Relationship between dry eye and glycosylated haemoglobin among diabetics in Ibadan, Nigeria
Segun Isaac Olaniyan, Oluyemi Fasina, Charles Obu Bekibele, Ayobade Oluwole Ogundipe
The Pan African Medical Journal. 2019;33:14. doi:10.11604/pamj.2019.33.14.14074

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Relationship between dry eye and glycosylated haemoglobin among diabetics in Ibadan, Nigeria

Cite this: The Pan African Medical Journal. 2019;33:14. doi:10.11604/pamj.2019.33.14.14074

Received: 09/10/2017 - Accepted: 24/04/2019 - Published: 08/05/2019

Key words: Diabetes mellitus, dry eye, glycosylated haemoglobin, Ibadan, Nigeria

© Segun Isaac Olaniyan et al. The Pan African Medical Journal - ISSN 1937-8688. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Available online at: http://www.panafrican-med-journal.com/content/article/33/14/full

Corresponding author: Oluyemi Fasina, Department of Ophthalmology, University College Hospital, Ibadan, Nigeria (yemifash2000@yahoo.com)


Relationship between dry eye and glycosylated haemoglobin among diabetics in Ibadan, Nigeria

Segun Isaac Olaniyan1, Oluyemi Fasina1,&, Charles Obu Bekibele1, Ayobade Oluwole Ogundipe1

 

1Department of Ophthalmology, University College Hospital, Ibadan, Nigeria

 

 

&Corresponding author
Oluyemi Fasina, Department of Ophthalmology, University College Hospital, Ibadan, Nigeria

 

 

Abstract

Introduction: dry eye is a fairly common ocular surface disorder which significantly affects the quality of life of patients. This study aimed to determine the prevalence, and relationship between dry eye and glycosylated haemoglobin (HbA1c) among patients with diabetes mellitus.

 

Methods: this was a descriptive hospital-based study conducted among patients diagnosed with diabetes mellitus and attending the Diabetic Clinic at a tertiary health facility in Ibadan, south-western Nigeria. Dry eye was assessed using the standardized Ocular Surface Disease Index Questionnaire administered to the eligible respondents on dry eye symptoms. Detailed ocular examination including the tear break-up time (TBUT) and Schirmer I test were carried out and a recent glycosylated haemoglobin value was also obtained.

 

Results: one hundred and eighty-nine Type 2 diabetic patients were studied, with 68.8% female and a mean age of 60.2 ± 10.3 years. The frequency of dry eye among patients was 21.7% (95% CI, 15.8-27.6). The most commonly reported symptoms of dry eye was "feeling of gritty sensation" (78%, 95% CI, 65.4-90.7) and "blurred vision" (73.2%, 95% CI, 59.6-86.7) while "discomfort in windy areas" (61%, 95% CI, 46.0-75.9) was the most common environmental trigger. No statistically significant correlation was noted between dry eye and HbA1c (r = 0.086, p= 0.239), and age (r = 0.096, p = 0.1).

 

Conclusion: dry eye is fairly common among patients with diabetes mellitus with most frequent symptoms being gritty sensation and blurred vision. No significant correlation was noted between dry eye and glycosylated haemoglobin (HbA1c).

 

 

