Dry Eye Dx and Tx

Sjögren’s Syndrome...in a 10-Year-Old Boy?

BY AMBER GAUME GIANNONI, OD, FAAO

A young boy is sitting in your exam chair. His mother tells you that he seems to blink a lot and it looks like his eyes bother him constantly. When you ask the child directly about symptoms, he shrugs his shoulders and says that everything is “fine.”

Would Sjögren’s Syndrome (SS) be on your rule-out list? Would it even make your top three? In the case of a young patient I saw last year, that’s exactly what his diagnosis was—confirmed by salivary gland biopsy. Luckily for me, he had already been diagnosed by a rheumatologist; however, I can’t help but wonder how long I would have followed him before suspecting autoimmune disease and ordering blood work. Six months? A year? This isn’t the typical demographic for SS—but that also might be precisely why an autoimmune process should be considered.

Dry Eye in a Child Is a Red Flag

Most healthy children don’t complain about their eyes; in fact, it is estimated that less than 1.5% of all children have dry eye symptoms (Akinci, Cakar et al, 2007; Akinci, Cetinkaya et al, 2007). On the contrary, children who have juvenile diabetes or juvenile arthritis report up to an eight-fold increase (Akinci, Cakar et al, 2007; Akinci, Cetinkaya et al, 2007). When a child (or his parent) vocalizes anything resembling ocular discomfort, take notice and investigate further.

Finding the Source

How do you investigate dry eye symptoms in a child? Of course, you must rule out the more likely possibilities for this demographic first. Is he suffering from allergic conjunctivitis, or is it a side effect of antihistamines (or another oral/topical medication)? Is he a contact lens wearer who is abusing his lenses or perhaps developing a sensitivity to a noncompatible care solution? Have you ruled out meibomian gland dysfunction (MGD) and anterior blepharitis?

Sometimes children also do strange things that are a little more difficult to tease out. For example, could he be purposely instilling a foreign substance in his eyes to get parental attention? Yes, unfortunately this happens.

Most eyecare practitioners perform a cursory slit lamp examination on children, but they probably don’t do much more to screen for dry eye. I’d venture to say that many of us aren’t using vital dyes in this population because most children are normal, and compliance can be unpredictable. But if we’re not actively assessing kids for MGD, blepharitis or corneal staining, how many are getting through the cracks?

Many other dry eye specialists with whom I’ve spoken believe that they are observing MGD more frequently in kids than in years past, but it’s also possible that we’re simply getting better at looking for it. This particular patient was negative for all of the above, except for moderate, bilateral punctate keratitis.

Once these more likely possibilities have been eliminated and you’ve determined that the problem isn’t transient, a history of autoimmune disease, including arthritis, lupus, diabetes, and thyroid disorder, should be investigated. Ask about joint pain, dry mouth, rashes, increased or decreased thirst or hunger, weight gain or loss, cold or heat intolerance, lethargy and hair loss, etc. Positive responses to any of these questions, or children who exhibit persistent ocular surface staining or symptoms without an obvious cause, should have blood work drawn and be referred to their primary care physician and/or rheumatologist. CLS

For references, please visit www.clspectrum.com/references and click on document #240.

Dr. Gaume Giannoni is a clinical associate professor at the University of Houston College of Optometry and is the director of the Dry Eye Center at the University Eye Institute. She also sees patients in a private practice setting and has received authorship honoraria from Bausch + Lomb.