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Pediatric dry eye disease (PDED) is considered a rare condition, but it is also on the rise. We know the risk for dry eye disease (DED) increases with age, but this well-known fact could cause practitioners to unintentionally miss early signs in our younger patients, or lead us to assume that minor dry eye-related complaints in children must be due to something else. Because DED tends to be overlooked in kids, it is possible that our epidemiological data may not be entirely accurate and that PDED isn’t quite as rare as we think it is.

So why do experts believe that PDED is on the rise? I don’t think I’m ruining any surprises when I tell you that increased screen time and lifestyle factors such as poor diet, stress, and lack of physical activity are likely contributors. Another common theory relates to the rising prevalence of autoimmune conditions (another known risk factor for DED) in our younger population. In 2020, the U.S. National Health and Nutrition Examination Survey (NHANES)¹ found that the prevalence of antinuclear antibodies (ANA), which is the most common autoimmunity biomarker, increased by nearly 300% in adolescents aged 12 to 19 from the 1980s to 2012. This was the largest ANA increase by any age group in the 14,211-participant study. Of course, not everyone with positive ANA bloodwork has an autoimmune disease, but this increase is noteworthy nonetheless.

Dry eye symptoms are often not assessed in internal medicine, endocrinology or rheumatology clinics, just as autoimmune disease may remain undiagnosed in an ophthalmic setting where patients are seeking relief for DED symptoms. This missing link between autoimmunity and DED is likely even further decreased for our pediatric populations across all health care disciplines. Improving that knowledge link is crucial for earlier diagnosis and the prevention of permanent systemic and ocular complications.

Our columnists in this issue start this conversation. We offer tips for assessing DED in your younger patients; the newest epidemiologic data for this age group; and information on the IRIS (Intelligent Research in Sight) Registry.

1. Dinse GE, Parks CG, Weinberg CR, et al. Increasing prevalence of antinuclear antibodies in the United States. Arthritis Rheumatol. 2020 Jun;72(6):1026-1035. doi:10.1002/art.41214

Amber Gaume Giannoni, OD, FAAO
Editor

Pediatric Dry Eye Disease

The incidence and prevalence of dry eye disease in children is on the rise,¹ but what is causing it? Is pediatric dry eye disease (PDED) really more common or is it just being diagnosed more as our awareness of it improves? I believe it’s both. The increase could be linked to lifestyle changes, such as prolonged screen time—which reduces blink rates and contributes to tear film instability—or more children and teenagers taking systemic medications for juvenile rheumatoid arthritis, diabetes, anxiety, depression, allergies and acne, all of which can predispose them to developing dry eye signs and symptoms. Eyelid conditions such as Demodex blepharitis and habits like wearing make-up and false lashes can also contribute to loss of homeostasis of the ocular surface.

Despite being less common than DED in adults, PDED can have significant implications on a child’s quality of life, as well as their visual function and academic performance. Intentionally being on the lookout for patients in the pediatric population with DED is essential for timely diagnosis and effective management.

The clinical presentation of PDED can vary, and children may not always articulate their symptoms clearly. I ask my pediatric patients to complete a SPEED™️ questionnaire to help them with this. Common symptoms include eye discomfort, itching, burning, redness, foreign body sensation and blurred vision, especially after prolonged visual activities like reading or using electronic devices. Some children may also present with excessive tearing as a reflex response. I’ve even seen kids who are missing more than 75% of their meibomian glands.

Let’s look at one of my patients as an example:

A 16-year-old was referred to me with complaints of eye discomfort, blurred vision and an inability to wear contact lenses, even after switching to a single-use modality. She also had a history of a corneal ulcer. She was on the pom team and her prescription was -6.00 and -6.50 in the right and left eyes, respectively. As an active teenager, she needed good, stable vision with her contact lenses without putting her at risk.

On examination, her BCVA was only 20/30. She had severe scattered and coalesced corneal staining OU. Her meibomian gland function and SPEED™ score were poor, which indicated severe symptoms. After a lengthy discussion of when the problem started, we were able to ascertain that a switch in her birth control was likely the culprit. In the short term, I treated her with topical ophthalmic steroids, preservative-free artificial tears and ointment at bedtime while we worked on getting a topical ophthalmic immunomodulator approved by insurance (at her age, this was not easy). Once her OB/Gyn changed her birth control, she greatly improved.

