May 2005
Volume 46, Issue 5
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Clinical and Epidemiologic Research  |   May 2005
Association between Symptoms and Signs of Dry Eye among an Elderly Chinese Population in Taiwan: The Shihpai Eye Study
Author Affiliations
  • Pei-Yu Lin
    From the Department of Ophthalmology, National Yang Ming University School of Medicine and Taipei Veterans General Hospital, Taipei, Taiwan;
  • Ching-Yu Cheng
    From the Department of Ophthalmology, National Yang Ming University School of Medicine and Taipei Veterans General Hospital, Taipei, Taiwan;
    Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; the
    Institute of Clinical Medicine, the
  • Wen-Ming Hsu
    From the Department of Ophthalmology, National Yang Ming University School of Medicine and Taipei Veterans General Hospital, Taipei, Taiwan;
  • Su-Ying Tsai
    Community Medicine Research Center and Institute of Public Health, and the
  • Ming-Wei Lin
    Faculty of Medicine, National Yang Ming University, Taipei, Taiwan; the
    Department of Medical Research and Education, Taipei Veterans General Hospital, Taipei, Taiwan; and the
  • Jorn-Hon Liu
    From the Department of Ophthalmology, National Yang Ming University School of Medicine and Taipei Veterans General Hospital, Taipei, Taiwan;
    Cheng Hsin Rehabilitation Medical Center, Taipei, Taiwan.
  • Pesus Chou
    Community Medicine Research Center and Institute of Public Health, and the
Investigative Ophthalmology & Visual Science May 2005, Vol.46, 1593-1598. doi:10.1167/iovs.04-0864
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      Pei-Yu Lin, Ching-Yu Cheng, Wen-Ming Hsu, Su-Ying Tsai, Ming-Wei Lin, Jorn-Hon Liu, Pesus Chou; Association between Symptoms and Signs of Dry Eye among an Elderly Chinese Population in Taiwan: The Shihpai Eye Study. Invest. Ophthalmol. Vis. Sci. 2005;46(5):1593-1598. doi: 10.1167/iovs.04-0864.

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      © 2017 Association for Research in Vision and Ophthalmology.

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Abstract

purpose. To analyze the association between dry-eye symptoms and signs in an elderly Chinese population in Taipei, Taiwan.

methods. The participants were those of the Shihpai Eye Study, a population-based survey of eye diseases in the elderly (≥65 years) in Shihpai, Taipei, Taiwan. Of 2045 randomly selected noninstitutionalized residents, 1361 (66.6%) participated in the study. Dry-eye symptoms were evaluated with an interviewer-administered questionnaire. Dry-eye signs, including tear-film breakup time, Schirmer test result, score for fluorescein staining of the cornea, and meibomian gland dysfunction, were assessed. Correlations between symptoms and signs were analyzed.

results. Of the participants, 33.7% (459/1361) were symptomatic, defined as reporting one or more symptoms often or all the time. A Schirmer result of ≤5 mm was the only sign associated with frequent symptoms (P = 0.028). Its sensitivity and specificity in detecting symptomatic subjects were 62.5% and 43.7%, respectively. The agreement between each sign was statistically significant, although weak, except that no correlation was found between the Schirmer result and meibomian gland anomalies. Of the symptomatic subjects, 85.4% (392/459) had either a low Schirmer result or a meibomian gland anomaly; 38.8% (178/459) of them were abnormal on both tests.

conclusions. The Schirmer test was shown to be incapable of detecting meibomian gland disease. However, a low Schirmer result was significantly associated with dry-eye symptoms in this elderly Chinese population. This result differs from that of previous reports of elderly white populations. Further studies are needed to determine whether this difference indicates racial diversity in the distribution and behavior of dry-eye diseases.