Introduction    Down

Dry eye is defined as a multifactorial disease of the tears and ocular surface resulting in symptoms of discomfort, visual disturbance, and tear film instability with potential damage to the ocular surface. It is accompanied by increased osmolarity of the tear film and inflammation of the ocular surface [1]. Many patients with dry eye remain undiagnosed and untreated especially in developing countries which adversely affects their vision-related quality of life [2]. Diabetes mellitus is defined as a group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action or both [3]. It is a disease of public health importance affecting 38.2 million people worldwide with half of this population living in Africa, and it is reported to be on the increase [4]. Peripheral neuropathy, nephropathy, and retinopathy are well known major complications of diabetes mellitus while other ocular complications include dry eye, cataract, glaucoma, and recurrent corneal lesions [5, 6]. Diabetes mellitus can lead to dry eye through a variety of mechanisms [7, 8] and studies [9-12] had reported a high rate of dry eye among patients with diabetes mellitus. Prevalence of dry eye in patients with diabetes has been reported to range between 27.7%-54.3% [13-16]. The mechanism of dry eye in diabetes include diabetic neuropathy, metabolic dysfunction, or lacrimal gland dysfunction [6, 17, 18]. The vision-related quality of life in patients with dry eye is affected with symptoms ranging from mild transient irritation to persistent dryness, burning, itching, redness, pain, ocular fatigue, blurred vision and reduced contrast sensitivity which often affect daily activities such as reading, watching television and driving [19-21]. There are few studies [2, 22, 23] on dry eye disease in Nigeria, but to the best knowledge of the authors, there is no study on dry eye among diabetics in the country. Dry eye can be assessed using different parameters as documented by previous authors including the tear film osmolarity, [16] symptomatology, [24, 25] use of ocular lubricants, [10] combination of symptoms and sign of dry eye, [14] and the ocular surface disease index (OSDI) score [14]. The Ocular Surface Disease Index (OSDI) has been described as a valid and reliable instrument for measuring the severity of dry eye, and its psychometric properties makes it a useful tool in clinical practice [19]. Glycosylated haemoglobin (HbA1c) reflects average plasma glucose over the previous eight to twelve weeks [26]. An international expert committee recommended that HbA1c ≥ 6.5% is diagnostic of diabetes, [27] and some complications of diabetes such as retinopathy have been shown to be predictable using HbA1c levels [28]. This studyt hus aims to quantify the magnitude and pattern of presentation of dry eye among patients with diabetes mellitus attending the Out-Patient Clinic of a tertiary Center in Ibadan, southwestern Nigeria, and explore any correlation between HbA1c and dry eye among them.

 

 

Methods Up    Down

This was a descriptive hospital-based study carried out in the ophthalmology and diabetic clinics of a tertiary hospital in Ibadan, Nigeria between December 2014 and January 2015. A sample size of 189 was calculated based on a previously reported prevalence dry eye among diabetics of 52%, [13] 95% confidence interval, and adjustment fornon-response rate of 10%. Consecutive patients with diabetes mellitus aged 18 years and above, attending the Diabetic Clinic of the hospital as out-patients was recruited into the study until the calculated sample size was obtained. Excluded from the study were patients having ocular conditions that could affect the definition of dry eye such as microbial conjunctivitis, those who had undergone any extraocular or intraocular surgery or manipulation, patients with other systemic diseases such as hypertension, or on medications such as antihistamines, beta-blockers, and topical eye medications and those who declined to participate in the study. Patients recruited into the study were previously diagnosed diabetics using the American Diabetes Association (ADA) Expert Panel diagnostic criteria of diabetes mellitus [3]. A four-staged design was used with an interviewer-administered questionnaire carried out in the first stage to obtain patients' demographic data, past medical history, ocular history, duration of diabetes mellitus, use of insulin and a recent HbA1c report (within one week of recruitment). The patients were then examined with the slit lamp biomicroscope for eyelids abnormalities that could interfere with the normal spread of tear film, and conjunctival disorders like pterygium. In this study, dry eye was diagnosed using the Ocular Surface Disease Index (OSDI) questionnaire which consists of 12 questions on "symptoms within the past week" and gives scores ranging from 0 (least severe) to 100 (most severe). A score of 12 was used as a cut off for normal, 13-22 for mild dry eye, 23-32 for moderate dry eye, and ≥ 33 for severe dry eye [19].

 

Lastly, the tear break-up time (TBUT) was done followed by Schirmer I test with topical anaesthesia 30 minutes later to avoid any interference of results. TBUT was done by instilling a drop of 2% fluorescein strip wetted with sterile water into the conjunctival sac of each eye. The time interval between the last complete blink and the appearance of a random dark spot on the cornea under the cobalt blue filter of the slit-lamp was recorded with a stopwatch, and the mean of three timings was noted. A value of 10 seconds or less was considered as abnormal [29]. Schirmer I test was done with patients seated in a darkened room with fans and air-conditioning switched off. A pre-calibrated Schirmer strip (Whatmann filter paper no. 41) was placed at the inferior conjunctival sac at the junction of the lateral third and medial two thirds. Participants were asked to look straight and allowed to blink. After 5 minutes, the test strips were removed and the amount of wetting of the strips was recorded with a value less than or equal to 5mm considered as abnormal. For each study participant, Schirmer I test and TBUT were carried out in both eyes, and, the eye with the worse result was included in the analysis [29]. Ethical approval was obtained from the Ethical Committee of the hospital. Written and informed consent was obtained from the patients and the study followed the tenets of the Helsinki declaration.

