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My RO
Topics
 For most of us, when we hear the term dry eye, we picture a
“65-plus” postmenopausal female patient. Even though dry eye is most prevalent
in this population, there are other populations to consider, too.
In the pediatric population, dry eye appears much less
frequently in general practice. But, it should be taken seriously when it comes
to the implications of the patient’s ocular signs and symptoms.
Little data is available on the prevalence of dry eye in the
population under age 18, but dry eye is known to occur in children due to a
variety of causes.
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| Frequent blinking, eye rubbing, tendency to shy away from
light, or general ocular redness, grittiness or foreign body sensation can all
suggest dry eye in kids. |
As with any type of dry eye, it is important to investigate
and understand the etiology of a patient’s dry eye in order to effectively
treat the condition.
Many cases of dry eye in children suggest the presence of
systemic causes or result from exposure to adverse conditions, increased visual
tasking (e.g., computer and video game use) or lid abnormalities (such as
congenital malformations or paresis).1
Underlying Causes of Dryness
Systemic conditions associated with dry eye include
inflammatory, congenital, nutritional and endocrinologic origins.
• Inflammatory causes. Dry eye in children with diminished
tear production can be caused by inflammatory conditions including Sjögren’s
syndrome, graft-versus-host disease (GVHD) and juvenile rheumatoid arthritis.
In a retrospective study of 14 patients under 18 years of age with dry eye, two
cases involved patients whose dry eye manifested due to primary Sjögren’s, and
two cases involved patients who were diagnosed with GVHD after bone marrow
transplantation.1
Although Sjögren’s is most common among women in the fifth decade of life, reports suggest that disease onset can occur as early as five
years of age and that it may be underdiagnosed in pediatric populations.2,3
Sjögren’s syndrome is characterized by lymphocytic infiltration of exocrine
glands, so xerostomia (dry mouth) generally accompanies dry eye in patients
with the disease, as well as potential association with other connective tissue
diseases (in secondary Sjögren’s).2
Dry eye can also be associated with juvenile rheumatoid
arthritis (JRA). In one study of 64 children diagnosed with JRA between the
ages of 8 and 12, 1.5% were found to have probable diagnoses of dry eye, and
10.9% and were determined to have definite diagnoses.4 Additionally, among
children with JRA, both males and those participants with a longer duration of
disease were determined to be more likely to have decreased basal tear
secretion and tear film stability than others.
• Congenital disorders. Congenital disorders can also cause
dry eye in children. Familial dysautonomia, a condition that occurs almost
exclusively among people of Ashkenazi Jewish descent (roughly one in 3,600
people in this population have the disease), affects the autonomic nervous
system.5 Patients with familial dysautonomia (also known as Riley-Day syndrome)
exhibit alacrima (deficiency or absence of tear production) and corneal
hypoesthesthia—conditions that typically involve decreased blinking frequency
and decreased sensitivity to corneal trauma, which can lead to epithelial
erosions.
Particularly in this disease, ocular signs and symptoms tend
to manifest prior to systemic effects (e.g., progressive impairment of motor,
sensory and peripheral functions), so be certain to question parents about any
family history of the disease.1,5
Patients can also present with signs and symptoms of dry eye
if they have alacrima alone, Allgrove syndrome (or “triple-A,” a rare autosomal
disease exhibiting alacrima, achalasia—a disorder of esophageal function that
leads to difficulty swallowing—and adrenal deficiency), cystic fibrosis (which
affects all secretory epithelia) or ectodermal dysplasia syndromes.6
• Poor nutrition. The lack of proper nutrition can also
influence dry eye. Undernutrition, a significant problem especially in
developing parts of the world, can lead to vitamin A deficiency, which can also
be caused by diets low in animal sources providing vitamin A, diets low in
iron, cystic fibrosis, and other causes of malabsorption syndrome.
Children with vitamin A deficiency can also exhibit clinical
signs and symptoms of dry eye disease. Approximately 250,000 to 500,000 vitamin
A-deficient children worldwide become blind each year (and half of them die
within 12 months of blindness), so efficient diagnosis of the deficiency is
crucial.7
• Diabetes. Demonstrated to be a significant risk factor in
the overall dry eye population, diabetes is yet another possible cause of dry
eye in children. One in every 400 to 600 people under the age of 20 years is
estimated to have type 1 diabetes.8 Although type 2 diabetes is clinically rare
in children, clinical reports and regional studies suggest that it is being
diagnosed more frequently in youth.