Studies of the epidemiology of dry eye are often hindered by the fact that there is no gold standard for the diagnosis of dry eye. Some recent population-based studies defined dry eye as having frequent dry-eye symptoms, 1 2 3 4 5 which is reasonable because the treatment goal for dry eye is primarily to relieve the patient’s symptoms. In clinical practice, dry-eye tests are often performed in symptomatic patients to confirm the diagnosis. However, a poor correlation between dry-eye symptoms and dry-eye tests has been demonstrated in population-based studies by Schein et al. 1 in the United States and McCarty et al. 6 in Australia. The heterogeneity of dry eye and the reporting bias of the participants are potential explanations suggested by the authors. 1 7 Each dry-eye test that is frequently performed in clinical practice seeks only to measure a specific disorder of dry eye. Consequently, a patient with normal Schirmer test results, which reflects normal aqueous tear secretion, may report dry-eye symptoms resulting from meibomian gland disease. If the dry-eye symptoms could also be categorized into subtypes (i.e., symptoms of aqueous tear deficiency, symptoms of meibomian gland diseases, and symptoms of mucin anomalies), then more logical analyses of the correlations between symptoms and signs could be made. 
Another explanation of the poor association between dry-eye symptoms and signs is that the frequently used dry-eye tests do not reliably reflect the tear-film conditions in the non–clinic-based general population and consequently have limited value as screening tests. 
To clarify the correlation between dry-eye symptoms and signs, analyses were performed on data gathered from the Shihpai Eye Study, a population-based survey of subjects ≥65 years of age in Shihpai, Taipei, Taiwan. 
Materials and Methods
Subjects
The methods used in the Shihpai Eye Study have been described previously. 4 8 To summarize briefly, this study was conducted between July 1, 1999, and December 31, 2000. The goal was to recruit a random sample of residents of Shihpai, Taipei, Taiwan, aged at least 65 years, for participation in several distinct studies related to ocular disease and aging. In 1999, the Shihpai community, located in the Peitou district of Taipei, had 4750 residents aged at least 65 years, according to the official household registration database. Our goal was to recruit a random sample of approximately 2000 residents 65 years of age or older with complete baseline information. The sample size was chosen based on the estimates of the prevalence of visual impairment. Excluding vacant households (n = 658), residents who died before they were interviewed (n = 48), and inpatient, paralyzed, and disabled residents (n = 298), 3764 residents were eligible. Of these 3764 subjects, 2045 were randomly selected to be enrolled in the Shihpai Eye Study. 
Questionnaire and Examinations
The study protocol was approved by the institutional review board, and the study was conducted according to the tenets of the Declaration of Helsinki of the World Medical Association regarding scientific research on human subjects. 
Trained interviewers contacted the potential participants and administered a structured questionnaire that included questions addressing demographic data, health and drug history, psychological condition, personal habits, lifestyle, and dry-eye symptoms. The questions regarding dry-eye symptoms consisted of eight items 4 (see Appendix). Six of the items were the same as those used by Schein et al. 1 Two more symptoms (sticky and tearing) were added because they are included in the questionnaires of other dry-eye studies. 6 9 When a respondent indicated the presence of a symptom, he or she was asked to indicate whether the symptom was experienced rarely, sometimes, often, or all the time. The subjects were then invited to the Taipei Veterans General Hospital for detailed eye examinations. 
The dry-eye tests included the tear-film breakup time test, fluorescein staining of the cornea, slit-lamp assessment of the meibomian gland, and the Schirmer test. The tear-film breakup time test was performed before the other dry-eye tests to avoid any untoward interference. The test was repeated three times for each eye, and the average time was recorded. Fluorescein staining of the cornea was observed through a slit lamp with a cobalt-blue filter and was graded 0 (no staining), 1 (mild staining with a few disseminated stains, and limited to less than one third of the cornea), 2 (moderate staining with a severity between grades 1 and 3), or 3 (severe staining with confluent stains, and occupying half or more of the cornea). 6 The condition of the meibomian gland was determined by observing the lid margin with a slit lamp. Because there is no universal grading system of meibomian gland dysfunction (meibomian gland disease), we defined meibomian gland disease as the presence of meibomian gland orifice plugging or lid margin telangiectasia. The presence of lid margin telangiectasia was recorded, and any meibomian gland obstruction was graded (we defined grade 0 as no obstruction; grade 1, plugged with translucent serous secretion when the lid margin was compressed; grade 2, plugged with viscous or waxy white secretion when the lid margin was compressed; and grade 3, plugged with no secretion when the lid margin was compressed). The Schirmer test was performed last, so that ocular irritation by the test strip would not interfere with other examination results. One minute after instillation of a drop of 0.5% proparacaine, any visible fluid in the inferior fornix or lid margin was gently dried with a cotton swab. A precalibrated filter strip (Color Bar; Eagle Vision, Inc., Memphis, TN) was then placed temporally in each lower fornix and left in place for 5 minutes. The patient was allowed to either blink normally or to close his or her eyes. After 5 minutes, the strip was removed, and the amount of wetting (in millimeters) was recorded from the precalibrated strip. We did not perform rose bengal staining, because rose bengal is toxic to epithelial cells and irritating to the eye. We were reluctant to add more discomfort and waiting time to these elderly study participants. 
