At the completion of this article, the reader should be able to improve their management of dry eye disease in children, including:
- Understand the adverse ocular effects of digital device use in children
- Consider the impact on the ocular surface of myopia control interventions
- Understand the value and the shortcomings of dry eye questionnaires for children
- Review clinical management strategies for dry eye in children
Just like adults, dry eye can be uncomfortable and painful for children. Still, there is a genuine lack of data on the subject, which presents several diagnostic and management challenges for the optometrist. The authors explore the systemic, environmental and medical interventions that can exacerbate the condition, and provide clinical management strategies for dry eye in children.
Ngozi C. Chidi-Egboka
OD MPH PhD, FNCO FAAO
School of Optometry and Vision Science, Faculty of Medicine and Health, UNSW, Sydney, Australia
Rebecca Dang
B Optom/B Sci (Hons) M Optom
School of Optometry and Vision Science, Faculty of Medicine and Health, UNSW Sydney, Australia
Dr Pauline Kang
B Optom (Hons) GradCertOcTher PhD FAAO
School of Optometry and Vision Science, Faculty of Medicine and Health, UNSW, Sydney, Australia
A neglected field of study
Dry eye is a chronic condition affecting one in five people globally. Although it has been highly investigated in adults, there is significantly less dry eye research in children. Risk factors which pre-dispose adults to dry eye including digital device use, contact lens wear, Asian ethnicity and female sex have not been well investigated in children. In addition, with increasing prevalence of myopia, clinicians are likely to concurrently manage both progressive myopia and dry eye, as many myopia control interventions may cause or exacerbate dry eye symptoms.
Greater understanding of ocular surface characteristics in children and the potential threat to ocular surface health posed by the challenges of modern lifestyle and myopia control interventions will enhance eyecare practitioners’ ability to manage their patients more holistically.
Dry eye in adults is diagnosed by the presence of ocular surface symptoms and clinical signs such as low tear break up time (TBUT), corneal staining, meibomian gland dysfunction, fast tear evaporation and increased tear osmolarity. However, limited research in ocular surface in children makes it difficult to draw valid comparisons to the adult ocular surface.1
Surveys investigating the prevalence of dry eye symptoms in children have found less symptoms compared to adults.2 However, these studies used adult questionnaires not validated for use in children. Notably, a recent study found a high number of children (87%) had thin lipid layers using the 75 nm cut off criteria used in adults.3 In addition, variations in meibomian gland function and appearance (gland expressibility and appearance of tortuous glands) were found in children as young as six years.3,4
Similar to adults, there is no association between tear film function and ocular symptoms in children.5 However, children have less experience reporting abnormal ocular symptoms and may not understand the concept of ocular surface discomfort.2 The criteria to diagnose dry eye from normal ocular health may therefore be significantly different in children compared to adults. Greater understanding of dry eye in children is required.
Contemporary predisposing factors to dry eye in children
Digital device use
Digital-device use in children is increasing due to their integration into educational models and increased recreational use. However, digital-device use is associated with ocular complications. Studies in adults and adolescents have shown that sustained use of digital devices (smartphones, tablets, computer screens) can trigger disorders of the ocular surface. This includes increased dry eye symptoms, reduced tear film stability and distorted patterns of blinking.6,7
Smartphone use in children was reported to increase dry eye symptoms and cause immediate and sustained slowing of blinking evident up to one hour during smartphone use.8 Given the increasing use of smartphones and other digital devices by children in the real world, the effects on the ocular surface may persist or worsen over a longer term, causing cumulative damage to the ocular surface.
Optimal blinking is essential to maintain the integrity of the pre-corneal tear film and ocular surface homeostasis.9,10 Incomplete blinking has been implicated as an important marker of ocular surface symptoms during digital device use.6,7 For these reasons, incorporating blink assessment into routine clinical practice is essential.
