Rising tide of ocular surface disease in young patients needs to be addressed

For many years, I have seen older patients with obvious meibomian gland dysfunction at the lid margin, often combined with blepharitis. Their gland openings are problematic, but when we do meibography, the internal glands are intact.

Today, at least half of the patientswho come to me are younger than 50 years of age, and I have been seeing younger patients who have beautiful lid margins but are symptomatic with dry eye. In some cases, the condition is so extreme that they have neovascularization of their corneas. When we do meibography, I see they have meibomian gland atrophy.

In 2018, about the time I began noticing this rising trend in pediatric ocular surface disease (OSD), Preeya K. Gupta, MD, published a paper reporting results of a study done with participants between 4 and 17 years old. She and her team found that 42% of the participants had evidence of meibomian gland atrophy.

In my experience, this younger generation tends to have more evaporative dry eye rather than aqueous deficiency. The patients generally do not have thyroid or other autoimmune diseases that coexist with aqueous deficiency. In addition, younger patients with ocular surface disease have been shown to have thinner average lipid layer thickness than older patients. I believe this higher rate of evaporative disease is related to the loss of meibomian gland function.

My patients in their 30s and early 40s grew up with far more digital device use than older populations, and they have used computers, cell phones and tablets for much of their lives. Numerous studies have reported reduced blink rate during screen use. Blinking exerts pressure on the meibomian glands, helping to express the lipid secretions, and is vital for the activation of the glands. When the glands are not activated by regular and frequent blinking, the glands begin to atrophy.

I find that younger generations are also more likely to wear contact lenses, adding to eye dryness, or they turn to refractive surgery to correct their vision, a process that requires a healthy cornea upfront, as surgery can exacerbate dry eye symptoms. It is clear to me that as more patients — and especially those younger than 40 years — start to display signs and symptoms of OSD, ophthalmologists need to be prepared to tackle this growing epidemic head-on and adjust their treatment protocols to match the needs of their patients.

Creating awareness

When younger patients come to me with dry eye symptoms, they often believe the cause is something other than OSD. It is necessary to educate them about OSD as a real disease state that can impact their visual health. I use topography, Placido images and meibography to visually demonstrate the disease state and show them changes over time in follow-up visits.

I believe it is our duty to begin educating our children and young adults on the importance of establishing a good lid hygiene routine early to maintain a healthy ocular surface over the course of their lives. In the same way that dentists have been able to convince the public to brush twice a day and floss for good oral health, it is essential that we educate our patients on the importance of good ocular surface care.

OSD is sometimes overlooked by eye care providers who are busy or preoccupied with other medical and surgical priorities. We have a responsibility as doctors to look for evidence of any disease and to listen to our patients as their symptoms may signal us to look specifically for evidence of OSD. We need to see the eye as a whole, and this includes risk factors and signs of OSD, especially in the young population.

Matching treatments to patient lifestyles

To help these patients care for their ocular surfaces, we must recommend routines that fit with their lifestyle. Blinking is an easy place to start. My younger patients are mobile, and conscious blinking can be done anywhere. There are also several apps available that will remind them to blink throughout the day, and I encourage them to download one if they might benefit from these regular prompts.

I have also found that most of my patients are already taking supplements for their general health, so incorporating one to support eye health is easier than asking them to take on more involved treatments that would be new to their routine. I recommend the nutraceutical HydroEye (ScienceBased Health), which contains gamma-linolenic acid from black currant seed oil as well as omega-3s and nutrient cofactors that support fatty acid metabolism, allowing the body to combat inflammation through multiple pathways. The nutraceutical’s ability to reduce irritation, support eye comfort and maintain corneal smoothness was demonstrated in a multicenter, placebo-controlled, double-masked trial.

My patients are receptive when I tell them that this supplement helps combat inflammation in their whole body, and many of them report feeling better when they take their nutraceuticals daily. I use it as a first-line treatment in my younger patients who are symptomatic or have signs of OSD, and I can visually present to them diagnostic evidence from techniques such as meibography.

I also recommend preservative-free drops for all my patients. My drop of choice is iVizia sterile lubricating eye drops (Thea). I personally use iVizia in the morning before I put my contacts in, and it keeps my vision clear through a whole day of staring into the microscope during surgery. The multiuse bottle is also more appealing to environmentally conscious individuals compared with single-dose vials.

These three measures form a solid foundation for maintenance and comfort. When appropriate, I will recommend other treatments based on the severity of the disease and the patient’s lifestyle, but I want to make sure to get them started on a proven routine that will easily become an established part of their lives.

Conclusion

Ophthalmologists cannot afford to ignore the rapidly growing segment of ocular surface disease patients younger than 40 years. These patients have a serious condition that is affecting their work performance and their enjoyment of life and possibly setting them up for a progressive and chronic disease that can require an increasingly complex therapeutic regimen. This population is entering our offices at a younger age, which gives us the opportunity to support the development of healthy habits that can remain in place for decades. We know that OSD is chronic and progressive, and not giving the condition careful attention will have consequences down the road. By providing care and education early, we can help younger patients maximize their ocular surface health and maintain productive lifestyles.

• References:
• Freudenthaler N, et al. Graefes Arch Clin Exp Ophthalmol. 2003;doi:10.1007/s00417-003-0786-6.
• Gupta PK, et al. Cornea. 2018;doi:10.1097/ICO.0000000000001476.
• Patel S, et al. Optom Vis Sci. 1991;doi:10.1097/00006324-199111000-00010.
• Sheppard JD Jr, et al. Cornea. 2013;doi:10.1097/ICO.0b013e318299549c.
• Tsubota K, et al. N Engl J Med. 1993;doi:10.1056/NEJM199302253280817.
• Weng HY, et al. J Formos Med Assoc. 2021;doi:10.1016/j.jfma.2020.10.028.

• For more information:
• Lisa K. Feulner, MD, PhD, a comprehensive ophthalmologist and cataract, refractive and glaucoma surgeon at Advanced Eye Care & Aesthetics in Bel Air, Maryland, can be reached at lisa.feulner@vipeyes.com.

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