Features of the clinical course, diagnosis and treatment of dry eye syndrome in children
In recent years, dry eye syndrome (DES) is one of the most common diseases of the organ of vision. At the same time, it is traditionally associated with “adult” ocular pathology and, at first glance, has relatively little significance for children.
However, in recent years, exogenous factors of development of CVS associated with the achievements of civilization are becoming increasingly important: the wide distribution of computers, air conditioners, contact vision correction products, cosmetics, etc. And if earlier these etiological factors of the dry eye syndrome were important only for adults, it is now increasingly common in children. In addition, other causes of the development of DES should not be ignored in this regard: functional insufficiency of the eyelids, pathology of the epithelium of the ocular surface, some syndromic conditions, etc.
The lack of information regarding the characteristics of the development and clinical course of dry eye syndrome in children has stimulated a comprehensive study in this area.
To study the most significant etiological factors of DES in children, to characterize the features of its clinical course, the effectiveness of modern methods of diagnosis and treatment.
Material and methods
In the period from 2008 to 2015, we used 350 traditional children with a clinical signs of CCG using traditional clinical ophthalmological and functional methods of research.
Among the rather wide list of etiological factors of the “dry eye” syndrome, applied to children’s age, the following were the main ones:
- computer visual syndrome;
- wearing soft contact lenses and orthokeratology lenses;
- artistic factors associated with the peculiarities of the child’s stay indoors and outside;
- instillation of drugs that reduce tear production or tactile sensitivity of the cornea;
- effects of surgery on the cornea, conjunctiva and orbital structures;
- consequences of diseases (including congenital), injuries (including as a result of surgery) of brain structures with impaired sensory and trophic innervation of the eyeball and / or secretory innervation of the lacrimal glands;
- dysfunction of the meibomian glands, meibomian blepharitis;
- congenital and posttraumatic colobomas of the eyelids, violation of the congruence of the eyelids and the eyeball (on the basis of dermoids and other formations);
- some systemic diseases (rheumatoid arthritis, diabetes mellitus, pathology of the thyroid gland, etc.);
- congenital diseases and syndromes accompanied by a decrease in tear production (lacrimal gland aplasia, congenital alacrimia, familial hereditary dysautonomy – Riley-Day syndrome, etc.).
Despite the fact that the pathology in children is considered, on the one hand, according to the pathogenesis, it is most similar to that in adults, but at the same time it has specificity regarding the clinical course of the disease. It is associated with scant (relatively adult) complaints of the child, in combination with relatively mild objective signs of xerosis (with the exception of its extremely severe forms). Often, even an extensive congenital coloboma of the century for a long time may not be complicated by the xerotic process, of course, with the preservation of the trophic and motor innervation of the eyeball.
Dry eye syndrome in children, as well as in adults, can occur in mild, moderate, severe and extremely severe clinical forms. At the same time, as our observations have shown, in the majority of children (with the exception of cases of marked xerosis), the pathognomonic clinical signs for it recede into the background, masking themselves with indirect symptoms. Therefore, only a careful analysis of the entire set of clinical manifestations of corneal-conjunctival xerosis in combination with a functional study of the production and stability of the tear film will allow such a child to be given the correct diagnosis and to treat it in a timely manner.
Accordingly, the diagnosis of CVS in children differs from that in adults, due to the significant loss of significance of the evaluation of complaints and the history of the child and / or his parents, whereas in adults it carries extremely high diagnostic information. Nevertheless, the active exclusion of risk factors for the development of “dry eye” syndrome in childhood and competent analysis of the subjective signs of the disease, during the interview of the child and / or his parents, is the first step in the diagnosis of corneal conjunctival xerosis.
In addition, in young children, due to their restless behavior during the examination, it was very difficult to conduct a number of functional diagnostic tests.
In such cases, the results of eye surface biomicroscopy using vital dyes come to the fore.
At the same time, in children, as well as in adults, the leading functional symptom of DES is a decrease in the stability of the prerocovar tear film. Usually, a decrease in the stability of the tear film is indicated when the time of its rupture does not exceed 9 s, however, in children, the following values of the Norn sample serve as age standards: up to 6 years – 8-12 s; 7-11 years old – 10-14 s and 12-18 years old – 14-17 s.
As for the assessment of tear production, then, in relation to children’s age, it is easier to assess it by the profile of the tear meniscus  than with traditional Schirmer and Jones samples. Taking into account the fact that it is necessary to place test strips of filter paper in the conjunctival cavity of a child, these tests are not always possible. In addition, their result is affected by lacrimation in the case of a “regular” crying child. However, studies by OA Vorontsova still managed to determine the age standards for tear production. And if in normal (in adults) total tear production is at least 15mm / 5min, then in healthy children under 6 years old the standard is the range of 26-33 mm; 7-11 years old – 17-26 mm and 12-18 years old – 20-28 mm.
The values of the main tear production in healthy adults exceed 10 mm / 5 min, and in children under the age of 6 they are 12-18 mm; 7-11 years old – 6-11 mm and 12-18 years old – 12-17 mm. Accordingly, the number of reflex tears in adults should be at least 5 mm, while in children under 6 years of age – 12-18 mm; at the age of 7-11 years old – 10-16 mm and over 12 years old – 6-12 mm ). However, its “reserve” is substantially higher than this value, since the irritant (filter paper) used in the examined samples is far from being the strongest.
Of course, the treatment of children with DES also has specificity. Mainly, it is associated with the presence of age restrictions for most of the drugs, widely used in the treatment of adults. First of all, it concerns steroid and non-steroid drugs, as well as cyclosporin A and even a number of metabolic drugs widely used in the treatment of severe and extremely severe forms of corneal conjunctival xerosis in adults. At the same time, and in relation to “artificial tears” drugs, the problem considered is just as relevant, which also requires focusing on the age limit for the administration of each such drug.
Along with the measures listed above, in the treatment of children with severe and extremely severe corneal-conjunctival xerosis, measures aimed at eliminating corneal degenerative changes are successfully used. For these purposes, depending on the severity of the ulcerative defect, the degree of corneal opacification and other circumstances, biological cornea coatings have been used: amnioplasty, autoconjunctival plasty, etc. Moreover, the technical options for such interventions are as varied as the clinic of xerotic corneal changes in children . For example, plastic according to Kunt has become widespread, the so-called biofilting of the cornea with the conjunctival flap “on the stem-base” (including with the tenon sheath), etc. At the same time, the amniotic membrane has been used as an independent application (in order to cover the cornea in one or several layers), and in combination with conjunctival plastics.
However, the above-mentioned surgical methods for treating DES and its complications in children had to be treated much less frequently than in adults.
In general, the arsenal of therapeutic and surgical methods of treatment of patients with corneal conjunctival xerosis is quite large. At the same time, a variety of clinical forms of the dry eye syndrome, etiology and pathogenesis of this disease in children require an individual approach to each particular child, which contributes to the demand and successful clinical application of the entire above-considered arsenal.
In general, dry eye syndrome is also relevant in childhood. Although, on the one hand, according to the etiology and pathogenesis of DES in children, it is most similar to that in adults, but at the same time it has specificity, mainly concerning the clinical course and treatment of this disease. First of all, these are extremely scant complaints of a child, in combination with relatively mild objective signs of xerosis (with the exception of its extremely severe forms). Finally, the specific treatment of children with corneal conjunctival xerosis is associated with the lack of permission to prescribe most of the drugs used in the treatment of dry eye syndrome in adults for children.
At the same time, the possibilities of diagnosing and treating dry eye syndrome are currently quite high, which requires their more persistent implementation in pediatric ophthalmology.