How Early In Life Can We Get Dry Eye Disease?
I often hear: “Isn’t my child too young to have dry eye disease?”
(or maybe, “Isn’t dry eye a disease of old people?” Most assuredly the answer is NO!
Dry eye disease appears to be on the rise and approaching a pandemic to match (or exceed) the Covid pandemic. Before writing this statement off as hyperbole, consider that the most common form of dry eye is evaporative in nature and caused by Meibomian Gland Dysfunction (MGD). A recent study (out of a tertiary care facility in India – though their observations match my mine, as well as many of my colleagues) showed that 95% of patients with clogged oil glands (obstructive MGD or o-MGD) have dry eye disease. Add to that, the fact that o-MGD is caused by lifestyle and dietary issues common to most Americans today, it comes as not surprise that more of us are affected – and at increasingly younger ages. Backing this up are several studies. One out of Duke University found that in nearly 100 children between the ages of 4-16 years (average age 10.5 years old), over half had some indication of MGD (yet few had any “symptoms.”) Another looked at high schoolers in Asia, where over half also had indication of MGD. Both of these studies were reported prior to the Covid pandemic (which appears another risk factor for dry eye – both from infections, from masks to avoid infections and from lifestyles associated with working and schooling from home on digital devices). I’ve published on two consecutive children referred for recurrent styes who had severe MGD, which was previously undiagnosed and not treated.
In earlier posts, I’ve explained the nature of these oil glands.
- First, they need basic building blocks of “good oil,” which are called “essential” because we can’t create them out of other oils. We need to eat them to make good oil for our tears (and as building blocks for every good oil in our bodies). These building blocks are called Omega 3, 6 and 9 and are generally best sourced in fish oil for the 3’s, tree nuts for the 6’s and seed oils for the 9’s.
- On top of eating them, we also need to digest and absorb them to nourish the oil glands in our eyelids (which in turn help support the clear, living surface of our eyes through our tears).
Two problems exist at this level.
- The first is that most Americans no longer subsist primarily on fish, nuts, and seeds (and perhaps like me, prefer pasta and pizza, hot dogs and hamburgers).
- The second is that many appear to have issues with digesting and absorbing what oils they do eat. This would be especially true of those with inflammatory intestinal issues, liver disease or gallbladder disease. While it is true that digestive issues are more common as we age, I see far too many young children dictating their menu and insisting on chicken tenders, mac and cheese, hot dogs, hamburgers, and pizza - to the exclusion of fish, nuts and seeds.
The next critical step is to “work” the oil glands, so they can produce their extremely important tear oils. These glands are composed of a series of tiny, sack-like balloons, lined by cells that produce the oils. The function of a strong blink is to “squeeze” these sacs and move the oil out of the balloons and into a common duct or passageway leading to the edge of the lid and then tiny, open “riverbeds” lining the lids, lead the oil to join our tears. The action of the lids spreading apart after full contact helps to drag the new, fresh oil and tear over the surface of the eye, while the action of the lids coming together with a slight squeeze helps to force the old tear down the passageway to the nose while simultaneously expressing the oil for the new tear.
Three problems exist at this level.
- The first is that too many of us are staring for long periods during the day (and night), while looking at our many digital devices. I’ve described this as the “ocular heart attack,” because a blink is both the “circulation” (turning over the lifeblood of our tears) and the impetus behind producing tear oils. No circulation of a tear is to the eye - like no circulation of our blood to our body (and the surface suffers). By not expressing oil, we are allowing the old unexpressed oils to “gel up” and by degree become more like candle wax than like the thin, “salad dressing oil” we need to float on top of our tear and seal it from evaporating.
- Second, we tend to do poor or “partial” blinks when we are engulfed in our digital world. This is a difficult concept for most, as we expect a blink to be a highly ingrained and automatic reflex (much like a heartbeat). But like a heartbeat, it can be weak or strong and when concentrating on our digital world (for work, communication, education, or play) we apparently “don’t want to miss anything.” Add that much of this digital experience happens when we are in a protected environment (house, office, school, or car), so there is less sunlight and wind to trigger the stronger blink responses. Remember to “blink strong.”
- Third, this stagnant oil sitting in our glands becomes better food for germs. These germs eating our tear oils will trigger our immune responses into inflammation (which can turn our eyes red and damage the cells making the watery portion of our tears). They also produce a gummy “biofilm” that – on our teeth we call plaque, but on our eyelids, we call “scurf.” This gummy plaque can “dam up” the riverbeds that would join the oil gland produce with our tears as well as to eventually cap over the oil glands and seal them. Waxy oils will further obstruct them and then you have obstructive MGD (and dry eyes).
Since all who develop o-MGD (and related dry eye) tend to do so slowly, over many months and years, it is common to “adapt” so that we can continue to function. Early on, we can increase our blink rate, to better keep up with the evaporation happening faster as we have less oil to seal the moisture in and dry air out. Normal blink rates average every 10-20 seconds, with longer periods between blinks when we concentrate (like when we stare at digital devices). Normal evaporation rates occur over 20 seconds or more (depending on the air dryness and general air quality). Blinking every few seconds is common (but also like running a marathon all day) when our oil is insufficient to seal and protect our tears from evaporation. Another adaptation is for the corneal nerves to gradually become “numb” (through various anatomic and physiologic responses). As children develop, they are good at adapting – but also tend to live in the moment as their collective recall of a distant past (when eyes felt and performed better) is limited by their age. Older adults who have experienced a youth of good eye health and tear function appear more apt to understand when this has “gone wrong.” For kids, the symptoms may be masked, or show up as recurrent styes or as under performance at schoolwork – or acting out when they don’t feel good but don’t understand what is wrong.
My earlier posts help to direct us to finding good sources for the essential omega oils 3, 6 and 9, as well as simple “lid crunches” coupled with warm moist compresses and lid hygiene. I’ve found that most younger patients (especially school-aged kids) will quickly respond to these simple steps and generally don’t require the more expensive and procedural approaches of my adult protocols (typically involving mechanical lid hygiene, IPL and RF-heated expressions of clogged MGs).
If In doubt about whether you or your children have dry eye disease, it is best to seek the examination and advice of a dry eye specialist who has the equipment and education to determine the health of the ocular surface and the tears that support that surface. I no longer treat children, but am happy to examine and treat adults and may be able to offer advice regarding their children.
To schedule an appointment with Dr. Jaccoma, call Excellent Vision at either of these two dry eye offices:
(1) 155 Griffin Rd, Portsmouth, NH 03801 (603) 574-2020
(2) 3 Woodland Rd, STE 112 Stoneham, MA 02180 (near Boston) (781) 321-6463
(July 23rd’s post includes an index to past posts which will not include this post but is otherwise a complete reference!)