Research into blink measurements is set to improve due to increased availability and accessibility of technologies such as high-speed digital cameras,11 wearable eye tracking headsets12 and mobile phones13 which provide improved methods for characterising human blinking. Blinking has been measured in children using a wearable eye tracking headset technology that allows free head and eye movement.4 A faster blink rate was associated with greater tear volume, but not symptoms in children.4
The impact of myopia control interventions
Increasing prevalence of myopia globally and in Australia has encouraged increased clinical use of myopia control interventions.14,15 These interventions include peripheral defocus spectacle lenses, soft multifocal contact lenses, orthokeratology and atropine eye drops,
many of which can have impacts on the ocular surface of children.
• Soft multifocal contact lenses
Soft multifocal contact lenses are a popular option for the treatment of progressive myopia and are available in both daily disposable and monthly options. Soft contact lens wear is a key risk factor for dry eye in adults, implicated as a factor for worsened ocular symptoms, distorted blinking, ocular surface inflammation and tear film dysfunction.
A long-term contact lens trial investigating daily disposable contact lens options found minimal impact of lens wear on ocular physiology after six years and very few side effects that would be considered dry eye disease.16 However, ocular surface related symptoms and signs has been found to be more prevalent and severe in children wearing contact lenses compared to non-wearers17 and so dry eye is still an important consideration in this patient cohort.
• Orthokeratology
Orthokeratology lenses involve closed-eye lens wear and so it could be expected that the impact on the ocular surface could be minimal. There have been conflicting reports on the impact of orthokeratology treatment on dry eye symptoms and clinical signs.18,19
Some of the effects include worsened ocular symptoms, increased tear secretion due to ocular irritation, tear film instability and corneal fluorescein staining. The increase in corneal staining was attributed to several factors including cornea hypoxia; mechanical abrasion during insertion or removal of lenses; or thinning of the corneal epithelium due to improper lens fitting. While it is not unusual to observe mild corneal and conjunctival staining in orthokeratology patients, these adverse effects are generally mild and rare, especially with proper instruction and care.20,21
• Atropine
The use of atropine eye drops for myopia control is increasing however, the potential effect on the ocular surface is not well studied. As atropine is a muscarinic receptor antagonist, topical instillation of atropine might also affect lacrimal gland secretion and alter the tear film on the ocular surface.
While the effect of preserved eye drops has not been studied in children, use of topical drops with preservatives, particularly benzalkonium chloride, have been found to have adverse effects on ocular surfaces in adults.22 Long-term use of topical medications such as required in glaucoma treatment or other inflammatory ocular conditions finds preserved eye drops increase discomfort upon instillation, including burning, stinging, foreign body sensations, tearing and itchy eyelids, which is ameliorated upon switching to non-preserved medications.23
Other risk factors
Allergy
Allergy has also been implicated as a possible risk factor for dry eye disease in both adults and children. Ocular allergy can impact key mechanisms behind dry eye including tear film instability, ocular surface inflammation and damage, and neurosensory abnormalities.24
Studies investigating children with allergic conjunctivitis finds a high incidence of dry eye compared to controls, with reduced TBUT of 6.5 seconds in the dry eye group compared to 10 seconds in the control.5 There have also been suggestions that the mechanical stress caused by continuous rubbing can lead to alterations in structure and function of the meibomian glands, although there needs to be further investigations in this area.24 It is important that clinicians conduct dry eye assessment in children with history of allergies.
Diabetes
Diabetes is a key risk factor for dry eye in adults and there is some evidence to also support this relationship in children.25,26 The prevalence of dry eye in adults with diabetes was found to be 52.8% compared to 9.3% of controls.27 Similarly, the rate of dry eye in children with Type 1 diabetes is significantly higher than that of controls, at 15.4% compared to 1.9%.
There is also evidence that higher HBA1C values correlate with higher the rate of dry eye syndrome.27 Research in adults finds diabetes is associated with decreased TBUT and Schirmer test values, and increased fluorescein/rose Bengal staining.25 Therefore, it is important that clinicians conduct a thorough history and assess diabetic children for dry eye signs.
Clinical evaluation of dry eye in children
Symptoms
A fundamental first step in the diagnosis of dry eye disease is to quantify patient symptoms with the use of a questionnaire.27 The Ocular Surface Disease Index (OSDI) and Dry Eye Questionnaire 5 (DEQ-5) questionnaires are included in the TFOS DEWS II report as the recommended questionnaires for dry eye diagnosis, but these questionnaires are only validated for use in adult population.