In short, diagnosing DED in children can be challenging, but utilizing validated symptom questionnaires and vital dyes, along with a thorough meibomian gland assessment, can help the process.

PDED is a multifaceted condition that is influenced by environmental and systemic factors, as well as lifestyle. Early recognition and intervention are crucial in preventing long-term ocular surface damage and improving the quality of life for affected children. As screen use and systemic medication prescriptions continue to rise in younger populations, awareness of PDED will become increasingly important for parents, educators and eye care providers.

1. Douglas VP, Hall N, Ross C, et al. The epidemiology of pediatric dry eye disease in the United States: An IRIS® registry (Intelligent Research in Sight) analysis. Ocul Surf. 2024 Apr;32:106-111. doi:10.1016/j.jtos.2024.01.012

Dry eye disease (DED) is becoming a more prevalent problem in health care, and has the potential for significant quality of life and financial burdens.¹ Traditional wisdom links risk factors such as age, sex, environment, medications and ocular or systemic comorbid conditions to DED, and most DED studies involve adults. Information on how the disease affects the pediatric population is less common.

Pediatric DED (PDED) is considered a rare ophthalmic disease that is usually associated with congenital, autoimmune and inflammatory disorders, and because it’s rare, it is often overlooked. Further, examination of the pediatric population comes with other factors that may contribute to under-recognition of the disease—including difficulties in assessing patients’ symptoms—that lead to diagnostic limitations, The aim of this retrospective cohort study was to investigate the demographic and clinical characteristics of patients with PDED, using patients from the IRIS® (Intelligent Research in Sight) Registry.¹ This is the largest registry database in the United States, with more than 70 million patients of all ages from across the country.

All patients in the IRIS Registry with a case of DED documented between January 1, 2013 and December 31, 2019 (4.7 million patients) were identified by using the most common DED ICD9/10 codes and were included in the study. Patients were then stratified into one of two predefined cohorts of interest: Either (1) the Adult Dry Eye Disease (ADED) cohort (4.5 million (95.76 %)), which encompassed patients who were 18 years of age or older at the time of their initial DED onset; or (2) the Pediatric Dry Eye Disease (PDED) cohort (203,171 (4.24 %)), which encompassed patients who were under 18 years of age at the time of their initial DED onset. PDED patients were further divided into four groups: 0 to 4 years old, 5 to 11 years old, 12 to 15 years old and 16 to 17 years old). Clinical variables included sex, race, ethnicity, age (categorized and uncategorized), U.S. state, U.S. division, U.S. region and the presence or absence of associated diagnoses, such as amblyopia, glaucoma, headache, refractive errors, strabismus, visual disturbance, corneal disorders, eyelid and conjunctival disorders, lens disorders, vitreous disorders and retina disorders.¹

The average age of DED diagnosis in adults in this study was 61.06 years while the average age of diagnosis in the pediatric cohort was 12.51 years. Within the PDED cohort, females were at higher risk (58% vs. 42%) and PDED was also more prevalent in children with refractive errors (76%) and eyelid/conjunctival disorders (41%). The largest discrepancies between PDED and ADED patients included female sex (58.08% vs. 68.12%), male sex (41.58% vs. 31.55%) and Caucasian race (50.24% vs. 67.06%) respectively.¹

The authors concluded that their study demonstrated significant differences in the PDED cohort and they recommended increased awareness among clinicians for pediatric dry eye assessment.1 We know that undiagnosed and untreated dry eye can lead to significant ocular complications in adults, and children are no different. Because their DED starts earlier, children may be at higher risk for permanent ocular changes.

1. Douglas VP, Hall N, Ross C, et al. The epidemiology of pediatric dry eye disease in the United States: An IRIS® registry (Intelligent Research in Sight) analysis. Ocul Surf. 2024 Apr;32:106-111. doi:10.1016/j.jtos.2024.01.012

The epidemiology of pediatric dry eye disease in the United States: An IRIS® registry (Intelligent Research in Sight) analysis

Vivian Paraskevi Douglas, Nathan Hall, Connor Ross, Konstantinos A.A. Douglas, Tobias Elze, Joan W. Miller, Alice C. Lorch, and Aisha S. Traish
Ocul Surf. 2024;32:106-111. doi:10.1016/j.jtos.2024.01.012

PURPOSE: Dry-eye disease (DED) is a chronic progressive ocular surface disorder with limited studies in the pediatric population. The Academy of Ophthalmology’s IRIS® Registry was leveraged to investigate the prevalence of DED in the pediatric population (PDED, patients <18 years old) and the demographic differences of DED between pediatric and adult patients (ADED).