Diagnosis and Statistical Analysis
Dry eye was defined as having one or more symptoms often or all the time. Positive signs were if one or both eyes revealed tear-film breakup time of ≤10 seconds, 10 a Schirmer test score of ≤5 mm, 11 a fluorescein score ≥1, 11 or the existence of meibomian gland disease which was diagnosed when telangiectasia at the lid margin or plugging of the gland orifices was present (≥ grade 1). 
Statistical analysis was performed to describe the distribution of symptoms and signs, to assess the correlations between variable clinical signs of dry eye, and to explore the association between dry eye symptoms and variable clinical signs. The normality of the data was checked with the Shapiro-Wilk test. A K-means cluster analysis was used to explore symptom reporting patterns and to understand better symptomatic heterogeneity in the study population. The technique is a classification technique that is particularly useful in identifying characteristics of homogeneous subgroups. In other words, subjects with similar dry eye symptoms were put in the same group. All data analyses were performed with a commercial statistical software package (Stata; Stata Corp., College Station, TX). 
Results
Of the 2045 subjects randomly recruited, 2038 (99.7%) cooperated with the household interview and completed the questionnaire. Seven (0.3%) subjects could not be contacted after three attempts and were not interviewed. After finishing the questionnaire, 1361 (66.6%) subjects came to the hospital and completed the eye examinations. The analyses of this study are based on data gathered from these 1361 participants. The comparison between the participants and nonparticipants has been described previously. 8 In general, participants (mean age, 72.2 ± 5.1 years; range, 65–91) were younger than nonparticipants (74.3 ± 6.0 years), more likely to be male (60.4%), and had a higher level of education and a higher frequency of current smoking and alcohol drinking (all P < 0.05). 
Table 1summarizes the results of the questionnaire on dry-eye symptoms by sex and age. The questionnaire data show that 33.7% of the population reported one or more symptoms to be present often or all the time. Table 2summarizes the result of the dry-eye tests in the worse eye only, by sex and age. The overall mean tear breakup time was 8.2 seconds. The overall mean Schirmer test result was 5.7 mm. The corneas of 33.4% of the participants were positively stained with fluorescein, 53.6% of participants had signs of meibomian gland obstruction, and 70% had lid margin telangiectasia. 
The associations between dry-eye symptoms and various dry-eye tests are shown in Table 3 . The Schirmer test was the only test to show a significant association with dry-eye symptoms, regardless of whether they were analyzed with all eight questions in the questionnaire or with only the six questions used by Schein et al. 1 Figure 1illustrates the frequencies of the Schirmer test results for the lower-scoring eye of each participant. Of all study subjects, 58.4% had a Schirmer result of ≤5 mm. With a cutoff value of 5 mm, the Schirmer test demonstrated 62.5% sensitivity and 43.7% specificity in detecting symptomatic subjects. The association between the Schirmer result and dry-eye symptoms became nonsignificant when the eight items in the questionnaire were analyzed individually. The same lack of association was identified between other dry-eye tests and individual items in the questionnaire, except that a significantly positive association was found between the question, “Are your eyes ever red?” and the presence of meibomian gland anomalies (plugging, P = 0.024; lid margin telangiectasia, P = 0.015). 
Categorizing various dry-eye symptoms to specific dry-eye disorders was attempted initially by grouping the subjects according to similar responses to the questionnaire, using K-means cluster analysis (Table 4) . The subjects could be grouped into 4 groups: group 1, more likely to report dry (192/1361 = 14.1%); group 2, more likely to report sticky and watery (234/1361 = 17.2%); group 3, more likely to notice crusting (33/1361 = 2.4%); and group 4, no dry eye symptoms. We then analyzed whether the subjects in any one group presented with specific dry-eye signs. However, no statistically significant result was obtained. 
The agreement between the various dry-eye test results is shown in Tables 5 and 6 . The correlations between tear breakup time, Schirmer result, and fluorescein staining score are statistically significant, although weak. The associations between meibomian gland disease and other signs are also significant, except with the Schirmer result. The results for the right eye were consistent with those for the left eye. 
Figure 2illustrates the distribution of subjects with low Schirmer results, meibomian gland disease (MGD), and frequent symptoms. Most subjects (85.4%, 392/459) with frequent dry-eye symptoms had either a low Schirmer result or a meibomian gland anomaly (MGD), whereas 38.8% (178/459) of them had abnormal findings on both tests. When the other two signs (tear breakup time of ≤10 seconds and corneal fluorescein staining score ≥1) were included, 96.1% (441/459) of symptomatic individuals had at least one positive sign. 
Discussion
This study shows that the Schirmer test result, with a cutoff value of 5 mm, correlates significantly with dry-eye symptoms (P = 0.028 for eight questions; P = 0.012 for six questions). This finding differs from that reported by Schein et al., 1 who observed no association between the presence of more frequent symptoms and a lower Schirmer result, regardless of whether the analysis was based on mean scores with a cutoff value of 5 or a cutoff value of 7. Although the Schirmer test was the only single test to be associated with frequent dry-eye symptoms in this population, we do not suggest that it could be used as the best screening tool for dry eye. Its sensitivity and specificity in detecting symptomatic subjects were low. One of the major reasons for the low sensitivity and specificity is the heterogeneity of dry-eye syndrome. The Schirmer result has been shown to be higher in patients with ocular irritation due to meibomian gland disease than in those due to aqueous tear deficiency. 12 Subjects with a normal Schirmer result might report dry-eye symptoms due to meibomian gland disease. Statistically significant correlations were demonstrated in this population between different dry-eye signs, except between the Schirmer result and meibomian gland anomaly. This finding provides more objective evidence to support the increasingly recognized classification of dry eye that includes deficient aqueous production and excessive evaporation. 13  