A recent study investigated the use of six existing dry questionnaires including OSDI and DEQ-5 in children.2 The study established that practitioners can reliably use existing dry eye questionnaires to examine the impact of challenges such as extensive use of digital devices and myopia control in school-aged children, however, it was reported that more time and assistance may be required when using these questionnaires in children. The DEQ-5 questionnaire and Instant Ocular Symptom Survey (IOSS) are recommended for use in younger age children due to their relative simplicity and ease of use.2
As some clinicians may not regularly use dry eye questionnaires,2,28 a thorough history should be conducted including asking questions on systemic health, digital device use and ocular symptoms of dryness, burning, stinging and watery eyes, to identify – or rule out – dry eye.
Tear film and other ocular surface homeostasis markers
Tear film instability, increased tear osmolarity and ocular surface staining are key markers for dry eye disease. Standard clinical assessment of the ocular surface as recommended by TFOS DEWS II diagnostic methodology report28 include non-invasive assessment of TBUT and tear osmolarity, and fluorescein and lissamine green staining of the cornea, conjunctiva and the eye lid margin.
Automated topography systems such as the Keratograph (OCULUS, Wetzlar, Germany) and interferometry technique such as LipiView (TearScience, Morrisville, NC) detects and maps locations of interference in the image capture of the tear film over time. Mapping the spatial distribution of the tear film break-up may provide a more detailed assessment of tear film instability in children.
The eyelid, lid margins, meibomian gland and lipid layer thickness can also be quantitatively evaluated using recent advances in technology that have led to the development of several multi-functionality systems with infrared cameras which allow the video capturing of images for retrospective evaluation. Such quantitative evaluation is useful for tracking of treatment effectiveness.
Clinical management strategies for dry eye in children
Selection and modification of myopia control treatment
Spectacle options are the first optical consideration for children with predispositions to dry eye as it does not cause changes to the ocular surface. However, if spectacle options are not suitable or are contraindicated, soft multifocal contact lenses and atropine are alternative options for myopia control. In prescribing atropine, practitioners should opt to use of non-preserved over preserved options and arrange regular follow-up care to ensure ocular surface health is not adversely impacted. While more expensive, switching from preserved to non-preserved formulations should produce less discomfort upon instillation and reduce the likelihood of dry eye.
If contact lens options are preferred for myopia control, appropriate choice of lens modality can be very effective in ameliorating dry eye signs and symptoms. Daily disposable contact lenses are associated with less dry eye symptoms compared to reusable soft contact lens options.29
Therefore, practitioners can consider switching from monthly lens options to daily disposables. In addition, the adjunct use of non-preserved artificial tears can be helpful in managing dry eye symptoms.
Orthokeratology may be another viable alternative to soft contact lenses particularly if children are experiencing symptoms of dry eye with soft contact lenses at the end of the day, although this area of research is still emerging.30,31
Patient education
Clinicians should endeavour to educate patients on healthy options to reduce the burden of dry eye.
Help them develop an awareness of early symptoms and signs of the effect of digital device use and the resultant impact on ocular surface homeostasis.
Educate parents on the screen time recommendations by the World Health Organization and other national health bodies including Australian Department of Health: no screen time for children under two years, not more than one hour daily screen time for children aged two to five years and two hours daily screen time for children under 17 years old.
Encourage parents to manage hours of digital device use and recommend frequent breaks as endorsed by the American Academy of Paediatrics.32 The recommended 20-20-20 rule screen breaks (20 seconds break to look at an object 20 feet away every 20 minutes) for children as practiced by adults can be recommended to avoid developing ocular symptoms.
Consider the ocular surface when selecting optimal myopia control treatments, and use ocular lubricants to moderate contact lens wear effects.
Finally, recommend routine dry eye work ups for high-risk children such as regular digital device users, contact lens wearers, and children known to have abnormal blinking, allergy or diabetes.
More reading
Dry eye disease and nutrition: are we what we eat?
Myopia Management: Implementing an evidence-based Standard of Care
Managing myopia with spectacle lenses
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