Dry eye symptoms in children: can we reliably measure them?

Effects of common eye diseases in children and their treatment measures on ocular surface homeostasis: A review

Ocular surface homeostasis plays a vital role in maintaining of eye health. Dry eye disease is one of the prominent and typical manifestations of disruption of ocular surface homeostasis that leads to the worsening of ocular surface homeostasis that leads to the worsening of ocular surface disease when it interacts with other pathogenic factors. However, disruption in ocular surface homeostasis in children is often overlooked because of the current methods of assessing ocular surface homeostasis. This review summarizes the main factors affecting ocular surface homeostasis in children, with the aim of drawing the attention of clinicians to the disruption of ocular surface homeostasis in children when dealing with such diseases. Ocular surface homeostasis involves several interrelated components, each of which plays a nonnegligible role in ocular surface homeostasis. Unlike adults, children have a stronger lacrimal gland secretion capacity and milder symptoms when there is a slight disruption of the ocular surface homeostasis. In addition, children's expressive abilities were weaker. Therefore, dry eye in children is often ignored by doctors and parents, and clinicians should pay more attention to the protection of ocular surface homeostasis when treating children with these diseases. Therefore, there is a need for diagnostic criteria for dry eye disease specific to children.

Appropriateness of Questionnaires for the Diagnosis and Monitoring Treatment of Dry Eye Disease

Objectives: If questionnaires contributing to the diagnosis of dry eye disease are to be recommended as alternatives to existing questionnaires, they must be comparable, with similar repeatability and treatment sensitivity. Comparability was thus examined for three common dry eye questionnaires along with identifying the individual questions that most strongly predicted overall scores. Methods: Anonymised data (n = 329) collected via the Ocular Surface Disease Index (OSDI), 5-item Dry Eye Questionnaire (DEQ-5) and Symptom Assessment in Dry Eye (SANDE) questionnaires (including responses to individual questions) from consenting patients were drawn from real-world dry eye clinics/registries in the United Kingdom, Australia and New Zealand; at follow-up, normalised changes were evaluated in 54 of these patients. Treatment data were also analysed from a 6-month, randomised controlled trial assessing artificial tear supplement treatments with 43 responders and 13 non-responders to treatment identified. The questions extracted from the OSDI which form the abbreviated 6-item OSDI were also analysed. Results: The agreement between the questionnaires ranged from r = 0.577 to 0.754 (all p < 0.001). For the OSDI, three questions accounted for 89.1% of the variability in the total score. The correlation between the OSDI and OSDI-6 was r = 0.939, p < 0.001. For the DEQ-5, two questions accounted for 88.5% of the variance in the total score. Normalised treatment changes were also only moderately correlated between the questionnaires (r = 0.441 to 0.595, p < 0.01). For non-responders, variability was 7.4% with both OSDI and OSDI-6, 9.7% with DEQ-5, 12.1% with SANDE-frequency and 11.9% with SANDE-severity scale. For responders, improvement with drops was detected with a 19.1% change in OSDI, 20.2% in OSDI-6, 20.9% in DEQ-5, and 27.5%/23.6% in SANDE-frequency/severity scales. Conclusions: Existing commonly used dry eye questionnaire scores do not show high levels of correlation. The OSDI was the least variable of the questionnaires and while displaying a slightly lower treatment effect than either the DEQ or SANDE, it was more sensitive to detection of a treatment effect. The quicker-to-complete OSDI-6 exhibited essentially the same outcome as the OSDI, with similar variability and treatment sensitivity.

Uveitis and Dry Eye Disease in Children: A Cross-Sectional Comparative Study

PURPOSE

This study aims to evaluate the ocular surface characteristics in children diagnosed with uveitis and explore the association between uveitis and dry eye disease (DED).

METHODS

We included 84 children, 42 with uveitis and 42 healthy children. We performed the OSDI questionnaire and several ocular surface tests, including osmolarity, NITBUT, Schirmer test, and vital staining. We used Fisher's exact test and Mann-Whitney to compare variables and a binomial logistic regression to determine the factors associated with DED.

RESULTS

The difference in the prevalence of DED between uveitis (54.8%) and healthy (31%) groups was statistically significant (p < 0.05). Most patients with uveitis had mixed DED, and none of the healthy subjects had a severe form of the disease. There were no statistically significant differences in most of the tear film tests. However, all parameters tended to worsen in the uveitis group, and lipid layer thickness was thinner (p < 0.036). The uveitis group exhibited significantly more symptoms (p < 0.05). In the multivariate logistic regression, uveitis was associated with an odds ratio (OR) of 3.0 (95% CI: 1.07-8.42, p < 0.05) for DED.

