Conjunctival surface changes in diabetics: an unusual cytological study

  • Adeeb A Khan
  • Divya Kesarwani
  • Shaista M Vasenwala
  • A K Amitava
  • Zia Siddiqui
  • Kafil Akhtar
Keywords: Diabetic retinopathy, Conjunctival impression cytology, Dry eye, Cytology


Background: To study the conjunctival surface changes in diabetics with and without retinopathy, its relation to systemic factors and comparison to control.Methods: In this study, 123 eyes of 74 subjects were divided into two study groups (Diabetes with and without retinopathy) and control. Diabetes mellitus (DM) without retinopathy comprised of 34 cases with 50 eyes, diabetic retinopathy (DR) of 19 cases with 33 eyes and control of 21 cases with 40 eyes. Conjunctival impression cytology (CIC) was compared in the three groups. We also noted relationship of CIC to the sign and symptoms of dry eye, duration of diabetes, the status of retinopathy and metabolic control in diabetes.Results: CIC analysis showed that goblet cell density (GCD) was significantly lower in diabetics as compared to controls which was related to worsening retinopathy and dry eye symptoms(p<0.05) but not with duration of diabetes and poor metabolic control. Highly significant conjunctival squamous metaplasia (CSM) was seen in diabetics as compared to control group. (p<0.0001) The median CSM grade was poorer with long duration diabetes and worsening retinopathy (p<0.015), with no relation to dry eye symptoms and metabolic control.Conclusion: Conjunctival surface changes in diabetics include goblet cell loss and CSM. Interestingly, diabetics with retinopathy had significantly worse changes on CIC analysis than those without it, and both groups showed worse changes than controls.


1) Branwald E, Fauci S, Kasper D, Hauser LS, Longo DL, Jameson JL. Diabetes Mellitus. Harrison Principle of Internal Medicine. 15th Edn. 2001; pp 2121-3.
2) Saini JS, Khandalavla B. Corneal epithelial fragility in diabetes mellitus. Can J Ophthalmol 1995; 30:142-6.
3) Inoue K, Kato S, Ohara C, Numaga J, Amano S, Oshika T. Ocular and systemic factors relevant to diabetic keratoepitheliopathy. Cornea 2001; 20:798-801.
4) Dogru M, Katakami C, Inoue M. Tear function and ocular surface changes in noninsulin-dependent diabetes mellitus. Ophthalmol 2001;108:586-92.
5) Goebbels M. Tear secretion and tear film function in insulin dependent diabetics. Br J Ophthalmol 2000; 84:19-21.
6) Yoon KC, Im SK, Sco MS. Changes of tear film and ocular surface in diabetes mellitus. Korean J Ophthal 2004; 2:168-74.
7) Braunwald E, Kasper DL, Fauci AS, Hauser SL, Longo DL, Jameson JL: Harrison’s Principle of Internal Medicine. 17th Edn. 2008; pp 2276-9.
8) Anshu A, Munshi MM, Sathe V, Ganar A. Conjunctival impression cytology in contact lens wearers. Cytopathol 2001;12:314-20.
9) Nelson JD. Impression cytology. Cornea 1988; 7:71-81.
10) Tseng SC. Staging of conjunctival squamous metaplasia by impression cytology. Ophthalmol 1985; 9:728-33.
Original Article