In our previous report, 4 we have emphasized that 96% of the individuals who had dry-eye symptoms also had at least one positive sign, which indicated the importance of symptoms in the diagnosis of dry eye. Of the symptomatic subjects, 62.5% had a low Schirmer result, 61.7% had positive signs of meibomian gland dysfunction, 85.4% had abnormal results on either test, and 38.8% on both tests. Schein et al. 7 reported that of the symptomatic individuals, 15.1% had a low Schirmer result (≤5 mm), and 5.8% had anatomic features of meibomitis, as reflected by a slit lamp grade of 2 or 3 for collarettes or meibomian gland plugging. There was no mention of the fractions of symptomatic individuals with abnormalities on either test or on both tests. The lower incidence of meibomitis in Schein et al. compared with our data is partly due to different definitions of meibomitis. McCarty et al. 6 did not report any information about meibomian gland function. 
Why did the Schirmer test reach a significant association with dry-eye symptoms in this study, despite the fact that dry eye is heterogeneous in etiology? One explanation is that meibomian gland dysfunction may play a less significant role in causing dry-eye symptoms in this Chinese population in Taiwan. Ong 14 observed that Asians produced more meibomian secretion than whites. Bowman et al. 15 noted that meibomian gland dysfunction occurred less frequently among patients with blepharitis in warmer climates compared with cooler climates. Taiwan has a subtropical climate. Further studies are necessary to resolve this question. 
We had hoped that the responses describing symptoms could be sorted into groups that were in accord with specific presentations of signs. An initial cluster analysis grouped the symptomatic subjects into those who were more likely to report “dry,” those more likely to report “sticky and watery,” and those more likely to report “crusting.” However, further analyses failed to associate the three groups significantly with any specific presentation of signs. Perhaps a more sophisticated questionnaire could resolve the complexity of the correlations between dry-eye symptoms and signs. 
The other problem in identifying dry-eye disease with dry-eye tests is in deciding the cutoff values. McCarty et al. 6 concluded that, among the clinical tests they performed, the Schirmer test was the least useful in discriminating symptoms. However, they defined dry eye using a less strict cutoff value for the Schirmer result (8 mm), but a stricter cutoff for tear breakup time (8 seconds) and fluorescein staining (grade 2) than we used in this analysis. This is probably one of the reasons why the Schirmer test yielded the highest number of false positives in McCarty et al. We set the cutoff value at 5 mm for the Schirmer test to comply with the criteria often used for the diagnosis of keratoconjunctivitis sicca. The false-positive rate was still rather high; 37.3% (508/1361) of subjects who had a low Schirmer result did not report frequent symptoms. The use of anesthetics has been suggested to explain this high false-positive rate. 6 A previous study showed that topical anesthesia reduces the Schirmer result by 40%. 16 Topical anesthesia might dampen the initial reflex secretion due to irritation, although the Schirmer result increased in variability, probably because of differences in susceptibility to the anesthetic. 17 We used anesthetics in this study because other similar population-based studies 1 6 performed the test under anesthesia and because we wanted to minimize the discomfort and false-negative responses induced by the irritation caused by the test strips. 
In the study by Schein et al., 7 individuals reporting their general health to be poor had a higher tendency to report dry-eye symptoms than did other respondents (16.9% vs. 10.6%, respectively; P < 0.001), but did not display a lower Schirmer result. A similar phenomenon was observed in the Shihpai population. Individuals reporting poor general health were more likely to report dry-eye symptoms than were other respondents (9.4% vs. 4.9%, respectively; P = 0.001). None of the dry-eye tests was associated with self-reported general health. The possibility of reporting bias proposed by Schein et al., (i.e., that some subjects are simply more likely to report symptoms in general) is also relevant in this study. However, most subjects (96.1%) reporting frequent dry-eye symptoms had at least one positive dry-eye sign, indicating that they did have certain ocular-surface problems. 
In conclusion, a low Schirmer result of ≤5 mm is associated in this population with frequent dry-eye symptoms. However, the high false-positive rate reduces the usefulness of this test in identifying asymptomatic subjects. The Schirmer test also has limitations in detecting patients with dry eye secondary to meibomian gland disease, because the association between the Schirmer result and meibomian gland anomaly is low. A low Schirmer result is significantly associated with symptoms in this elderly Chinese population but not in elderly white populations, as reported previously. 1 6 This finding suggests a different distribution of dry-eye etiologies between white and Asian populations. 
Appendix 1
Dry Eye Questionnaire
(Allowable responses: never, rarely, sometimes, often, or all the time.) 
  1.  
    Do your eyes ever feel dry?
  2.  
    Do you ever feel a gritty or sandy sensation in your eyes?
  3.  
    Do your eyes ever have a burning sensation?
  4.  
    Do your eyes ever feel sticky?
  5.  
    Do your eyes ever feel watery or tearing?
  6.  
    Are your eyes ever red?
  7.  
    Do you notice much crusting or discharge on your lashes?
  8.  
    Do your eyes ever get stuck shut in the morning?
 