METHODS: Retrospective cohort study. Patients with DED between January 1st, 2013 and December 31st, 2019 (N = 4,795,979) were included. Descriptive statistics, Pearson’s chi-squared tests and two-sample proportions tests were conducted to compare key demographic distributions between the ADED and PDED cohorts.

RESULTS: The average age at onset for ADED patients was 61.06 (±14.75) years and for PDED patients was 12.51 (±3.86). The overall tests for independence and the individual tests of proportions of each category were statistically significant for all demographic characteristics (p < 0.001). Characteristics with the largest discrepancies between patients of PDED and the IRIS Registry pediatric patient pool (PIRIS) included female sex (58.08 % vs. 50.60 %), male sex (41.58 % vs. 48.78 %) and Asian race (6.02 % vs. 3.11 %) respectively. Within the PDED cohort, females were at higher risk of PDED (58 % vs. 42 %). PDED was more prevalent in children with refractive errors (76 %) and eyelid/conjunctival disorders (41 %). Characteristics with the largest discrepancies between PDED and ADED patients included female sex (58.08 % vs. 68.12 %), male sex (41.58 % vs. 31.55 %) and Caucasian race (50.24 % vs. 67.06 %) respectively.

CONCLUSIONS: Significant differences in the PDED cohort are demonstrated in this study. PDED was more prevalent in the female sex and Caucasian race compared to PIRIS and was more commonly associated with refractive errors and eyelid/conjunctival disorders.

Use and Impact of the IRIS Registry

The American Academy of Ophthalmology (AAO) has long been interested in a registry of clinical data to support big-data analytics in eye care. A couple of early attempts—the National Eyecare Outcomes Network in 1996 and the Ophthalmic Patient Outcomes Database in 2010—were met with only modest success, primarily because they both required manual entry of data.¹ With lessons learned from past attempts and an eye on the ever-evolving landscape of electronic medical records (EMRs), a Clinical Registry Task Force developed forward-looking objectives and consulted with potential registry vendors. Ultimately, the group’s recommendations were approved by the AAO Board, and the Intelligent Research in Sight (IRIS) Registry was launched in 2014.¹

The IRIS Registry has now grown into the nation’s largest clinical registry serving a single specialty: ophthalmology. It is a centralized and de-identified data repository that directly integrates with EMRs to extract eye care-relevant data (such as visual acuities, intraocular pressures, cup-to-disc ratios and more) from approved individual practices across the country. The IRIS Registry can be accessed to evaluate practice patterns, access to care, treatment outcomes and natural history data.¹

According to the AAO’s website,² the IRIS Registry includes more than 669.7 million visits and 78.9 million unique patients. Currently, more than 15,000 clinicians and more than 2,800 practices actively contribute to the IRIS Registry through their EMRs.² A quick review of the academy’s website reveals at least 150 publications from this rich data source.²

The impact of this registry grows by the day; indeed, our own Dr. Lonsberry discusses its recent use by Douglas, et al.³ in this issue. The AAO’s goal of developing a resource that can contribute to continual improvement in the delivery of care is well underway.

1. Pershing S, Lum F. The American Academy of Ophthalmology IRIS Registry (Intelligent Research in Sight): current and future state of big data analytics. Curr Opin Ophthalmol. 2022 Sep;33(5):394-398. doi:10.1097/ICU.0000000000000869
2. American Academy of Ophthalmology. IRIS Registry Data Analysis. Accessed September 25, 2024. https://www.aao.org/iris-registry/data-analysis/requirements
3. Douglas VP, Hall N, Ross C, et al. The epidemiology of pediatric dry eye disease in the United States: an IRIS registry (Intelligent Research in Sight) analysis. Ocul Surf. 2024 Apr;32:106-111. doi:10.1016/j.jtos.2024.01.012.