dry eye

Detecting OSD in Children

While we don't expect dry eye in kids, it can portend serious systemic disease.

Amber Gaume Giannoni, O.D., F.A.A.O.
Kelly Nichols, O.D., M.P.H., Ph.D. (left) coordinates the “Dry Eye” column. Dr. Giannoni (right)

Dry eye is a hot topic, but when was the last time you considered the possibility of ocular surface disease in children? Understandably, this may not be on your radar. Only about 1.5% of healthy children ever complain of dry eye symptoms, such as burning, and we rarely observe signs of dry eye in this population.¹ We don't routinely employ vital dye staining or assess tear production and stability in toddlers, for instance, partly because it's difficult to get them to sit still long enough for these tests, and partly because we feel we won't find anything.

Did you know, however, that many children who express dry eye complaints have an underlying systemic association? In fact, studies show more than an eight-fold increase in dry eye complaints among children with juvenile arthritis and type 1 diabetes.^1,2 In addition, dry eye is a known factor in several genetic, autoimmune and inflammatory conditions.

As you may have guessed, my special interest in pediatric dry eye stems from a personal experience. In this article, I'll discuss this experience, as well as the diagnosis and treatment of dry eye in children.

Toddler's unusual complaint

From the time my oldest daughter started talking, at about 15 months, she often complained that a mosquito was biting her eye. I'd hear these grumblings a few times a week, usually at the end of the day when she was tired, but they didn't last long. She never looked particularly uncomfortable, and her eyes were never red, teary or swollen. A routine eye examination by a pediatric optometrist when she was a year old had been normal. So, I chalked it up to silly things that children say. I soon learned her complaints weren't so silly.

At 22 months of age, my daughter was diagnosed with pauciarticular juvenile arthritis and could no longer walk across a room. As I began to monitor her ocular health more closely, I found that her corneas and conjunctivae consistently lit up like a Christmas tree with fluorescein and lissamine green dyes. In retrospect, I realize I missed a fairly obvious complaint that might have led to an earlier diagnosis of her systemic disease, or at least a suspicion that something was brewing. I believe this occurred for two reasons: 1) Dry eye is rare in a healthy one-year-old; and 2) my daughter's complaints were expressed in terms that most of us aren't used to hearing. So, how can we improve our ability to detect and treat ocular surface disease in children?

What to look for and to ask

Believe it or not, children don't complain much about their health, so any complaints about their eyes, regardless of how unconventional their descriptions may be, should be explored. In fact, a child's dry eye complaints may be the only indication of an underlying problem. Asking about burning, stinging or gritty eyes — terms that adults understand — may elicit only a blank stare from a child, especially a younger child. And if the problem is intermittent, the child may not even remember that it occurs.

Asking parents about visible signs of dryness may help. This can include excessive blinking, redness or eye rubbing, especially in the sun, windy environments or in areas with air conditioning or heating systems. Bouts of excessive tearing or no tearing at all when the child cries can also be telltale signs.

If you suspect a child has dry eyes, try to obtain objective test results, if possible.

Investigators in one study were able to determine corneal staining, tear breakup time and Schirmer testing in some patients as young as three months of age.³ In younger or uncooperative patients, hand-held devices are often needed to adequately assess the anterior segment. If a hand-held slit lamp isn't available, a Burton lamp can work well. In addition, a direct ophthalmoscope with a cobalt filter, combined with fluorescein dye and a +20.00D condensing lens can give you valuable information about corneal integrity.

Treatment options for children

For patients of any age, lubrication with artificial tears is the most common therapy for dry eyes. I have found that recommending a specific brand of tears and prescribing a specific daily regimen helps ensure compliance. If drops are to be used more than q.i.d., I recommend non-preserved formulations to avoid the potential for an adverse reaction to benzalkonium chloride.⁴ When treating children, be aware that most schools require a prescription for eye drops, even over-the-counter drops, that are to be administered in school.

If tear film instability is related to meibomian gland disease (MGD), adjunctive lid therapy (i.e. warm soaks) will help achieve a sustainable effect, and lubricants geared toward addressing a lipid deficiency may be beneficial.

Remember that oral tetracyclines, although commonly prescribed to treat MGD in adults, are contraindicated in children because they are associated with permanent side effects, such as tooth discoloration and stunted growth.

Topical antibiotic ointments and lid hygiene can be prescribed if considerable anterior blepharitis is present, and the child is not allergic to the medication.

In some cases, punctal occlusion may provide substantial benefits to parents and children, especially in children who refuse drop instillation at home or school. Controlling lid disease, inflammation and ocular allergy prior to plug insertion is critical. Otherwise, tears containing increased concentrations of allergens and inflammatory cytokines will stagnate on the cornea and exacerbate the problem.

A recent study revealed that silicone punctal plugs are a safe option for children as young as 18 months, although about two-thirds of study subjects required mild general sedation for the procedure.⁵ Side effects were few, and undesirable outcomes that are typically reported in adults, such as epiphora, conjunctival erosion, pyogenic granuloma, punctal scarring and canalicular stenosis, were not observed in this study population. The most common complication was spontaneous plug extrusion (19%). Interestingly, 72% of the study subjects had a concurrent systemic disease, and in some cases, it was the ophthalmic examination that led to the discovery of the systemic condition.

Some practitioners prescribe cyclosporine ophthalmic emulsion 0.05% (Restasis, Allergan) for these children, however, this is an off-label use. Restasis is approved only for patients age 16 and older; it has not been tested on children or pregnant women.

Diagnosis in children

Paying attention to clinical signs of dry eye in children can result in the early diagnosis of an underlying systemic problem, which can improve overall outcomes. As we know, delays in discovering conditions, such as juvenile arthritis, lupus or diabetes, can have devastating and sometimes life-threatening effects. In my opinion, persistent signs and symptoms of dry eye in a child warrant blood work because of the association with many systemic conditions.

In my daughter's case, the diagnosis of juvenile arthritis led to additional blood work, which indicated she was at a high risk for developing uveitis. For this reason, she was observed every two-to-three months, and the uveitis was detected early.

For many patients, however, uveitis precedes joint pain and is asymptomatic. Parents don't know there is a problem because the child has no pain, redness or light sensitivity. Anterior chamber inflammation often goes undiagnosed until permanent damage and vision loss have occurred.

Even in the absence of systemic disease, untreated dry eye in children can cause discomfort, and more importantly, it can lead to poor or fluctuating vision, epithelial defects of the cornea, increased risk for infectious ulcer, neovascularization, permanent scarring, vision loss and possibly amblyopia. Clearly, the take home message here is to keep an eye out for dry eye when seeing kids, and parents, in your practice. OM

1. Akinci A, Cakar N, Uncu N, et al. Keratoconjunctivitis sicca in juvenile rheumatoid arthritis. Cornea. 2007 Sep; 26(8):941-944.
2. Akinci A, Cetinkaya E, Aycan Z. Dry eye syndrome in diabetic children. Eur J Ophthalmol. 2007 Nov-Dec;17(6):873-8.
3. Mac Cord Medina F, Silvestre de Castro R, Leite SC, et al. Management of dry eye related to systemic diseases in childhood and long-term follow-up. Acta Ophthalmol Scand. 2007 Nov;85(7):739-44.
4. Baudouin C, Labbe A, Liang H, et al. Preservatives in eyedrops: the good, the bad and the ugly. Prog Retin Eye Res. 2010 July;29(4):312-34.
5. Mataftsi A, Subbu RG, Jones S, Nischal KK. The use of punctal plugs in children. Br J Ophthalmol. 2012 Jan;96(1): 90-2.