Table 1.
 
Subjects Reporting Dry Eye Symptoms
Table 1.
 
Subjects Reporting Dry Eye Symptoms
None or Rarely Sometimes Often or All the Time P *
n % (95% CI) n % (95% CI) n % (95% CI)
Total 443 32.6 (30.1–35.1) 459 33.7 (31.2–36.3) 459 33.7 (31.2–36.3)
Sex
 Male 297 36.1 (32.8–39.5) 277 33.7 (30.5–37.0) 248 30.2 (27.0–33.4) <0.001
 Female 146 27.1 (23.4–31.1) 182 33.8 (29.8–37.9) 211 39.1 (35.0–43.4)
Age group (y)
 65–69 156 32.4 (28.3–36.8) 170 35.3 (31.1–39.8) 155 32.2 (28.1–36.6) 0.814
 70–74 165 33.5 (29.4–37.9) 156 31.7 (27.6–36.0) 171 34.8 (30.5–39.1)
 75–80 84 31.3 (25.8–37.3) 96 35.8 (30.1–41.9) 88 32.8 (27.2–38.8)
 80+ 38 31.7 (23.5–40.8) 37 30.8 (22.7–39.9) 45 37.5 (28.8–46.8)
Education level
 Illiterate or no education 63 28.8 (22.9–35.3) 71 32.4 (26.3–39.1) 85 38.8 (32.3–45.6) 0.143
 Elementary school 132 30.9 (26.6–35.5) 147 34.4 (29.9–39.1) 148 34.7 (30.1–39.4)
 Junior or senior high school 146 32.3 (28.0–36.8) 152 33.6 (29.3–38.2) 154 34.1 (29.7–38.6)
 College and above 102 38.8 (32.9–45.0) 89 33.8 (28.1–39.9) 72 27.4 (22.1–33.2)
Table 2.
 
