Tear Film And Ocular Surface Assessment In Pediatrics

Pediatric dry eye disease (PeDED) is an underrecognized yet increasingly prevalent condition, with its incidence rising due to environmental and lifestyle factors. Despite its clinical significance, PeDED remains challenging to diagnose due to the limited feasibility of standard ocular surface assessments in children.

This study aimed to evaluate the feasibility and outcomes of tear film and ocular surface examinations across different pediatric age groups, both with and without ocular surface symptoms, compared to adults. By identifying age-related limitations in diagnostic procedures, we sought to provide insights into optimizing pediatric assessment strategies for PeDED.

A cross-sectional study was conducted at University Eye Clinic of San Giuseppe Hospital (Milan) between Genuary and December 2024.

A convenience sample of 150 pediatric patients (300 eyes, 1–17 years old) and a control group of 40 young adults (80 eyes, 20–40 years old) were consecutively recruited. Exclusion criteria included acute or severe chronic ocular diseases other than dry eye and conditions potentially interfering with test feasibility.

Patients' assessments were based on the Tear Film and Ocular Surface Dry Eye Workshop II reccommendations and scheduled to minimize mutual interference and included: anamnestic interview (conducted with patients and/or parents), standardized questionnaires for dry eye symptoms (Visual Analogue scale, Numerical Rating Scale, Instant Ocular Symptoms Survey, Ocular Surface Disease Index, and Dry Eye Questionnaire-5), tear film osmolarity (TearLab), tear film stability (fluorescein and non-invasive break-up time – FBUT and NIBUT), ocular surface staining, conjunctival redness and infra-red meniscometry (Keratograph5M), Schirmer test, and infra-red meibography (Keratograph5M).

Among 150 children, 64 (43%) reported PeDED symptoms. Feasibility varied by test type and age. Tear film osmolarity was the most feasible (98%), followed by NIBUT (67%), FBUT (38%), and ocular surface staining (35%) (P<0.01). Meniscometry, Schirmer test, and meibography had variable feasibility, with age-related trends and some exceptions (e.g., Schirmer test feasible in 55% of infants vs. 32% of toddlers; P<0.05).

Symptomatic children showed significantly higher tear film osmolarity (297.79±10.94 vs 287.87±54.46), lower NIBUT (7.07±9.11 vs 9.05±8.21), greater conjunctival redness (0 [0–1] vs 1 [0–1]), and lower Schirmer test (15.65±6.55 vs 18.66±6.56) (P<0.05). No significant differences were found between symptomatic children and adults.

This study highlights the need for age-specific, feasibility-driven diagnostic approaches for PeDED. Standard dry eye assessments may be particularly challenging in younger children, requiring methodological adaptations to improve diagnostic accuracy. Additionally, symptom assessment in pediatric patients is complex due to age-related differences in perception, communication skills, and response consistency. Optimizing both subjective and objective evaluations could enhance the ability to quantify the impact of ocular surface dysfunction on children's quality of life and improve the distinction between pathological conditions and para-physiological variations.