) 1.0 (0.02.0) 0.0 (0.02.0)
p-value 0.035 < 0.001* 0.16 0.74 0.86 0.87 0.19
Yamaguchi score
(b)
Overall median 2.0 (2.02.0) 2.0 (2.02.0) 2.0 (2.02.0) 2.0 (2.02.0) 18.0% (15.0, 21.6)
(interquartile range)
RA 2.0 (1.03.0) 2.0 (1.02.0) 2.0 (2.0230) 2.0 (1.02.0) 24.0% (11.5, 43.4)
No RA 2.0 (2.02.0) 2.0 (2.02.0) 2.0 (2.02.0) 2.0 (2.02.0) 17.7% (14.6, 21.4)
p-value 0.52 0.17 0.82 0.70 0.43
DM 2.0 (2.03.0) 2.0 (2.02.0) 2.0 (2.03.0) 2.0 (2.02.0) 16.7% (7.3, 33.6)
No DM 2.0 (2.02.0) 2.0 (2.02.0) 2.0 (2.02.0) 2.0 (1.02.0) 18.1% (14.9, 21.8)
p-value 0.003 0.08 0.08 0.053 0.84
TD 2.0 (1.02.0) 2.0 (2.02.0) 2.0 (2.02.0) 2.0 (1.03.0) 17.1% (8.5, 31.3)
No TD 2.0 (2.02.0) 2.0 (2.02.0) 2.0 (2.02.0) 2.0 (2.02.0) 18.2% (14.9, 21.9)
p-value 0.20 0.54 0.99 0.67 0.86
Smoking 2.0 (2.03.0) 2.0 (2.03.0) 2.0 (2.02.3) 2.0 (2.02.0) 24.2% (12.8, 41.0)
No smoking 2.0 (2.02.0) 2.0 (2.02.0) 2.0 (2.02.0) 2.0 (1.02.0) 17.6% (14.5, 21.3)
p-value 0.037 0.006 0.65 0.085 0.34
LASIK 2.0 (2.02.0) 2.0 (2.02.0) 2.0 (2.02.0) 2.0 (2.02.0) 8.7% (2.4, 26.8)
No LASIK 2.0 (2.02.0) 2.0 (2.02.0) 2.0 (2.02.0) 2.0 (1.02.0) 18.4% (15.2, 22.1)
p-value 0.73 0.47 0.78 0.44 0.68
Cataract surgery 2.0 (2.03.0) 2.0 (2.02.0) 2.0 (2.03.0) 2.0 (2.02.0) 23.4% (13.6, 37.2)
No cataract surgery 2.0 (2.02.0) 2.0 (2.02.0) 2.0 (2.02.0) 2.0 (1.02.0) 17.4% (4.2, 21.1)
p-value < 0.001* 0.006 < 0.001* 0.001* 0.75
CL wear 2.0 (2.02.0) 2.0 (2.02.0) 2.0 (2.02.0) 2.0 (2.02.0) 21.1% (14.0, 30.6)
No CL wear 2.0 (2.02.0) 2.0 (2.02.0) 2.0 (2.02.0) 2.0 (1.02.0) 17.4% (14.1, 21.4)
p-value 0.02 0.008 0.50 0.89 0.40
RA, rheumatoid arthritis; DM, diabetes mellitus; TD, thyroid disease; CL, contact lens.
MannWhitney U-test.
*p < 0.001.
522 Ophthalmic & Physiological Optics 32 (2012) 518526 2012 Singapore Eye Research Institute
S-Y Lee et al. Systemic conditions and associations with dry eye
plaques
eye in Asian patients. Since dry eye patients may present
0.689
with more than one predisposing factor for dry eye, we
MG
performed multivariate analysis adjusted for age, sex, and
other predisposing factors. After adjustments, we found
<0.001*
Lower-
0.297
that RA was associated with more severe signs of dry eye
nasal
which had not been reported previously. This current
temporal study did not include normal control subjects as the focus
<0.001*
of this study was to assess the relationship between sever-
Lower-
0.369 ity of dry eye and selected systemic and ocular condi-
tions.