Clinical Signs of Dry Eye
Table 2.
 
Clinical Signs of Dry Eye
Tear Break-up Time (s) Schirmer Test (mm) Fluorescein Stain Score of Cornea* (%) Grade of Meibomian Gland Obstruction, † (%) Lid Margin Telangiectasia (%)
Mean ± SD Mean ± SD 0 1 2 or 3 0 1 or 2 3 Absent Present
Total 8.2 ± 5.3 5.7 ± 4.2 66.6 24.5 8.8 46.4 40.5 13.3 30.0 70.0
Sex, ‡
 Male 8.2 ± 5.1 6.0 ± 4.2 68.4 23.8 7.8 44.9 41.7 13.4 31.5 68.5
 Female 8.1 ± 5.5 5.4 ± 4.1 64.1 25.6 10.4 48.2 38.6 13.2 27.6 72.4
P = 0.328 P = 0.001 P = 0.146 P = 0.583 P = 0.283
Age group, ‡ (y)
 65–69 8.2 ± 5.1 5.7 ± 4.3 68.6 25.2 6.0 49.3 37.8 12.9 28.3 71.7
 70–74 8.5 ± 5.6 6.0 ± 4.2 68.9 21.8 9.4 44.4 40.9 14.4 29.1 70.9
 75–80 7.8 ± 5.1 5.3 ± 3.6 63.8 25.0 11.2 43.3 44.8 11.9 31.7 68.3
 80+ 7.9 ± 4.8 6.1 ± 4.6 55.0 32.5 12.5 46.7 40.0 13.3 36.7 63.3
P = 0.690 P = 0.308 P = 0.013 P = 0.451 P = 0.128
Table 3.
 
Associations between Symptoms with Various Clinical Signs of Dry Eye
Table 3.
 
Associations between Symptoms with Various Clinical Signs of Dry Eye
Sign All 8 Questions Excluding Questions 4 and 5
n (%) P * n (%) P *
Tear break-up time
 ≤10 sec 362 (33.6) 0.789 262 (24.3) 0.615
 >10 sec 97 (34.4) 69 (24.5)
Schirmer test
 ≤5 mm 287 (36.1) 0.028 213 (26.8) 0.012
 >5 mm 172 (30.4) 118 (20.9)
Fluorescein stain of cornea
 Score ≥1 154 (33.9) 0.914 116 (25.6) 0.146
 Score 0 305 (33.6) 215 (23.7)
Meibomian gland obstruction
 Grade ≥1 248 (33.9) 0.896 174 (23.8) 0.583
 Grade 0 211 (33.6) 157 (25.0)
Lid margin telangiectasia
 Present 142 (34.8) 0.582 105 (25.7) 0.283
 Absent 317 (33.3) 226 (23.7)
Figure 1.
 
Frequency of Schirmer test results for the lower-scoring eyes of the participants.
Figure 1.
 
Frequency of Schirmer test results for the lower-scoring eyes of the participants.
Table 4.
 
Cluster Analysis of Dry Eye Symptoms
Table 4.
 
Cluster Analysis of Dry Eye Symptoms
Symptoms Group 1 Group 2 Group 3 Group 4
Dry 0.81 0.26 0.18 0.00
Gritty 0.33 0.15 0.09 0.00
Burning 0.04 0.04 0.30 0.00
Sticky 0.02 0.67 0.21 0.00
Watery 0.00 0.96 0.00 0.00
Red 0.16 0.05 0.06 0.00
Crusted 0.00 0.09 0.79 0.00
Shut 0.01 0.01 0.30 0.00
n (%) 192 (14.1%) 234 (17.2%) 33 (2.4%) 902 (66.2%)
Table 5.
 