CONCLUSIONS

Our findings demonstrate a significantly higher prevalence of DED in children with uveitis compared to their healthy counterparts. Furthermore, our analysis indicates that the risk of DED in pediatric patients with uveitis is threefold higher than in healthy children. Therefore, it is crucial for clinicians to vigilantly monitor the development of DED in pediatric patients with uveitis and consider the implementation of preventive treatments.

Dry eye disease in the young: A narrative review

Dry eye disease (DED), a multifactorial ocular disease that significantly impacts quality of life, is most commonly reported in adults. This review describes the prevalence, risk factors, diagnosis and management of DED in children. A literature search, conducted from January 2000-December 2022, identified 54 relevant publications. Using similar diagnostic criteria to those reported in adults, namely standardized questionnaires and evaluation of tear film homeostatic signs, the prevalence of DED in children ranged from 5.5% to 23.1 %. There was limited evidence for the influence of ethnicity in children, however some studies reported an effect of sex in older children. Factors independently associated with DED included digital device use, duration of digital device use, outdoor time and urban living, Rates of DED were higher in children with ocular allergy and underlying systemic diseases. Compared with similar studies in adults, the prevalence of a prior DED diagnosis or a diagnosis based on signs and symptoms was lower in children, but symptoms were commonly reported. Treatment options were similar to those in adults, including lifestyle modifications, blinking, management of lid disease and unpreserved lubricants in mild disease with escalating treatment with severity. Management requires careful exploration of symptoms, medical history and the diagnosis and management of ocular comorbidities such as allergy and anterior blepharitis. Appropriately powered population-based studies are required to understand the prevalence of and risk factors for DED in children. Development of age-appropriate thresholds for signs and symptoms of DED would support better diagnosis of disease and understanding of natural history.

Blinking and normal ocular surface in school-aged children and the effects of age and screen time

PURPOSE

Baseline ocular surface characteristics in children require investigation. This study characterised blinking and relationships with ocular symptoms, tear film and digital device use.

METHODS

45 children aged 6-15 years (56% female) participated in a cross-sectional study. Ocular surface symptoms (Instant Ocular Symptoms Survey, Dry Eye Questionnaire 5, Symptoms Assessment in Dry Eye, Ocular Surface Disease Index, Ocular Comfort Index and Numerical Rating Scale) and clinical indices (lipid layer thickness, tear secretion and stability, meibomian gland) were assessed. Blink rate and interblink interval were measured in situ using a wearable eye-tracking headset (Pupil Labs GmbH, Germany). Associations between blinking, ocular surface, age, and digital device use (bivariate and partial correlations) and between automated and manually counted blink rate (Bland & Altman) were examined.

RESULTS

Mean blink rate and interblink interval were 20.5±10.5 blinks/min and 2.9±1.9 s during conversation. There was no difference between automated and manual blink rate (p=0.78) and no relationship between blinking and digital device use, age or sex. Mean group symptoms were within normal range and not associated with clinical measurements including blinking. Greater tear volume was associated with a faster blink rate (r=0.46, p=0.001) and shorter interblink interval (r=-0.36, p=0.02). Older age was associated with improved tear volume (r=0.37, p=0.01) and stability (r=0.38, p=0.01).

CONCLUSIONS

Blinking characterised in situ was not impacted by age or habitual digital device use. A faster blink rate was associated with greater tear volume but not symptoms. Improved tear function was found with age suggesting that the ocular surface continues to develop through childhood.

Assessment of Tear Meniscus Dimensions Using Anterior Segment Optical Coherence Tomography in Vitamin D Deficiency in a Pediatric Population

BACKGROUND

To investigate of the effect of vitamin D (Vit-D) deficiency on the tear film in children and compare it with that of healthy subjects.

METHODS

This prospective and cross-sectional study comprised 75 eyes of children who had Vit-D deficiency (Group 1) and 85 eyes of age- and gender-matched healthy children (Group 2). The tear-film break-up time (TF-BUT) and Schirmer test values, as well as the Ocular Surface Disease Index (OSDI) scores, were recorded for the participants in all groups. Measurement of the tear meniscus area (TMA) and tear meniscus height (TMH) was performed 2 times in the same day via the use of anterior segment-optical coherence tomography (AS-OCT).

