HEALTHY MEIBOMIAN GLANDS (MGs) are essential to a healthy ocular surface and a good quality tear film. Meibomian gland dysfunction (MGD) is the leading cause of dry eye disease (DED) (Nichols et al, 2011). MGD causes increased tear evaporation, hyperosmolarity, inflammation, an unstable tear film, and subsequent ocular surface damage (Chhadva et al, 2017).

MGD is characterized by MG obstruction and/or changes in meibum secretion, and its chronicity leads to MG atrophy over time (Nelson et al, 2011). The landscape of who is affected by MGD is changing; it is no longer just the postmenopausal female or older patient. More younger individuals are being affected (Gupta et al, 2018).

Research about the pediatric population has found that anywhere between 28% and 42% of patients younger than 18 years old have some evidence of MG atrophy (Wu et al, 2017; Gupta et al, 2018). A more recent retrospective study on MG atrophy found that 41% of children 6–17 years old who had no prior history of DED had severe atrophy (Cremers et al, 2021).

In one study, not only did the severe MG atrophy cases exhibit signs and symptoms of DED, but 41% of them had best-corrected visual acuity loss, 29% had some degree of corneal vascularization, and 14% had central corneal neovascularization, which is typically seen only in advanced stages of the disease (Cremers et al, 2021).

Kids cannot always articulate symptoms, so it’s important to ask the right questions about how their eyes look and feel, and also involve the parents in the case history. A parental or personal history of skin disorders such as rosacea or eczema and atopy can signal the likelihood for eyelid inflammation. Closely evaluating the lashes, lid margin, and MGs is crucial. Quick and painless diagnostic testing such as osmolarity, MMP-9, and meibography can be valuable.

Foundational treatment can be started by teaching children how to clean their lids and lashes with one of the many commercial preparations and about using warm compresses. Discussing environmental factors—such as screen time—is appropriate. Although it may be difficult to convince parents and patients to reduce this, discuss the importance of blinking fully and regularly. It can be beneficial for the patient to use the 20-20-20 rule.

For adolescents, it can be advantageous to discuss the use of cosmetics around the eye (such as avoiding applying eyeliner on the water line, which blocks the MG orifices), the proper disposal schedule, that they should not share cosmetics, and the importance of hygiene and daily removal of cosmetics. With parents of this age group, it can be helpful to explain that the use of systemic medications such as acne meds, antihistamines, antidepressants, anxiety meds, and birth control pills could contribute to and/or exacerbate the condition. Proactively having these conversations with young patients while their parents listen is an important step in educating about this chronic disease.

Although a study by Yeotikar and colleagues (2016) has demonstrated that MG atrophy increases with age, the number of kids and adolescents who have been found to already have atrophy and subsequent dry eye is staggering. Increasing amounts of screen time may be partially responsible for this (Cremers et al, 2021).

Given that screens are here to stay, it’s important to evaluate our younger patients closely and screen them for MGD and MG atrophy, because it may have implications for their long-term ocular surface health. Early identification and intervention can improve long-term outcomes for these younger patients before symptoms even begin. CLS

References

1. Nichols KK, Foulks GN, Bron AJ, et al. The international workshop on meibomian gland dysfunction: executive summary. Invest Ophthalmol Vis Sci. 2011 Mar 30;52:1922-1929.
2. Chhadva P, Goldhardt R, Galor A. Meibomian Gland Disease: The Role of Gland Dysfunction in Dry Eye Disease. Ophthalmology. 2017 Nov;124:S20-S26.
3. Nelson JD, Shimazaki J, Benitez-del-Castillo JM, et al. The international workshop on meibomian gland dysfunction: report of the definition and classification subcommittee. Invest Ophthalmol Vis Sci. 2011;52:1930–1937.
4. Gupta PK, Stevens MN, Kashyap N, Priestley Y. Prevalence of Meibomian Gland Atrophy in a Pediatric Population. Cornea. 2018 Apr; 37:426-430.
5. Wu Y, Li H, Tang Y, Yan X. Morphological Evaluation of Meibomian Glands in Children and Adolescents Using Noncontact Infrared Meibography. J Pediatr Ophthalmol Strabismus. 2017 Mar 1;54:78-83.
6. Cremers SL, Khan ARG, Ahn J, et al. New Indicator of Children’s Excessive Electronic Screen Use and Factors in Meibomian Gland Atrophy. Am J Ophthalmol. 2021 Sep;229:63-70.
7. Yeotikar NS, Zhu H, Markoulli M, Nichols KK, Naduvilath T, Papas EB. Functional and morphologic changes of meibomian glands in an asymptomatic adult population. Invest Ophthalmol Vis Sci. 2016 Aug;57:3996-4007.