Sleep quality, perceived stress, and dry eye disease among university students in Ghana: A cross-sectional study of individual and joint associations.

Dry eye disease was very common among the Ghanaian university students studied, with a prevalence of 77.9%.

• Analytical cross-sectional study of a random sample of university students aged 18-34 years (n = 403 in the univariate analyses).
• DED was diagnosed according to TFOS DEWS II criteria using the Ocular Surface Disease Index, tear break-up time, corneal staining, and Schirmer testing.

Sleep disturbance was highly prevalent, and a substantial minority of students reported high perceived stress.

• Sleep disturbance was present in 75.9% of participants.
• 21.3% reported high perceived stress.
• Sleep quality was assessed with the Pittsburgh Sleep Quality Index and stress with the Perceived Stress Scale.

In univariate analyses, both sleep disturbance and high perceived stress were significantly associated with DED prevalence.

• Sleep disturbance: χ²(1, 403) = 14.57, p < 0.0001.
• Stress: χ²(1, 403) = 4.20, p = 0.040.

Poor sleep quality was independently associated with higher DED risk after adjustment for sex and stress.

• Adjusted RR = 1.11, 95% CI: 1.05-1.18; p = 0.001.
• Estimated with robust Poisson regression models, adjusting for sex and the alternate exposure.

High perceived stress was independently associated with higher DED risk after adjustment for sex and sleep quality.

• Adjusted RR = 1.06, 95% CI: 1.01-1.11; p = 0.015.
• The association was smaller in magnitude than that for poor sleep quality.

Participants with both poor sleep quality and high stress had the highest DED risk, but no significant interaction between the two exposures was found.

• Combined exposure RR = 1.18, 95% CI: 1.10-1.27; p < 0.0001.
• Interaction was assessed on both additive and multiplicative scales and was not significant.
• There was no evidence that stress modified the association between sleep disturbance and DED.