 

Data management and analysis: data collected was analyzed using the Statistical Package for Social Sciences (SPSS) software (SPSS for windows version 21.0; SPSS Inc, Chicago, Illinois). Summary statistics were presented using frequency tables, charts, means and rates. Chi-square and Fishers exact tests were used for categorical variables. Spearman rank-order correlation co-efficient was used to determine the relationship between dry eye and HbA1c. Level of statistical significance was set at < 5%.

 

 

Results Up    Down

One hundred and eighty-nine patients participated in the study of which 59(31.2%) were males, (Figure 1) (M: F = 1: 2.2) and the mean age was 60.2 ± 10.3 years. The mean age for the males was 63.5 ± 11.3 years and 58.7 ± 9.4 years for the females. All the patients in the study had type 2 diabetes mellitus with a mean duration of 9.8 ± 7.3 years (range, 6 months to 37 years) (Table 1). One hundred and thirty (68.8%) patients were on oral medications only while 22(11.6%) were on treatment with insulin (Table 1). Glycosylated haemoglobin < 6.5% was observed in 106(56.1%) patients while ≥ 9% was noted in 25(13.2%) patients. The mean value for HbA1c was 7.1% (Table 1). The most common symptoms of dry eye among all the patients was "gritty sensation" (49.7%) and "blurred vision" (31.2%), while the most common environmental trigger was "discomfort in windy conditions" (21.2%), and the least common was "discomfort in low humidity and in air-conditioned areas" (0.5%). These symptoms were not exclusive as some patients experienced more than one symptom (Table 2). The prevalence of dry eye in this study was 21.7% (95% CI, 15.8-27.6) and this was higher among male patients (25.5%, 95% CI, 14.3-36.5) than females (20.0%, 95% CI,13.1-26.9) (p = 0.267), with 143(78.3%) patients classified as normal (Table 3). There was an increase in the prevalence of dry eye with increasing age (p= 0.107) as well as with specific age group (Table 4). There was no significant association between dry eye and some characteristics including the tear break-up time, Schirmer's test, and Hb A1c among the patients with Chi square analysis (Table 5). Also, there was no significant correlation between dry eye and glycosylated haemoglobin (r = 0.086, p = 0.239), dry eyeand age (r = 0.096, p = 0.190), and, dry eye and duration of diabetes mellitus (r = 0.027, p = 0.714) among the patients.

 

 

Discussion Up    Down

The prevalence of dry eye in this study was 21.7% (95% CI,15.8-27.6), similar to findings of Kaiserman et al. [10] (20.6%) and the Beaver Dam study [24, 25] (18.1%). Fuerst et al. [13] however, reported a prevalence of 52%, and this may be attribuited to the longer duration of diabetes (mean duration, 11.4 years [13] vs 9.8 years, present study) and racial differences among the studied participants. Longer duration of diabetes mellitus has been documented to correlate with increase in the prevalence of dry eye among the patients [14]. Dry eye was more common among males (25.5%, 95% C.I, 14.3-36.5) than females (20.0%, 95% C.I,13.1-26.9) but this was not statistically significant. Kaisermann et al. [10] and Fuerst et al. [13] also noted no significant difference in dry eye symptoms between sexes, although higher frequencies were found in females. Studies [24, 30] have shown that dry eye is more common among females in the normal population because of hormonal changes associated with menopause, however, in diabetics no gender predilection for dry eye has been observed and it was postulated that the association between female gender and dry eye is neutralised in the patients by the disease [10]. The prevalence of dry eye increased with age in this study, though, the association was not statistically significant (p = 0.415). This is similar to previous reports, [10, 13, 16] and has been attributed to the reduction in tear flow and volume, increased osmolarity, decreased tear film stability as well as alteration in the meibomian lipid composition of tears [31] with age. The duration of diabetes mellitus did not correlate with dry eye in this study (p = 0.714) similar to findings by Najafi et al. [16] but in contrast with the findings of Manaviat et al. [14]. Microvascular damage of the lacrimal gland with impairment of lacrimal gland function that has been implicated in the aetiopathogenesis of dry eye is known to correlate positively with a longer duration of diabetes mellitus [28]. Fuerst et al. [13] on the other hand, reported fewer dry eye symptoms among patients with longer duration of diabetes which they attributed to a possible reduction in corneal sensation. There was no statistically significant correlation between dry eye and HbA1c level in this study (p = 0.239). This is similar to reports of Fuerst et al. [13] and Sagdik et al. [32] but in contrast to findings in some studies [10, 12, 14, 16] where HbA1c had a significant positive correlation with dry eye. The overall fair glycemic control in our patients (mean HbA1c = 7.0 %) might have accounted for the lack of correlation in this study. Poor glycemic control is associated with microvascular complications of the lacrimal gland which impair lacrimal gland function causing dry eye among diabetics [28].

