Dry eye disease is one of the most common ocular condition presenting in the Ophthalmology Outpatient Clinics. Females in their forties are the ones most commonly affected. Dry eye conditions in children are less common than the adults. Very few studies are available on the prevalence of dry eyes in the pediatric age group. The causes can be many and symptoms differ from their adult counterparts. Donthienni et al have studied the incidence, demographics, risk factors and types of dry eye in India (1). They found the incidence of dry eyes in pediatric population to be 2688 per million and the prevalence to be 2.11%. Another study from China has shown a higher incidence of dry eyes in children with allergic conjunctivitis (2).The problem of dry eyes in children is increasing in this era of smartphones, with minimal outdoor activities. This was made evident by the study of Moon et al(3).
The Etiology
The causes of dry eyes in children can vary anywhere from a mild ocular surface disorder to severe systemic conditions.
Evaporative conditions: Meibomian gland dysfunction is one of the most common causes of dry eyes in children. These children usually present with recurrent history of chalazia or meibomian cysts. Prolonged use of smartphones, computers and spending more time indoors in air-conditioned rooms are some other causes of evaporative dry eye disease. Increased screen time tends to cause a decrease in the blink rate which causes dryness. Additionally, environmental pollution, and extreme hot or cold weather can also cause dry eyes.
Inflammations and infections: Blepharitis (both seborrhic and staphylococcus), adenoviral keratoconjunctivitis, and herpes simplex virus kerato conjunctivitis are some of the common infective and inflammatory conditions that lead to dry eyes. Demodex folliculorum mite infestation of eye lashes is a rare cause of dry eyes.
Seasonal Allergic conjunctivitis: This is a common condition in children which causes mild to very severe dry eyes.(2)
Vitamin A deficiency: Vitamin A deficiency causes a decrease in the goblet cell population resulting in decreased mucin in the tear film. It also causes keratinisation of meibomian duct orifices and resultant meibum deficiency. Despite being a potentially preventable condition, Vitamin A deficiency is still a major public health problem in many developing countries across the world.
Drug induced: Ocular drugs like anti glaucoma medications and cephalosporins cause epithelial toxicity and corneal dryness. Systemic drugs like anticancer therapy and anti psychotic drugs can also be a cause of dry eye in children.
Systemic diseases: Steven Johnson’s syndrome, epidermolysis bullosa, Sjogren syndrome, Riley Day syndrome, graft versus host disease, juvenile diabetes and juvenile rheumatoid arthritis are some conditions which can cause dry eye disease in children.
Diagnosing dry eyes in children
Diagnosing dry eye disease in children is a big challenge. Conventional tests done in adults are very difficult to perform in young patients. Measuring the tear meniscus height on the slit lamp and tear breakup time calculation are some of the easier procedures in this population group. Most importantly, a detailed history and a thorough examination of the ocular surface is the key to diagnosing dry eye disease in children. Measurement of tear film related parameters such as osmolarity and levels of inflammatory mediators are also useful.(4)
Treatment protocol of dry eye disease in the pediatric population
The management of dry eyes in children is largely similar to that in the adults with a few differences.
Tear substitutes: These are the most common treatment modalities both in adults and children and work mostly in evaporative dry eye conditions.
Treatment of the underlying cause: Successful treatment of dry eyes depends on addressing the underlying cause. Inflammatory conditions like seborrheic blepharitis improve with better lid hygiene or eyelid cleaners. Similarly, warm fomentation help relieve the blocked secretions from Meibomian glands. Application of a mild steroid and antibiotic combination ointment on the eyelids is also helpful for blepharitis. Oral doxycycline, often used in adults, is not recommended for children, because it adversely affects dentition and bone growth. (5) Furthermore, tear substitutes in conjunction with anti-allergy medications are effective for allergy related dry eyes in children. In this regard, Tacrolimus skin or eye ointment, 0.03%, is extremely useful in not only controlling the ocular allergy and inflammation, but helps restore the stability of the tear-film.
