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How is the management of dry eye disease for children different from adults?
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Parent compliance is needed
As with hypertension and other systemic conditions, the management of dry eye depends mostly on the effort of the patient with some added benefit from office-based treatment. The problem is the public does not yet understand the seriousness and long-term progression of this disease.
If you tell a parent that her child has glaucoma, you instantly have her undivided attention. If you tell a parent that her child has dry eye, she does not know what to think. The eyes do not look dry. Many children with advanced meibomian gland atrophy are completely asymptomatic, according to the recent Duke study.
Among the many competing priorities of parenthood, time-consuming treatments for dry eye, such as warm compresses and eyelid hygiene, simply may not “make the cut.”
Our failure to get our kids to limit their screen time and eat more healthy diets are two of the chief ways my wife and I feel guilty about our inadequate parenting. Don’t all parents struggle with these challenges?
To be successful in treating dry eye, above all we need patient compliance, which means parent compliance. We will also need new treatments that are both easy and effective to implement so parents can be successful in managing this life-altering disease for their kids.
- Reference:
- Gupta PK, et al. Cornea. 2018;doi:10.1097/ICO.0000000000001476.
John A. Hovanesian, MD, FACS, is OSN Cataract Surgery Section Editor. Disclosure: Hovanesian reports he consults and invests with a number of eye care companies, including some in the dry eye space.
Treatment varies with age
The management of dry eye disease in children varies greatly depending on the age, maturity and cooperativeness of the child in question, as well as the severity of the disease. In adults, we have the full armamentarium of treatment modalities, from drops to oral agents and physical manipulation of the lids. For children, we are sometimes lucky if we can get them to sit through a basic examination without screaming bloody murder before the fluorescein even gets into their eyes. This limits some of our options such as large pills (omega-3 supplements), extensive drop regimens and manual expression of the meibomian glands. Certain treatments such as oral tetracyclines have to be eliminated altogether due to safety reasons in children.
For mild dry eye in younger children, I typically blame excessive screen time. This is usually confirmed with a nod and an “I told you so” from the patient’s parents. I like to quote the 20-20-20 rule, explaining that they should take a 20-minute break from their electronics every 20 minutes to look at something 20 feet in the distance. Reducing overall screen time to a couple of hours per day is also useful and welcomed advice, at least for the parents. If the patient is symptomatic, then I try to keep further management simple by introducing a few drops of artificial tears when needed or 5 to 10 minutes of warm compresses to the lids daily, depending on whether the dry eye disease appears to be more aqueous deficiency or evaporative driven. These tend to be reasonable options even for the most uncooperative patient.
When I see more advanced dry eye in children, I start to suspect more specific etiologies. It is important to take a careful history to rule out more uncommon causes such as early-onset Sjögren’s syndrome, graft-versus-host disease and vitamin A deficiency. Most commonly in my practice, allergic keratoconjunctivitis is the culprit. I will look more carefully at the staining pattern, which may indicate a corneal stem cell deficiency in severe disease. In these cases, frequent preservative-free artificial tears, alcaftadine, a short course of fluorometholone drops and a referral to an allergist to identify triggers are all helpful in improving the ocular surface and preventing ulceration and scarring.
Brad Kligman, MD, is a cornea, refractive and external disease specialist at SightMD in Garden City and Smithtown, New York, and is on staff at NYU Winthrop Hospital and Northwell Health. Disclosure: Kligman reports no relevant financial disclosures.