 

Treatment of diabetes with insulin was not statistically associated with dry eye in this study, (p = 0.1367). This is similar to previous studies [12, 13, 16] which reported no association between the type of treatment for diabetes and dry eye, thus, suggesting that insulin therapy does not affect the severity of dry eye among patients with diabetes mellitus. The most common symptom of dry eye was "gritty sensation", followed by "blurred vision" and "discomfort in windy conditions", similar to the study by Manaviat et al. [14]. These symptoms resulted from the disturbance in the quantity and quality of the pre-corneal tear film resulting in ocular surface inflammation [19, 33-35]. Schirmer test score was abnormal in 20.8 % of patients with dry eye while tear break up time was abnormal in 23.1% with neither test having any significant association with dry eye symptoms. Manaviat et al. [14] reported 11.5% of their patients had both abnormal tear break up time and Schirmer's test score with no significant association with subjective symptoms of dry eye. The lack of association between symptoms and signs of dry eye among patients with the disease has been documented [36]. However, decreased basal tear secretion indicated by abnormal Schirmer's test score has been reported in patients with diabetes mellitus, [6, 17] and this had been attributed to the microvasculature damage of the lacrimal glands and autonomic neuropathy leading to lacrimal gland dysfunction [37]. Limitations to this study include the absence of patients with type 1 diabetes mellitus such that associations between dry eye and type 1 diabetes mellitus could not be assessed. More studies involving control groups will be helpful in evaluating further the relationship between dry eye and diabetes.

 

 

Conclusion Up    Down

In conclusion, dry eye is fairly common among patients with type 2 diabetes mellitus in our black African population with most of the affected patients experiencing the mild form of the disease. No significant correlation was noted between dry eye and glycosylated haemoglobin (HbA1c).

What is known about this topic

  • Dry eye affects the ocular surface and results in tear film instability;
  • Prevalence of dry eye increases with age and is higher among females;
  • Patients with diabetes mellitus have higher prevalence of dry eye disease.

What this study adds

  • A prevalence value for dry eye was derived for the region which can be used in further studies;
  • No significant gender predilection for dry eye was noted in this study;
  • No significant correlation was also noted between dry eye and glycosylated hemoglobin.

 

 

Competing interests Up    Down

The authors declare no competing interests.

 

 

Authors’ contributions Up    Down

SIO participated in the design and conduct of the study, and participated in writing the manuscript, OF participated in the deign and conduct of the study, and in the writing and editing of the manuscript, COB contributed to the study design and writing of the manuscript, while AOO contributed to the design of the study, and editing the manuscript.

 

 

Acknowledgments Up    Down

Special thanks to Mr Friday for the statistical analysis.

