Are you seeing more dry eyes in kids? Dry eye disease (DED) in children has historically been considered a rare condition largely due to limited epidemiological data, lack of clear consensus on diagnostic criteria, and absence of standardized treatment protocols.
Additionally, inadequate symptom quantification in young patients has only added to the diagnostic blind spot, further contributing to an incomplete understanding of pediatric DED. However, recent studies documenting ocular surface changes in children are challenging this traditional view.
As evidence continues to emerge, pediatric dry eye is gaining recognition as a significant condition, emphasizing the need for further investigation and refined diagnostic approaches. While diagnosis is one hurdle, effective treatment presents an even greater challenge.
Numbers don’t lie: Epidemiology of pediatric dry eye disease
A large cross-sectional study by Uchino and colleagues involving 3,433 Japanese high school students found that 4.3% of boys and 8.0% of girls were diagnosed with DED. However, there is a striking gap between symptoms and diagnosis, as 21% of boys and 24% of girls actually reported dry eye symptoms, signaling significant underrecognition of the disease.1
Furthermore, the COVID-19 pandemic amplified the pediatric dry eye crisis, with digital screen time surging to unprecedented levels—a key factor in the rising prevalence of dry eye symptoms.2 A Thailand-based study utilized the validated DEQ-5 (5-Item Dry Eye Questionnaire) to assess 603 children during the pandemic, revealing that 62.5% had dry eye symptoms.2
Current estimates now place pediatric DED prevalence between 5.5 to 23.1%, making it clear that early screening and intervention are critical.3
To learn more about the connection between dry eye and digital screen time, check out Chicken or Egg: Digital Eye Strain and Dry Eye!
Causes of dry eye disease in children
Children with ocular allergies, underlying systemic diseases, and females face a higher risk of DED.3 Both allergic conjunctivitis (AC) and DED are often considered epidemics of the 21st century.4
Depending on the study, the prevalence of allergic conjunctivitis ranges from 40 to 47% in adults and is even more common in pediatric populations.4 Although the potential association between ocular allergy and dry eye has been well documented, recent evidence has shed light on the pathogenic mechanisms that may link these two conditions.
Severe forms of AC, such as vernal keratoconjunctivitis (VKC) and atopic keratoconjunctivitis (AKC), have been shown to reduce tear breakup time (TBUT), impair meibomian gland function, and decrease mucin secretion—leading to symptoms of dry eye disease. Interestingly, patients with AC often present with increased tearing, which may mask the underlying DED.5,6
However, this perceived absence of dryness may not reflect a true lack of ocular surface disease. Rather, it may highlight a disconnect in patient understanding—where excessive tearing is mistakenly interpreted as a sign of ocular hydration, when in fact it can be a reflex response to ocular surface irritation and dryness.
Beyond allergies, endocrine and autoimmune diseases significantly increase the risk of pediatric DED. Conditions such as diabetes, systemic lupus, Sjögren’s disease, and juvenile idiopathic arthritis disrupt immune regulation and induce chronic inflammation, both of which compromise tear film stability and ocular surface health.7
Modern lifestyle factors are also fueling the rise of DED in children. Increased digital device use, prolonged screen time, reduced outdoor activity, and urban living have all been identified as independent risk factors.7 Extended daily use of digital devices reduces blink rates and often leads to incomplete blinking, leading to increased tear evaporation and heightened ocular discomfort.8
In addition, similarly to adults, certain medications, contact lens use, and exposure to air pollution can also contribute to DED in children.9
Diagnosing pediatric DED
Diagnosing DED in children presents unique challenges due to the absence of pediatric-specific normative data and validated diagnostic thresholds. Moreover, most existing diagnostic tools and questionnaires were developed for adults, often using language that is not age-appropriate for younger patients.
While dry eye questionnaires can still be used reliably in pediatric eyecare, younger children may require additional time and support to complete them accurately. The DEQ-5 and IOSS have been recommended as suitable tools for use in this population.10,11
Due to the limited ability of pediatric patients to effectively communicate symptoms, non-invasive diagnostic tests are especially well-suited for evaluating dry eye disease in children. These include TBUT, ocular surface staining with sodium fluorescein, and a thorough slit-lamp examination to assess for signs of ocular allergy and DED.¹
Meibography, another non-invasive imaging technique, is valuable for evaluating the morphology of the meibomian glands and grading the severity of disease.12 The Schirmer test without anesthesia, though a well-standardized method for assessing tear film secretion, is relatively invasive and may not be well tolerated in children.12
Lifestyle changes are the first-line treatment for DED in kids
The first-line treatment for pediatric DED centers on modifying environmental factors, reducing screen time, improving sleep quality are key to prevention and management.12 A study by Moon et al. demonstrated that children who halted smartphone use for 4 weeks showed significant improvement in both objective signs and symptoms of DED.13
Lauricella et al. found that parent screen time is the strongest predictor of child screen time, suggesting that interventions must involve the entire family. Instead of placing the responsibility solely on the child, household rules should promote balanced screen use, encourage regular breaks, and prioritize outdoor activities to support better ocular health.14
Rethinking the 20-20-20 rule
The widely recommended 20-20-20 rule for screen use has been questioned. A study by Johnson et al. found that a 20-second break did not improve symptoms, regardless of the frequency of break intervals.15
The authors noted that accommodation can take up to 90 seconds to return to baseline. Instead, newer recommendations suggest taking breaks longer than 20 seconds, ideally 5 minutes every 25 minutes of screen use.15
Blue-blocking glasses: What the research really says
Although the impact of blue-blocking lenses on sleep quality remains uncertain, a Cochrane review by Singh et al. found no benefit for eye strain relief.16 Similarly, the American Academy of Ophthalmology (AAO) does not endorse blue light-blocking glasses for digital eye strain, citing a lack of scientific evidence supporting their efficacy.17
The sleep and DED connection
Poor sleep is a major risk factor for DED. In the US, 60% of adolescents fail to get enough sleep, and poor sleep increases DED risk by 50%.18 Addressing sleep hygiene should be part of a comprehensive DED management plan.19
Artificial tears: Less is more
Preservative-free artificial tears are preferred, but overuse increases treatment burden and reduces compliance. Not all drops are the same, making careful selection essential.20
Since most cases of DED have an evaporative component or are meibomian gland dysfunction (MGD) related, we normally prescribe lipid or emulsion tears.21
Pharmacological approaches in pediatric DED
Research on the safety and effectiveness of DED treatments in children remains limited, and many pharmacological options lack pediatric approval. Table 1 outlines pharmacological options for DED and age indications.
