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Ocular surface disease (OSD) has historically been predominantly a female issue, occurring more frequently in women, especially older women. But men and children are increasingly developing dry eye issues. With the rise of digital device use, a wider population is experiencing dry eye disease (DED) at younger ages. Data show that increased screen time is a considerable risk factor for dry eye in children.1 American teens use media for, on average, 9 hours per day, in addition to time spent online for schoolwork.2
Similarly, meibomian gland atrophy is no longer a risk for only the elderly.3 Gland loss is being found equally in men and women,4 and in much younger patients as well.4,5
TO THE POINT
DED is not unique to women. The rise of digital device use may be to blame for the rise of DED in children and men, and the problem with children is particularly alarming.
Children may be more asymptomatic than other patients or may not understand the symptoms of DED they do experience. As for men, they are particularly notorious for not reporting illness, which could be due to societal norms. In addition, perhaps men experience symptoms less severely than women.
In order to ensure that all patients receive appropriate care for DED, it is necessary to break down preconceived barriers and understand that this disease does not affect only one certain patient population. Regardless of who is sitting in the chair—man, woman, or child—the same conversation must take place.
Questionnaires such as the Ocular Surface Disease Index (OSDI) and Standard Patient Evaluation of Eye Dryness (SPEED) delve into digital device use and are simple, proactive ways to diagnose DED symptoms. Both questionnaires produce quantitative values that you can discuss with your patients. These numbers can guide your conversation regarding screen time, especially the use of multiple digital devices at once. This practice can exacerbate potential risk factors, such as blink rates, which tend to decrease significantly with visual tasks and screen use.6 Often, blink rate decreases from the patient’s basal blink rate by as much as 40%.6
Appropriate diagnosis is always crucial, but even more so in children. It is common for DED in children to be mistaken for pink eye or allergy. Testing should be kept short, and the child should be made as comfortable as possible. For instance, a phenol red thread (PRT) test (Zone-Quick, FCI Ophthalmics) can be used rather than Schirmer strips for testing tear volume in children. This may be preferred, as it tends to be much better tolerated by kids.7 Taking the time for due diligence and avoiding the impulse to jump to conclusions is particularly important with children.
I screen for matrix metalloproteinase-9 (MMP-9) with InflammaDry (Quidel). I generally do not perform InflammaDry on kids because it is too uncomfortable, but it is an excellent test for adults. I also perform osmolarity testing and meibography.
TREATING MEN AND CHILDREN
I follow a tiered treatment strategy, starting simple and adding modalities as necessary. Lipid-based, preservative-free artificial tears and ocular dietary supplements are good base treatments. Discussing lid hygiene and possibly performing an in-office cleaning procedure such as BlephEx (Rysurg) are important steps for men and children, who typically are not as accustomed to routine facial cleansing as women.
Silicone masks, lid massages, lid wipes, and more involved therapies, such as Lipiflow (TearScience) or intense pulsed light (IPL) therapy, can also be prescribed. In adults, if there is an inflammation component to the DED, I consider prescribing cyclosporine ophthalmic emulsion 0.05% (Restasis, Allergan) or lifitegrast ophthalmic solution 5% (Xiidra, Shire).
I consider using punctal plugs in men after I have ensured the absence of inflammation. Plugs offer considerable convenience, providing relief without the need to deal with daily medications or therapies. Dissolvable plugs that last approximately 180 days, such as Comfortear Lacrisolve 180 Absorbable Plugs (Paragon BioTeck), are particularly beneficial, as we can implant them and revisit therapy needs once the plug dissolves.
For children, treatment regimens must be as pain-free as possible and not require an overabundance of administration times and dosages. Once DED is diagnosed, I typically begin with the most basic treatment possible. For evaporative DED, I start with an occasional artificial tear or silicone-beaded mask. I pay special attention to lid hygiene, as I see an increasing amount of blepharitis in children. Pediatric versions of omega-3 fatty acid supplements can be beneficial; they even come in a convenient gummy form.
When we discuss a child’s use of devices with the patient and parents, we recommend reducing their use, and we offer treatments such as blink exercises. I do not typically use punctal plugs in children; however, that is also determined on a case-by-case basis.
Although DED in men has been historically underdiagnosed, I believe the increase in DED in children is a unique phenomenon. In my opinion, we are seeing an evolution in diagnosing DED, and part of that is surely due to digital device use. Raising awareness of this issue—and calling attention to the variety of patients who are now affected by DED—will lead to better outcomes and ensure that patients are not being misdiagnosed or slipping through the cracks.
1. Moon JH, Lee MY, Moon NJ. Association between video display terminal use and dry eye disease in school children. J Pediatr Ophthalmol Strabismus. 2014;51(2):87-92.
2. Rosenfield M. Computer vision syndrome: a review of ocular causes and potential treatments. Ophthalmic Physiol Opt. 2011;31(5):502-515.
3. Nien C, Massei S, Lin G, et al. Effects of age dysfunction on human meibomian glands. Arch Ophthalmol. 2011;129(4):462-469.
4. Young C, Kading D. Prevalence of meibomian gland atrophy in a pediatric population. Paper presented at: American Academy of Optometry annual meeting; November 9-12, 2016; Anaheim, CA.
5. Schachter S, Schachter A, Kwan J, Hom M. Gender differences of meibomian gland atrophy in younger patients. Paper presented: at American Academy of Optometry annual meeting; November 9-12, 2016; Anaheim, CA.
6. Acosta M, Gallar J, Bellmonte C. The influence of eye solutions on blinking and ocular comfort at rest and during work at video display terminals. Exp Eye Res. 1999;68(6):663-669.
7. Vashisht S, Singh S. Evaluation of phenol red thread test versus schirmer test in dry eyes: a comparative study. Int J Appl Basic Med Res. 2011;1(1):40-42.
Whitney Hauser, OD
• associate professor, Southern College of Optometry, Memphis, Tenn.
• financial disclosure: board member, Paragon BioTeck, TearLab; speaker and/or consultant, Akorn, Allergan, Bio-Tissue, ScienceBased Health, Lumenis, NovaBay, Shire, TearScience
• @drwhauser; DryEyeCoach@gmail.com