 

 

Tables and figure Up    Down

Table 1: duration of diabetes mellitus, type of treatment and glycosylated haemoglobin (HbA1c) values among patients

Table 2: frequency of symptoms among patients with dry eyes using the OSDI score

Table 3: prevalence and grades of dry eye among the patients using the Ocular Surface Disease Index Score

Table 4: prevalence of dry eye by age group

Table 5: association between dry eye and some characteristics in patients with diabetes mellitus

Figure 1: age and gender distribution of patients

 

 

References Up    Down

  1. No authors listed. The definition and classification of dry eye disease: report of the Definition and Classification Subcommittee of the International Dry Eye WorkShop. Ocul Surf. 2007;5(2):75-92. PubMed

  2. Bekibele CO, Baiyeroju AM, Ajaiyeoba A, Akang EEU, Ajayi BGK. Case control study of dry eye and related ocular surface abnormalities in Ibadan, Nigeria. Int Ophthalmol. 2010;30(1):7-13. PubMed | Google Scholar

  3. American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care. 2008;31(Supplement 1):S55-S60.

  4. International Diabetes Federation. Promoting diabetes care, prevention and a cure worldwide. Diabetes Atlas, fifth edition. Accessed 09 October 2017

  5. Rehany U, Ishii Y, Lahav M, Rumelt S. Ultrastructural changes in corneas of diabetic patients: an electron-microscopy study. Cornea.2000;19(4):534-8. PubMed | Google Scholar

  6. Inoue K, Kato S, Ohara C, Numaga J, Amano S, Oshika T. Ocular and systemic factors relevant to diabetic keratoepitheliopathy. Cornea. 2001;20(8):798-801. PubMed | Google Scholar

  7. Alves Mde C, Carvalheira JB, Modulo CM, Rocha EM. Tear film and ocular surface changes in diabetes mellitus. Arq Bras Oftalmol. 2008;71(6):96-103. PubMed | Google Scholar

  8. Goebbels M. Tear secretion and tear film function in insulin dependent diabetics. Br J Ophthalmol. 2000;84(1):19-21. PubMed | Google Scholar

  9. Hom M, De Land P. Self-reported dry eyes and diabetic history. Optometry.2006;77(11):554-8. PubMed | Google Scholar

  10. Kaiserman IN, Kaiserman N, Nakar S, Vinker S. Dry eye in diabetic patients. Am J Ophthalmol. 2005;139:498-503. PubMed | Google Scholar

  11. Seifart U, Strempel I. Trockenes Auge und Diabetes mellitus [The dry eye and diabetes mellitus]. Der Ophthalmologe. 1994;91(2):235-9. PubMed

  12. Nepp J, Abela C, Polzer I, Derbolav A, Wedrich A. Is there a correlation between the severity of diabetic retinopathy and keratoconjunctivitis sicca? Cornea. 2000;19(4):487-91. Google Scholar

  13. Fuerst N, Langelier N, Massaro-Giordano M, Pistilli M, Stasi K, Burns C, Cardillo S, Bunya VY. Tear osmolarity and dry eye symptoms in diabetics. Clin Ophthalmol. 2014;8:507-15. PubMed | Google Scholar

  14. Manaviat MR, Rashidi M, Afkhami-Ardekani M, Shoja MR. Prevalence of dry eye syndrome and diabetic retinopathy in type 2 diabetic patients. BMC Ophthalmol. 2008;8(1):10-13. PubMed | Google Scholar

  15. Yu L, Chen X, Qin G, Xie H, Lv P. Tear film function in type 2 diabetic patients with retinopathy. Ophthalmologica. 2008;222(4):284-91. PubMed | Google Scholar

  16. Najafi L, Malek M, Valojerdi AE, Aghili R, Khamseh ME, Fallah AE et al. Dry eye and its correlation to diabetes microvascular complications in people with type 2 diabetes mellitus. J Diabetes Complications. 2013;27(5):459-62. PubMed | Google Scholar

  17. Dogru M, Katakami C, Inoue M. Tear function and ocular surface changes in noninsulin-dependent diabetes mellitus. Ophthalmology. 2001;108(3):586-92. PubMed | Google Scholar

  18. Grus FH, Sabuncuo P, Dick HB, Augustin AJ, Pfeiffer N. Changes in the tear proteins of diabetic patients. BMC Ophthalmol. 2002;2(1):4-9. PubMed | Google Scholar

  19. Schiffman RM, Christianson MD, Jacobsen G, Hirsch JD, Reis BL. Reliability and validity of the Ocular Surface Disease Index. Arch Ophthalmol. 2000;118:615-21. PubMed | Google Scholar