Addressing underlying factors such as ocular allergies and lagophthalmos is essential in pediatric patients as well. In more severe or chronic cases, steroid-sparing therapies should be considered for long-term management.
Topical cyclosporine (CsA) has been shown to improve VKC and AKC by inhibiting mast cell and eosinophil activation, which drives inflammation. A 6-month study involving 2,597 patients found a significant decrease in symptoms with 0.1% CsA, with 30% of patients able to discontinue steroids within 3 months.22
Similarly, Jiao et al. found that 0.05% CsA monotherapy was more effective than 0.1% olopatadine with preservative-free artificial tears in allergic conjunctivitis-associated dry eye, significantly improving symptoms of ocular itching and increasing TBUT.23
Tacrolimus, another immunomodulator, is also emerging as a potential treatment. Originally developed as an immunosuppressant for organ transplantation, tacrolimus ointment is used for atopic dermatitis and has been reported to be 100 times more effective than CsA in inhibiting calcineurin.24 Studies suggest its effectiveness for DED, VKC, and AKC.
Table 1: List of pharmacological treatments for DED and age indications.
| Drug | Age | Brand |
|---|---|---|
| Cyclosporine | 16 years | RESTASIS / CEQUA |
| Lifitegrast | 17 years | XIIDRA |
| Perfluorohexyloctane | 18 years | MIEBO |
| Loteprednol | 18 years | EYSUVIS |
| Varenicline | 18 years | TYRVAYA |
| Cyclosporine / Perfluorobutylpentane | 18 years | VEVYE |
| Cyclosporine 0.1% | 4 years | VERKAZIA |
| Loteprednol | Birth | LOTEMAX GEL |
| Tacrolimus 0.02% to 0.1% | 2 to 15 years | Off label |
| Olopatadine 0.1% | 2 years | PATADAY |
| Bepotastine besilate 1.5% | 2 years | BEPREVE |
In-office treatment options for pediatric DED
While numerous in-office dry eye treatments exist for adults, there is currently no strong evidence supporting device-assisted therapies for pediatric dry eye disease. FDA approvals for in-office treatments vary by age. OptiLight by Lumenis is approved for patients 22 and older, while LipiFlow and iLux are approved for those 18 and up.29,30
However, emerging studies highlight the potential of light-based therapies for younger patients. Zhai et al. demonstrated that low-energy intense pulsed light (IPL) can safely and effectively treat pediatric blepharitis in children aged 5 to 16, significantly improving TBUT, meibomian gland structure and function, while also reducing severe corneal neovascularization, limbal pannus, and conjunctival congestion.31
Similarly, Jiang et al. found that IPL significantly outperformed hot compresses in children under 12, achieving higher cure rates and better outcomes for granulomatous chalazion.10
Case Study: 16-year-old male with severe ocular discomfort
A 16-year-old male presented with complaints of redness, tearing, puffy eyelids, burning, and light sensitivity, significantly affecting his school performance. His parents reported excessive screen time and a bedtime between 1 and 3am.
Figure 1: Slit lamp image of lagophthalmos.
Figure 1: Courtesy of Mahnia Madan, OD, FAAO.
Figure 2: Inferior corneal fluorescein staining indicative of exposure keratopathy due to lagophthalmos.
Figure 2: Courtesy of Mahnia Madan, OD, FAAO.
Figure 3: Papillary conjunctivitis of the lower tarsal conjunctiva.
Figure 3: Courtesy of Mahnia Madan, OD, FAAO.
This case highlights the multifactorial nature of pediatric dry eye and ocular surface disease, where digital strain, sleep deprivation, and allergies drive ocular surface inflammation and MGD, exacerbating symptoms and complicating diagnosis.
Treatment of dry eye disease in the pediatric population should be multi-faceted, targeting both ocular surface inflammation and contributing behavioral or environmental factors. In this case, the patient was treated with Eyeseals moisture goggles and lubricating ointment at night to support overnight moisture retention.
Anti-inflammatory therapy included loteprednol etabonate tapered over 6 weeks, bepotastine besilate was prescribed to address allergic components, and preservative-free hyaluronic acid artificial tears were used for surface lubrication.
In addition to pharmacologic therapy, lifestyle modifications such as improving sleep hygiene and reducing screen time were emphasized as essential components of the treatment plan.
Closing thoughts
Once considered rare, pediatric dry eye is increasingly common yet widely overlooked. Excessive screen time, environmental factors, and systemic conditions fuel its rise, while diagnostic gaps delay intervention.
Early detection, lifestyle changes, and targeted treatments are essential. It's time to recognize, diagnose, and treat pediatric DED before it becomes a lifelong burden.