One study of 104 children with type 1 diabetes found that
15.4% reported dry eye symptoms compared with 1.9% of 104 age- and sex-matched
controls.9 Clinical signs of dry eye were observed in 7.7% of children with
type 1 diabetes vs. less than 1% of children in the control group.
Other causes of dry eye in children include systemic
medications, environmental factors, and ocular causes. Systemic antihistamines
can decrease tear production due to their antimuscarinic activity.10 Retinoids
for acne vulgaris are theorized to cause adverse effects of ocular dryness by
decreasing lipid production.11 Environmental factors—including exposure to low
humidity, exposure to urban pollutants, and significant time spent performing
visual tasks—can adversely impact tear film stability.6,12,13
Blink rate during video game usage has been observed to
decrease to nearly one-quarter of normal resting blink rate.14 The average
American child (age 17 and younger) is estimated to spend seven hours playing
video games every week, which could suggest diminished ocular surface
protection.
Borderline dry eyes may become symptomatic with contact lens
wear, and approximately 50% of people begin to wear contacts under age
18—another potential cause of dryness in children and adolescents.15
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| Ocular surface staining
with liquid fluorescein or lissamine green administered via a pipette (as
opposed to a strip) makes dry eye assessment easier for young patients.
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Investigating the Source
Diagnosis of dry eye in any patient can be challenging due
to the multifarious causes and manifestations of the disease. Diagnosing dry
eye in children can be especially challenging due to their potential difficulty
articulating their symptoms. Well-tuned and efficient diagnosis in these cases
is very important, considering the possibility that this is the first medical
notice of what could be a systemic disease.
In order to carefully examine the potential underlying root
of the case, it is first important to capture a thorough medical history.
Family history of diseases known to contribute to dry eye, systemic medication
usage, and discussion of ocular and systemic symptoms can lend significant
insight. The patient could complain about itchy, red eyes, for example, which
might suggest ocular allergy. Patient or parent accounts of frequent blinking,
the child rubbing his or her eyes often, tendency to shy away from light, or
general ocular redness, grittiness or foreign body sensation can all suggest
dry eye.
Systemic symptoms can give the practitioner a glimpse into
what, if any, systemic involvement is present. Patient complaints of dry mouth
in addition to dry eye, for example, should trigger investigation into
Sjögren’s syndrome. This can be confirmed using anti-Ro and anti-La serum
testing.
When the medical history suggests dry eye, the clinician
should perform an array of tests for clinical signs of the disease.
Typical dry
eye assessments include ocular surface staining, tear film break-up time
(TFBUT) assessment, blink rate assessment, and calculation of the Ocular
Protection Index (OPI). The OPI, which translates to average ocular surface protection,
is easily calculated by dividing TFBUT by inter-blink interval (an OPI less
than 1.0 exhibits insufficient protection and an OPI of 1.0 or more
demonstrates sufficient levels of protection).16
Diagnostic approaches—such as tear meniscus height assessed
through the slit lamp, phenol red threads (or Schirmer’s test with anesthetic)
to assess tear production, and ocular surface staining observation using liquid
fluorescein or lissamine green administered via a pipette (as opposed to the
commonly-used strip)—can all make dry eye assessment easier for the young
patient.
If a systemic cause is suspected at the end of testing,
referral to a specialist may be warranted. If the patient experiences mild
symptomatology and displays lesser severity in clinical signs, then consider
asking about the frequency of video display use (e.g., gaming or computer use),
extended close work (e.g., reading, studying, etc), and exposure to adverse
environmental conditions.
Replenishing the Moisture
If a systemic cause has been determined, ideally it should
first be treated systemically. For instance, if the use of oral antihistamines
causes the dryness, the patient could potentially benefit from switching to the
use of a topical ocular antihistamine.
For treatment of ocular manifestations of systemic diseases,
refer the patient to the appropriate specialist and then to follow up in order
to treat any residual ocular dryness.
If over-activity of computer use or gaming seems to be the
problem, behavior adjustment may be necessary, along with patient and family
education about the importance of awareness of blinking frequency, which could
improve the patient’s situation tremendously.