RESULTS

The mean age of the participants in Group 1 was 12.42 ± 3.40 years, while in Group 2, it was 12.59 ± 2.32 years (p = 0.758). Group 1 comprised 43 females and 32 males, while Group 2 comprised 44 females and 41 males (p = 0.250). The mean TMH, TMA, and Schirmer test values were found to be significantly lower in children with Vit-D deficiency (Group 1) than in healthy children (Group 2), with p < 0.05 for all the values. It was concluded that there was no significant difference in the values for the mean TF-BUT and OSDI scores (p = 0.029 and p = 0.596, respectively).

CONCLUSION

The children with Vit-D deficiency exhibited lower TMH, TMA, and Schirmer test values. The alterations that were observed in these parameters were more prominent in the participants who had lower Vit-D levels.

Prevalence and associated factors for self-reported symptoms of dry eye among Thai school children during the COVID-19 outbreak

PURPOSE

COVID-19 pandemic caused an increase in digital screen time, which seemed to increase the prevalence of dry eye symptoms among the population with abnormally high digital screen usage hours. However, there are no reports of dry eye symptoms in school children with high digital usage hours. Therefore, the present study aimed to assess the prevalence of dry eye symptoms and evaluate the associated factors among school children aged 12 to 18 years during the COVID-19 outbreak.

METHODS

Multistage cluster sampling was applied, and six sections of online questionnaires were distributed to selected respondents in November 2021. The odds ratio (OR) with confidence intervals (CIs) for the factors was calculated using binary logistic regression. All statistical significance was determined at p < 0.05.

RESULTS

The findings revealed that 62.5% of 603 students showed symptoms of dry eye (DEQ-5 score ≥ 6). Significant associated factors included being female (adjusted OR (aOR) 1.54; 95% CIs 1.05-2.25), higher-grade student (aOR 1.77; 95% CIs 1.23-2.57), digital screen time use (6 to < 12 hours: aOR 2.00; 95% CIs 1.12-3.57, ≥12 hours: aOR 2.54; 95% CIs 1.39-4.76), and perceived stress (aOR 1.12; 95% CIs 1.08-1.16). The Thai-Perceived Stress Scale-10 scores were positively correlated with the scores on the 5-item dry eye questionnaire (Spearman's r = 0.38, p-value < 0.01).

CONCLUSION

A high prevalence of dry eye symptoms might be common among school children during the COVID-19 outbreak. Significant risk factors include being female, being a higher-grade level student, prolonged use of digital screens, and perceived stress. However, contact lens use, smoking, and the most common digital device usage patterns were not found to be contributing factors.

Smartphone gaming induces dry eye symptoms and reduces blinking in school-aged children

Purpose

Smartphone use by children is rising rapidly, but its ocular surface impact is unknown. This study examined the effect of smartphone use on blinking, symptoms, and tear function in children.

Methods

Prospective intervention study where 36 children aged 6–15years (14 M:22 F) played games on a smartphone continuously for one hour. Symptoms (SANDE, IOSS, NRS) and tear film (lipid layer thickness, tear secretion, stability) were assessed before and after gaming. Blink rate and interblink interval were measured in situ using an eye tracking headset, before (during conversation) and continuously throughout gaming. Symptoms and tear film changes were examined using paired t-tests. Changes in blinking throughout one hour were examined using repeated measures ANOVA, post-hoc comparisons with Bonferroni correction. Associations examined using Pearson bivariate correlation. Significance level was 0.05.

Results

Symptoms worsened following one hour smartphone gaming (SANDE + 8.2units, p = 0.01; IOSS + 1.3units, p < 0.001; NRS-average +6.3units, p = 0.03; NRS-comfort +7.6units, p = 0.04; NRS-tiredness +10.1units, p = 0.01), but tear film remained unchanged. Blink rate reduced from 20.8 blinks/min to 8.9 blinks/min (p < 0.001) and interblink interval increased from 2.9 s to 8.7 s (p = 0.002) within the first minute of gaming relative to baseline conversation, and this effect remained unchanged throughout one hour of gaming.

Conclusions

Smartphone use in children results in dry eye symptoms and immediate and sustained slowing of blinking, with no change in tear function evident up to one hour. Given the ubiquitous use of smartphones by children, future work should examine whether effects reported herein persist or get worse over a longer term causing cumulative damage to the ocular surface.

Evaluation of the meibomian glands using the tear interferometer wearing orthokeratology lenses

Background

To investigate the impact of orthokeratology wear on meibomian glands in Korean pediatric population using the tear interferometer.

Methods

Fifty-three orthokeratology wearers and 79 non-lens wearers were evaluated using the LipiView® II ocular surface interferometer which shows incomplete blink rate, average lipid layer thickness, and meiboscores.