Autologous serum: This modality of treatment has shown very promising results in adults with severe and refractory dry eye conditions.(6) Preparation and preservation can be difficult and studies on its use in children are limited(7); however, in severe dry eye disease especially following Stevens-Johnson Syndrome, Allo-Serum Eye drops prepared by donation of blood from parents is a very promising option.
Vitamin A deficiency: The treatment of this entity is especially important in children from low socioeconomic backgrounds. Vitamin A deficiency has many stages of ocular manifestations, ranging from night blindness to corneal ulcers and corneal melting. Conjunctival xerosis, apparent as bitot’s spots, is one of the earliest signs of Vitamin A deficiency. Children should be given Vitamin A supplements according to the WHO protocol to prevent these complications. (8)
Punctal plugs: These are popularly used in adults. Matafsti et al has shown them to be safe and effective in children with 19% of them having extrusion of plugs as a complication.(9)
The PROSE (prosthetic replacement of the ocular surface ecosystem) device: Some studies on the use of PROSE have shown promising results in children with severe dry eyes (10) and in conditions like toxic epidermolysis bullosa and Steven-Johnson syndrome. (11) Placement of and retaining these devices in children with dry eyes is quite challenging.
Conclusion
Dry Eye disease can occur in children following any prolonged ocular surface inflammatory condition. A thorough history, careful examination and choosing suitable treatment options are the mainstay of therapy for managing dry eyes in the pediatric population. Early diagnosis and treatment is important, as chronic ocular surface inflammation and tear-film loss can lead to irreversible damage to the ocular surface and permanent blindness.
References:
- Donthineni PR, Kammari P, Shanbhag SS, et al. Incidence, demographics, types and risk factors of dry eye disease in India: Electronic medical records driven big data analytics report I. Ocul Surf. 2019 Apr;17(2):250-256.
- Chen L, Pi L, Fang J, Chen X, Ke N, Liu Q. High incidence of dry eye in young children with allergic conjunctivitis in Southwest China. Acta Ophthalmol. 2016 Dec; 94(8):e727-e730.
- Moon JH, Kim KW, Moon NJ. Smartphone use is a risk factor for pediatric dry eye disease according to region and age: a case control study.BMC Ophthalmol. 2016 Oct 28;16(1):188.
- Vanesa Caserous Eye world June 2013.Dry eye diagnosis in children takes some detective work. www.eyeworld.org
- Laura B Kauffman Are we missing dry eyes in children>? October 2012. American academy of Ophthalmology.www.aao.org
- Pan Q, Angelina A, Marrone M, Stark WJ, Akpek EK. Autologous serum eye drops for dry eye. Cochrane Database of Systematic Reviews2017, Issue 2. Art. No.: C
- PawelJozef Laguna, Jolanta AntoniewiczPapis, Alina Szajkowska, Magdalena Letowska, Application of Autologous Artificial Tears in a Case of an 8-Year-Old Girl with Vernal Keratoconjunctivitis (Spring Catarrh)Blood 2017 130:4931;
- WHO. Guideline: Vitamin A supplementation for infants and children 6-59 months of age. Geneva, World Health Organization;2011(http://www.who.int/nutrition/publications/micronutrients/guidelines/vas_6to59_months/en/).
- Mafasi A et al Punctal plugs for children. Br.J. Ophthalmol. 2012;96(1):90-92
- Rathi VM, Mandathara PS, Vaddavalli PK, Fluid filled scleral contact lens in pediatric patients: challenges and outcome. Cont Lens Anterior Eye. 2012 Aug;35(4):189-92.
- Wang Y, Rao R, Jacobs DS. Prosthetic Replacement of the Ocular Surface Ecosystem Treatment for Ocular Surface Disease in Pediatric Patients With Stevens-Johnson Syndrome. Am J Ophthalmol 2019 May;201:1-8.