CLINICAL

  pediatrics

Ocular Surface Disease in Children

A look at allergic conjunctivitis and dry eye disease

LEONARD J. PRESS, O.D., F.A.A.O., F.C.O.V.D.

When April showers bring May flowers, they also tend to bring kids’ allergies. As a result, when a child presents complaining of burning eyes during the spring months, we tend to think ocular allergy. Makes sense.

Yet, it’s important to keep in mind that although dry eye disease (DED) is more common in adults, children also can have the condition, which can pop up at any time. And, as is the case with adults, these young patients can also have concurrent ocular allergy and DED.

Here, I discuss how each condition affects young patients, how to distinguish between the two of them and the most appropriate treatments.

Pediatric ocular allergy

It has been estimated that as many as 40% of children in the U.S. experience allergic conjunctivitis. A child’s immune system tends to overreact to foreign substances, so the condition tends to be chronic in childhood. As children progress through the teen years, however, in many instances the immune system becomes more effective at modulating these responses. Allergic conjunctivitis falls under two forms: vernal keratoconjunctivitis (VKC) and perennial allergic conjunctivitis (PAC).

VKC results from allergens, such as pollen that goes airborne through grass, weeds, mold and trees, though the condition can also be triggered by airborne pollutants, such as smoke and fumes.

Itchy eyes with frequent rubbing should raise your suspicion of allergic conjunctivitis.

PAC occurs more frequently among children who have generalized allergic conditions, such as hay fever, in which case the nose is itchy and runny in addition to the eyes. It results from allergens, such as dust mites and animal dander. (With regard to the latter, pet dander should be considered an allergen that can be transferred to the eyes either by the hands or through airborne means.)

The symptoms of allergic conjunctivitis are itchy eyes with frequent rubbing, increased tearing and burning. The signs are chemotic conjunctiva bilaterally, mild swelling of the eyelids, either no discharge or a minimal sticky, stringy mucus discharge and no pain or fever.

In terms of treatment, you want to prescribe a cool washcloth to be placed over the closed lids when symptoms are mild, and mast cell stabilizers and antihistamines when worse. For parents who prefer the “natural” route, homeopathic allergy relief drops are available.

Pediatric DED

Statistics are scarce on the prevalence of DED in children. Although DED can be aqueous deficient, evaporative or both, children tend to have the evaporative form more frequently, as their tear film quality is usually quite good. That said, keep aqueous deficient DED (decreased tear secretion from the lacrimal glands) on your diagnostic radar when the young patient has an autoimmune disease. For example, juvenile arthritis can affect the ball-in-socket arrangement of the eye, causing DED.

Evaporative DED occurs as a result of contact lens wear, meibomian gland dysfunction, blepharitis, low blink rate (think overuse of personal digital devices), lid abnormalities (e.g., lagophthalmos) and allergic conjunctivitis. The symptoms of DED are blurred or fluctuating vision, burning, dryness, eye fatigue, foreign-body sensation, gritty feeling, itching and stinging.

A diagnostic rule of thumb is that DED doesn’t have the severe itching and runny nose effects that allergic conjunctivitis has, the conjunctiva tends not to be chemotic, and the condition manifests more with frequent blinking. That said, any time irritation is present, patient history, as well as palpebral and conjunctival staining aids in the differential diagnosis.

DED treatment for children is largely the same as in adulthood. Artificial tears can be tried initially. When ocular surface disease is secondary to blepharitis or meibomian gland dysfunction, conservative treatment with lid hygiene and manual gland expression is tried first. If this is not effective, doxycycline is used rather than tetracycline. This is because tetracycline can cause permanent yellowing or graying of the teeth in children, and it can stunt a child’s growth. If the child wears contact lenses, have him cease wear until DED signs and symptoms are under control. As with allergies, parents who desire a conservative approach may prefer homeopathic drops for DED.

The take home

Although allergy tends to be a chronic condition in childhood, it’s important to remember that our young patients can indeed have DED. Therefore, be sure to keep this condition in mind when children present with complaints of ocular burning, even if they come to your office in the spring. OM

DR. PRESS IS THE OPTOMETRIC DIRECTOR OF THE VISION & LEARNING CENTER IN FAIR LAWN, N.J. HE SPECIALIZES IN PEDIATRIC VISION. HE COMPLETED HIS RESIDENCY PROGRAM IN PEDIATRIC OPTOMETRY AT THE EYE INSTITUTE OF THE PENNSYLVANIA COLLEGE OF OPTOMETRY, AND HE SERVED AS CHIEF OF THE PEDIATRIC UNIT OF THE EYE INSTITUTE. IN ADDITION, HE’S A DIPLOMATE OF THE AAO AND HAS WRITTEN THREE TEXTBOOKS ENCOMPASSING PEDIATRIC OPTOMETRY AND IS A DIPLOMATE IN THE PEDIATRIC OPTOMETRY/BINOCULAR VISION AND PERCEPTION SECTION OF THE AAO. E-MAIL HIM AT VISIONLECTURE@GMAIL.COM, OR VISIT TINYURL.COM/OMCOMMENT TO COMMENT ON THIS ARTICLE.