<0.001*
We first analysed the severity of each clinical feature
Upper-
0.327
Yamaguchi Score
nasal
with age and found that most clinical signs were more
Mean age of patients who presented with MG plaques was 53.7 15.1 years and mean age of patients without MG plaques was 53.8 13.9 years. pronounced with increasing age, although such correla-
temporal
0.377
0.159
0.069
0.120
0.030
Rheumatoid arthritis
Inferior
0.091
0.040
0.414
Schirmers
0.638
0.314
0.315
sensitivity
0.369
p-value
Ophthalmic & Physiological Optics 32 (2012) 518526 2012 Singapore Eye Research Institute 523
Systemic conditions and associations with dry eye S-Y Lee et al.
524 Ophthalmic & Physiological Optics 32 (2012) 518526 2012 Singapore Eye Research Institute
S-Y Lee et al. Systemic conditions and associations with dry eye
Clinical relevance the Salisbury Eye Evaluation Study. Arch Ophthalmol 2000;
118: 819825.
The current study revealed findings that affect the man- 6. Schaumberg DA, Sullivan DA, Buring JE & Dana MR.
agement of dry eye patients. The severity of corneal fluo- Prevalence of dry eye syndrome among US women. Am J
rescein staining in patients with RA implied that these Ophthalmol 2003; 136: 318326.
patients would usually require more intense anti-inflam- 7. Kim KW, Han SB, Han ER et al. Association between
matory therapy. Clinicians managing cases of dry eye depression and dry eye disease in an elderly population.
should be familiar with signs and symptoms of diseases Invest Ophthalmol Vis Sci 2011; 52: 79547958.
such as RA in order to detect these undiagnosed systemic 8. Chia EM, Mitchell P, Rochtchina E et al. Prevalence and
conditions and facilitate appropriate treatment. Since the associations of dry eye syndrome in an older population:
study population is predominantly Chinese, results may the Blue Mountains Eye Study. Clin Exp Ophthalmol 2003;
not be applicable to populations consisting of other 31: 229232.
races. 9. Moss SE, Klein R & Klein BE. Prevalence of and risk fac-
tors for dry eye syndrome. Arch Ophthalmol 2000; 118:
12641268.
Conclusion 10. Kassan SS & Moutsopoulos HM. Clinical manifestations
The study found that patients with RA were not only pre- and early diagnosis of Sjogren syndrome. Arch Intern Med
disposed to having dry eye, but also tended to have more 2004; 164: 12751284.
severe dry eye. In the management of dry eye, the sys- 11. Fujita M, Igarashi T, Kurai T et al. Correlation between
dry eye and rheumatoid arthritis activity. Am J Ophthalmol
temic diseases should always be assessed, and discussions
2005; 140: 808813.
with non-ophthalmic physicians on the diagnosis of the
12. Dogru M, Katakami C & Inoue M. Tear function and
systemic illness should be one component of the manage-
ocular surface changes in noninsulin-dependent diabetes
ment plan.
mellitus. Ophthalmology 2001; 108: 586592.
13. Goebbels M. Tear secretion and tear film function in
Acknowledgements insulin dependent diabetics. Br J Ophthalmol 2000; 84:
1921.
Grant support was provided by NMRC/1206/2009, 14. Albietz JM, Lenton LM & McLennan SG. Dry eye after
NMRC/CSA/013/2009, NMRC/TCR/002-SERI/2008 and LASIK: comparison of outcomes for Asian and Caucasian
NMRC/CG/SERI/2010 from National Medical Research eyes. Clin Exp Optom 2005; 88: 8996.
Council (NMRC), Singapore, and BMRC 10/1/35/19/670 15. De Paiva CS, Chen Z, Koch DD et al. The incidence and
from Biomedical Research Council (BMRC), Singapore. risk factors for developing dry eye after myopic LASIK.
Am J Ophthalmol 2006; 141: 438445.
Competing interest 16. Shoja MR & Besharati MR. Dry eye after LASIK for myo-
pia: Incidence and risk factors. Eur J Ophthalmol 2007; 17:
None to declare. 16.
17. Minassian DC, Rosen P, Dart JK et al. Extracapsular cata-
ract extraction compared with small incision surgery by
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