  20. Miljanovic B, Dana R, Sullivan DA, Schaumberg DA. Impact of dry eye syndrome on vision-related quality of life. Am J Ophthalmol. 2007;143(4):409-15. PubMed | Google Scholar

  21. Begley CG, Caffery B, Chalmers RL, Mitchell GL. Use of the dry eye questionnaire to measure symptoms of ocular irritation in patients with aqueous tear deficient dry eye. Cornea. 2002;21(7):664-70. PubMed | Google Scholar

  22. Onwubiko SN, Eze BI, Udeh NN, Arinze OC, Onwasigwe EN, Umeh RE. Dry Eye disease: prevalence, distribution and determinants in a hospital-based population. Contact Lens Ant Eye. 2014; 37(3):157-161. PubMed | Google Scholar

  23. Olaniyan SI, Fasina O, Bekibele CO, Ogundipe AO. Dry eye disease in an adult population in South-West Nigeria. Contact Lens Ant Eye. 2016; 39:359-364. PubMed | Google Scholar

  24. Moss SE, Klein R, Klein BE. Prevalence of and risk factors for dry eye syndrome. Arch Ophthalmol. 2000;118:1264-8. PubMed | Google Scholar

  25. Moss SE, Klein R, Klein BE. Incidence of dry eye in an older population. Arch Ophthalmol. 2004;122(3):369-73. PubMed | Google Scholar

  26. Nathan DM, Turgeon H, Regan S. Relationship between glycated haemoglobin levels and mean glucose levels over time. Diabetologia. 2007;50(11):2239-44. PubMed | Google Scholar

  27. International Expert Committee. International Expert Committee report on the role of the A1C assay in the diagnosis of diabetes. Diabetes Care. 2009;32(7):1327-34. Google Scholar

  28. Diabetes Complications Trial Research Group. The relationship of glycemic exposure (HbA1c) to the risk of development and progression of retinopathy in the Diabetes Control and Complications Trial. Diabetes. 1995;44(8):968-83. Google Scholar

  29. Bron AJ, Smith JA, Calonge M. Methodologies to diagnose and monitor dry eye disease: report of the Diagnostic Methodology Subcommittee of the International Dry Eye WorkShop (2007). Ocul Surf. 2007;5(2):108-52. PubMed | Google Scholar

  30. McCarty CA, Bansal AK, Livingston PM, Stanislavsky YL, Taylor HR. The epidemiology of dry eye in Melbourne, Australia. Ophthalmology. 1998;105:1114-9. PubMed | Google Scholar

  31. Sullivan BD, Evans JE, Dana MR, Sullivan DA. Influence of aging on the polar and neutral lipid profiles in human meibomian gland secretions. Arch Ophthalmol. 2006;124(9):1286-92. PubMed | Google Scholar

  32. Sagdik HM, Ugurbas SH, Can M, Tetikoglu M, Ugurbas E, Ugurbas SC, Alpay A, Uçar F. Tear film osmolarity in patients with diabetes mellitus. Ophthalmic Res.2013;50(1):1-5. PubMed | Google Scholar

  33. Stern ME, Beuerman RW, Fox RI, Gao J, Mircheff AK, Pflugfelder SC. The pathology of dry eye: the interaction between the ocular surface and lacrimal glands. Cornea, 1998;17(6):584-9. Google Scholar

  34. Goto E, Yagi Y, Matsumoto Y, Tsubota K. Impaired functional visual acuity of dry eye patients. Am J Ophthalmol. 2002;33:181-6. PubMed | Google Scholar

  35. Tutt R, Bradley A, Begley C, Thibos LN. Optical and visual impact of tear break-up in human eyes. Invest Ophthalmol Vis Sci. 2000;41:4117-23. PubMed | Google Scholar

  36. Nichols KK, Nichols JJ, Mitchell GL. The lack of association between signs and symptoms in patients with dry eye disease. Cornea. 2004;23(8):762-70. PubMed | Google Scholar

  37. Rahman A, Yahya K, Ahmed T, Sharif-Ul-Hasan K. Diagnostic value of tear films tests in type 2 diabetes. JPak Med Ass. 2007;57(12):577-80. PubMed | Google Scholar

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 


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Keywords

Diabetes mellitus
Dry eye
Glycosylated haemoglobin
Ibadan
Nigeria

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