Correlation between Various Dry Eye Signs*
Table 5.
 
Correlation between Various Dry Eye Signs*
BUT Schirmer Test F/S
BUT 0.23, † −0.02
Schirmer test 0.25, † −0.07, ‡
F/S −0.07, ‡ −0.13, †
Table 6.
 
Correlation between Meibomian Gland Disease and Other Dry Eye Signs
Table 6.
 
Correlation between Meibomian Gland Disease and Other Dry Eye Signs
Meibomian Gland Disease P *
Present Absent
Right eye
 BUT (s) 8.4 ± 5.4 10.3 ± 5.9 <0.001
 Schirmer test (mm) 6.7 ± 4.9 7.1 ± 5.0 0.087
 F/S 0.5 ± 0.7 0.2 ± 0.6 <0.001
Left eye
 BUT (s) 8.5 ± 5.6 10.4 ± 6.0 <0.001
 Schirmer test (mm) 6.9 ± 4.8 6.9 ± 5.1 0.894
 F/S 0.4 ± 0.7 0.3 ± 0.6 <0.001
Figure 2.
 
Agreement between dry-eye symptoms, a low Schirmer result, and meibomian gland disease (n = 1361). MGD, meibomian gland disease.
Figure 2.
 
Agreement between dry-eye symptoms, a low Schirmer result, and meibomian gland disease (n = 1361). MGD, meibomian gland disease.
The authors thank Yung-Chieh Yen for excellent statistical assistance and helpful discussions of the manuscript. 
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Figure 1.
 
Frequency of Schirmer test results for the lower-scoring eyes of the participants.
Figure 1.
 
Frequency of Schirmer test results for the lower-scoring eyes of the participants.
Figure 2.
 
Agreement between dry-eye symptoms, a low Schirmer result, and meibomian gland disease (n = 1361). MGD, meibomian gland disease.
Figure 2.
 
Agreement between dry-eye symptoms, a low Schirmer result, and meibomian gland disease (n = 1361). MGD, meibomian gland disease.
Table 1.
 
Subjects Reporting Dry Eye Symptoms
Table 1.
 
Subjects Reporting Dry Eye Symptoms
None or Rarely Sometimes Often or All the Time P *
n % (95% CI) n % (95% CI) n % (95% CI)
Total 443 32.6 (30.1–35.1) 459 33.7 (31.2–36.3) 459 33.7 (31.2–36.3)
Sex
 Male 297 36.1 (32.8–39.5) 277 33.7 (30.5–37.0) 248 30.2 (27.0–33.4) <0.001
 Female 146 27.1 (23.4–31.1) 182 33.8 (29.8–37.9) 211 39.1 (35.0–43.4)
Age group (y)
 65–69 156 32.4 (28.3–36.8) 170 35.3 (31.1–39.8) 155 32.2 (28.1–36.6) 0.814
 70–74 165 33.5 (29.4–37.9) 156 31.7 (27.6–36.0) 171 34.8 (30.5–39.1)
 75–80 84 31.3 (25.8–37.3) 96 35.8 (30.1–41.9) 88 32.8 (27.2–38.8)
 80+ 38 31.7 (23.5–40.8) 37 30.8 (22.7–39.9) 45 37.5 (28.8–46.8)
Education level
 Illiterate or no education 63 28.8 (22.9–35.3) 71 32.4 (26.3–39.1) 85 38.8 (32.3–45.6) 0.143
 Elementary school 132 30.9 (26.6–35.5) 147 34.4 (29.9–39.1) 148 34.7 (30.1–39.4)
 Junior or senior high school 146 32.3 (28.0–36.8) 152 33.6 (29.3–38.2) 154 34.1 (29.7–38.6)
 College and above 102 38.8 (32.9–45.0) 89 33.8 (28.1–39.9) 72 27.4 (22.1–33.2)
Table 2.
 
Clinical Signs of Dry Eye
Table 2.
 