Results

No significant differences in the incomplete blink rate and meiboscores for upper eyelids, but the lipid layer thickness and meiboscores for lower eyelids were significantly higher in the Ortho-K group than in the control group (p = 0.024 and 0.007, respectively). Correlation analysis showed no significant correlation between the duration of orthokeratology wear and the parameters measured by LipiView® (p > 0.05 for all). Among subgroups based on average duration of lens wear, the longer duration (≥ 24 months) subgroup showed higher meiboscores of lower eyelids (p = 0.011), but no other significant differences.

Conclusions

Ortho-K wearers showed no significant differences in the incomplete blink rate and meiboscores of upper eyelids, but they were associated with increased LLT and higher meiboscores of lower eyelids. Thorough examination and close monitoring of orthokeratology wearers is necessary. Prospective and observational studies are needed to further elucidate the relationship between Orthokeratology and meibomian glands.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12886-022-02365-3.

Questionnaire Analysis on Incidence and Risk Factors of Dry Eye in Children From a Myopia Outpatient Clinic

Objective

To analyze the incidence and risk factors of dry eye in children from a myopia outpatient clinic via a questionnaire and Keratograph 5M.

Methods

A cross–sectional study was performed. sThere were 214 children (428 eyes) selected from the myopia outpatient clinic of the affiliated Eye Hospital of Shandong First Medical University from July 2021 to September 2021, including 105 boys (210 eyes) and 109 girls (218 eyes), with an average age of 10.1 ± 2.5 years. The incidence rate and influence factors for dry eye were calculated.

Results

Thirty–four of 214 children were diagnosed with dry eye, accounting for 15.9% of the patients. The correlation between fussy eating and the tear meniscus height was statistically significant (Z = −2.158, p = 0.039), along with the correlation between short–distance use of eyes and the tear meniscus height (Z = −2.135, p = 0.033). The degree of meibomian gland deficiency was graded. The meibomian gland was graded as grade 1 in 242 eyes (68.9%), grade 2 in 104 eyes (29.6%), and grade 3 in 5 eyes (1.4%). There was a significant difference in the correlation between eye rubbing and the incidence of dry eye in children (Z = −2.747, p = 0.008). There was also a significant difference in the correlation between picky eating and the incidence of dry eye in children (Z = −2.347; p = 0.024). There was a statistically significant correlation between the time of looking at electronic products and the morphology of the meibomian gland (Z = −2.201, p = 0.028). The results showed that the effect of mild and moderate ametropia on the non–invasive tear breakup time in children was statistically significant (Z = −2.027; p = 0.043).

Conclusion

There is a high incidence of dry eye in children in the myopia outpatient clinic. There is a significant correlation between picky eating, eye rubbing, and the incidence of dry eye. Looking at electronic products for a long time will also affect the morphology of the meibomian gland in children.

The Effects of Daily Digital Device Use on the Ocular Surface in Healthy Children

SIGNIFICANCE

Digital device usage among children has increased significantly in recent years. Prolonged screen exposure can have adverse effects on the eye, especially on the ocular surface.

PURPOSE

We aimed to evaluate the duration of screen exposure and its effect on the ocular surface in healthy children aged 10 to 18 years.

METHODS

This cross-sectional observational study included 200 healthy children. Screen exposure times of the children were ascertained, and the effect of screen exposure on the ocular surface was evaluated using tear breakup time, kerato-epitheliopathy (Oxford) score, and Schirmer test. The Ocular Surface Disease Index (OSDI) was used to assess subjective dry eye symptoms. Findings for subjects with a daily screen exposure time of fewer than 2 hours were compared with those reporting more than 2 hours of screen time. Statistical evaluation included the Shapiro-Wilk test, Student t test, and Pearson correlation analysis.

RESULTS

The mean ± standard deviation (SD) age was 14 ± 2.6 years, and 88.5% of the participants used mobile phones or computers every day. The mean ± SD tear breakup time was 10.3 ± 4.1 seconds, and the Schirmer test score was 15.6 ± 4.7 mm. The Oxford score was 0.4 ± 1, and no corneal staining was detected in 83.5% of the subjects. The mean ± SD OSDI score was 23.5 ± 17.8, and 67.5% of subjects had a mild-to-severe ocular surface disease. When daily screen exposure times less than and greater than 2 hours were compared, there was no statistically significant difference between the two groups in tear breakup time, Schirmer test, Oxford score, and OSDI score. Whereas there was a statistically significant weak positive correlation (r = 0.307, P = .001) between OSDI score and screen exposure time, there was no correlation between tear breakup time, Schirmer test, and Oxford score and screen exposure time.

CONCLUSIONS

Screen exposure in healthy children may cause ocular surface symptoms without causing changes in ocular surface findings.