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30 EW CORNEA June 2013 Dry eye diagnosis in children takes some detective work by Vanessa Caceres EyeWorld Contributing Writer The causes and treatment in pediatric patients take on a slightly different twist than in adults D iagnosing dry eye in children is not as straightforward as it is in adults. "Kids don't offer up their symptoms like adults do," said David B. Granet, MD, professor of ophthalmology and pediatrics, Anne Ratner Chair of Pediatric Ophthalmology, and director, Anne F. and Abraham Ratner Children's Eye Center, Shiley Eye Center, University of California, San Diego. Instead, parents are usually the ones who notice that their child is blinking or rubbing his or her eyes more. As children usually have healthier tear films than adults, tear film layer deficiencies are not often the cause of dry eye issues in this patient group, said Dr. Granet. However, there are rare diseases that might prompt tear film problems in kids. With children, ophthalmologists are more likely to see dry eye exacerbated by blepharitis, ocular rosacea, meibomian gland dysfunction (MGD), or even an infection. "One of the most common reasons we see dry eye is due to either a Staph infection or Demodex blepharitis and related conditions," said Esen K. Akpek, MD, associate professor of ophthalmology and rheumatology, and director, Ocular Surface Diseases and Dry Eye Clinic, Wilmer Eye Institute, Johns Hopkins University, Baltimore. "Some children get such thick oily discharge that the meibomian glands get clogged and need to be expressed," Dr. Granet said. Vitamin A deficiency can be another cause of dry eye in children, he added. Allergy should also be considered in the differential diagnosis because the symptoms can be similar, Dr. Akpek said. Children with cancer who undergo chemotherapy or radiation may experience dry eye as well, said Dr. Granet. Pediatric patients with juvenile diabetes and juvenile idiopathic arthritis can also have some associated dry eye. There's another somewhat-debated cause of dry eye in pediatric patients discussed in recent years, according to Dr. Granet—dry eye caused by more screen time. "Children tend to stare at the screen as they're using the computer or playing video games," he said. Just as increased screen time and more time indoors with processed air can irritate adults' eyes, some clinicians are seeing this occur in children as well. If they suspect dry eye in children, Drs. Akpek and Granet will perform dry eye evaluations such as the Schirmer's test and other related exams for a more certain diagnosis. "The usual dry eye evaluations are fine, perhaps because younger children are not good at explaining symptoms," Dr. Akpek said. "Mea- suring tear film related parameters such as osmolarity and levels of inflammatory mediators using the latest point of care testing technology has a better role in children." "We look at everything from their meibomian glands to allergic causes to infections to mechanical irritation," Dr. Granet said. It's also important to rule out more severe corneal disease as a cause for the dry eye symptoms, he added. If an exam finds that aqueous tear deficiency is a problem, Dr. Akpek said that she also assesses for the presence of systemic issues such as Sjogren's syndrome. Treating dry eyes in children The same types of treatments for dry eye used in adult patients can be used in children as well. However— "We're looking more at root causes for their symptoms," Dr. Granet said. Artificial tears are an easy treatment to help alleviate irritating symptoms and can be used in milder and severe cases, said Dr. Granet. Punctal plugs are another option. Dr. Akpek said that she has a lower threshold for plugs in children because compliance with drops in children can be so problematic. In fact, a 2012 study published in the British Journal of Ophthalmology found that punctal plugs made a substantial difference in the pediatric patients' ocular surface disease. Visual acuity improved in 15 of the 25 patients who participated in the study, and lubricant use decreased in eight of the patients. The most common complication was spontaneous extrusion, which occurred in 19% of patients.1 Some physicians also try to increase omega 3 supplementation to fight inflammation, using products such as flaxseed oil, said Dr. Granet. Although pediatric patients can safely use Restasis (cyclosporine ophthalmic emulsion 0.05%, Allergan, Irvine, Calif.), it's not the go-to drug for dry eye in children as it often is with adults, said Dr. Granet. "Parents aren't patient with doing a drops regimen for a long time," he explained, noting that it can take a few weeks before Restasis is effective, and the chore of getting drops in their child's eyes may wear thin before the drug is effective. A small study published this year in the journal Pediatric Blood & Cancer examined Restasis use in 11 children who had dry eye as a complication of radiation therapy. They found that use of the medication improved dry eye in three of the children but not the others. The authors concluded that Restasis has limited use in children with radiation-associated chronic dry eye.2 If the child has blepharitis or MGD, Dr. Granet will try to manually express the eyelids as much as possible, keeping in mind that this kind of treatment is harder with squirmy children. Using doxycycline for MGD or rosacea is important versus tetracycline in adults. He has also discussed special glasses that use steam to help open the meibomian glands. EW References 1. Matafsi A, Subbu RG, Jones S, Nischal KK. The use of punctal plugs in children. Br J Ophthalmol. 2012;96:90-92. 2. Hoehn ME, Kelly SR, Wilson MW, Walton RC. Cyclosporine 0.05% ophthalmic emulsion for the treatment of radiation-associated dry eye in children. Pediatr Blood & Cancer. 2013;60(7):E35-E37. Editors' note: Dr. Akpek has financial interests with Alcon (Fort Worth, Texas) and Allergan. Dr. Granet has no financial interests related to this article. A 7-year-old boy with Demodex infestation of the lids. The cylindrical sleeves are a typical finding of this commonly overlooked problem. Source: Esen K. Akpek, MD Contact information Akpek: 410-955-5214, esakpek@jhmi.edu Granet: 858-534-7440, dgranet@ucsd.edu