Clinical Signs of Dry Eye
Tear Break-up Time (s) Schirmer Test (mm) Fluorescein Stain Score of Cornea* (%) Grade of Meibomian Gland Obstruction, † (%) Lid Margin Telangiectasia (%)
Mean ± SD Mean ± SD 0 1 2 or 3 0 1 or 2 3 Absent Present
Total 8.2 ± 5.3 5.7 ± 4.2 66.6 24.5 8.8 46.4 40.5 13.3 30.0 70.0
Sex, ‡
 Male 8.2 ± 5.1 6.0 ± 4.2 68.4 23.8 7.8 44.9 41.7 13.4 31.5 68.5
 Female 8.1 ± 5.5 5.4 ± 4.1 64.1 25.6 10.4 48.2 38.6 13.2 27.6 72.4
P = 0.328 P = 0.001 P = 0.146 P = 0.583 P = 0.283
Age group, ‡ (y)
 65–69 8.2 ± 5.1 5.7 ± 4.3 68.6 25.2 6.0 49.3 37.8 12.9 28.3 71.7
 70–74 8.5 ± 5.6 6.0 ± 4.2 68.9 21.8 9.4 44.4 40.9 14.4 29.1 70.9
 75–80 7.8 ± 5.1 5.3 ± 3.6 63.8 25.0 11.2 43.3 44.8 11.9 31.7 68.3
 80+ 7.9 ± 4.8 6.1 ± 4.6 55.0 32.5 12.5 46.7 40.0 13.3 36.7 63.3
P = 0.690 P = 0.308 P = 0.013 P = 0.451 P = 0.128
Table 3.
 
Associations between Symptoms with Various Clinical Signs of Dry Eye
Table 3.
 
Associations between Symptoms with Various Clinical Signs of Dry Eye
Sign All 8 Questions Excluding Questions 4 and 5
n (%) P * n (%) P *
Tear break-up time
 ≤10 sec 362 (33.6) 0.789 262 (24.3) 0.615
 >10 sec 97 (34.4) 69 (24.5)
Schirmer test
 ≤5 mm 287 (36.1) 0.028 213 (26.8) 0.012
 >5 mm 172 (30.4) 118 (20.9)
Fluorescein stain of cornea
 Score ≥1 154 (33.9) 0.914 116 (25.6) 0.146
 Score 0 305 (33.6) 215 (23.7)
Meibomian gland obstruction
 Grade ≥1 248 (33.9) 0.896 174 (23.8) 0.583
 Grade 0 211 (33.6) 157 (25.0)
Lid margin telangiectasia
 Present 142 (34.8) 0.582 105 (25.7) 0.283
 Absent 317 (33.3) 226 (23.7)
Table 4.
 
Cluster Analysis of Dry Eye Symptoms
Table 4.
 
Cluster Analysis of Dry Eye Symptoms
Symptoms Group 1 Group 2 Group 3 Group 4
Dry 0.81 0.26 0.18 0.00
Gritty 0.33 0.15 0.09 0.00
Burning 0.04 0.04 0.30 0.00
Sticky 0.02 0.67 0.21 0.00
Watery 0.00 0.96 0.00 0.00
Red 0.16 0.05 0.06 0.00
Crusted 0.00 0.09 0.79 0.00
Shut 0.01 0.01 0.30 0.00
n (%) 192 (14.1%) 234 (17.2%) 33 (2.4%) 902 (66.2%)
Table 5.
 
Correlation between Various Dry Eye Signs*
Table 5.
 
Correlation between Various Dry Eye Signs*
BUT Schirmer Test F/S
BUT 0.23, † −0.02
Schirmer test 0.25, † −0.07, ‡
F/S −0.07, ‡ −0.13, †
Table 6.
 
Correlation between Meibomian Gland Disease and Other Dry Eye Signs
Table 6.
 
Correlation between Meibomian Gland Disease and Other Dry Eye Signs
Meibomian Gland Disease P *
Present Absent
Right eye
 BUT (s) 8.4 ± 5.4 10.3 ± 5.9 <0.001
 Schirmer test (mm) 6.7 ± 4.9 7.1 ± 5.0 0.087
 F/S 0.5 ± 0.7 0.2 ± 0.6 <0.001
Left eye
 BUT (s) 8.5 ± 5.6 10.4 ± 6.0 <0.001
 Schirmer test (mm) 6.9 ± 4.8 6.9 ± 5.1 0.894
 F/S 0.4 ± 0.7 0.3 ± 0.6 <0.001
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