Often, the patient can be treated with artificial tears to
lubricate the ocular surface in conjunction with systemic treatment of the
underlying cause, or as primary treatment for external causes. These tears are
often chosen from the large variety available, including formulations
incorporating lubricants, osmo-protectors, mucomimetics and lipid replacements.
Several of these formulations are scientifically designed to have improved
interaction with the tear film.
The use of lubricant eye drops as prophylaxis for extended
periods of visual tasking could be a good recommendation for those patients who
experience ocular dryness symptoms frequently while performing these tasks, or
for patients with already-compromised ocular surfaces who anticipate video
display terminal use. Research recently demonstrated enhanced visual function
ability 90 minutes post-instillation of an ocular lubricant.17
Ophthalmic preservatives can also be an important factor in
deciding the appropriate formulation. Cytotoxicity can be a concern with
repeated dosing of preserved solutions, as might be the case in severe forms of
dry eye (e.g., due to Riley-Day syndrome).18 So, non-preserved artificial tears
can be beneficial for those patients requiring frequent or prolonged dosing.
Precautions and Prevention
Dry eye in youths may require treatments used in adult dry
eye cases, but take care to consider potential for side effects when choosing
specific medications in this age population. Topical corticosteroid use in
young patients, for example, has demonstrated cases of glaucoma and subcapsular
cataracts.19 Avoid systemic tetracyclines in patients younger than age 9 due to
reports of interrupted tooth and bone development.6
When treating with
tetracyclines, advise patients and/or their parents of the risk of sunburn and
potential interaction with concomitant medications (e.g., oral contraceptives).
Additional consideration, especially in young children,
should also address compliance issues, including frequency of dosing and the
potential necessity of school-day dosing. The school nurse can be an invaluable
asset for situations involving school-age children. By sending an order and
reviewing it with the nurse, or by writing separate prescriptions for the
school nurse, you can better ensure proper administration during the school
day.
As patients reach their teenage years, it’s great to empower
them to take charge of their own treatment by emphasizing habitual dosing
around everyday occurrences (e.g., breakfast, lunch, dinner and bedtime). This
timing strategy can also work well for home care in younger patients.
Additionally, patients and their families should be educated
on environmental hazards to the ocular condition and ways to avoid further
ocular surface damage external to their underlying cause (e.g., use of
polycarbonate eyeglasses or sunglasses as protection against wind and sun).
In short,
don’t neglect to diagnose this uncommon but troublesome condition in children.
If you can be proactive in efforts to identify these signs and symptoms, you’ll
provide preventative measures to tomorrow’s dry eye population.
Dr. Pietrantonio is director of eye services at East Boston
Neighborhood Health Center and adjunct clinical faculty at the New England
College of Optometry.
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al. Management of dry eye related to systemic diseases in childhood and
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2. Chudwin DS, Daniels TE, Wara DW, et al. Spectrum of
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7. World Health Organization. Micronutrient deficiencies.
Available at: www.who.int/nutrition/topics/vad/en (accessed November 13, 2008).
8. American Diabetes Association. Total prevalence of
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(accessed November 13, 2008).
9. Akinci A, Cetinkaya E, Aycan Z. Dry eye syndrome in
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10. Welch D, Ousler GW, Nally L, et al. Ocular drying
associated with oral antihistamines (loratadine) in the normal population—an
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11. Lebowitz MA, Berson DS. Ocular effects of oral
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12. Ousler GW, Gomes PJ, Crampton HJ, Abelson MB. The
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syndrome (CVS) exacerbated in a controlled adverse environment. Invest
Ophthalmol Vis Sci. 1999 Mar;40(4-ARVO Suppl):B722.
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allergy, dry eye and contact lenses. Rev Cornea Contact Lenses. 2008
Mar;144(2):15-18.
14. Tsubota K, Miyake M, Matsumoto Y, Shintani M. Visual
protective sheet can increase blink rate while playing a hand-held video game.
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17. Torkildsen G, Christensen A, Martin AE, et al.
Evaluation of functional visual performance using the IVAD method with
currently marketed artificial tear products. Invest Ophthalmol Vis Sci.
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18. Ayaki M, Yaguchi S, Iwasawa A, Koide R. Cytotoxicity of
ophthalmic solutions with and without preservatives to human corneal endothelial
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