We’ve built an entire clinical identity around dry eye disease (DED) as a condition that belongs to adults, but that perception has always reflected our clinical focus more than the disease itself. While adult patients still represent the majority of those we treat and manage, we’ve placed far less emphasis on the pediatric population which has created a significant blind spot in how we approach this disease. The child sitting in the chair—phone in hand, backpack full of screen-powered devices—whose meibomian glands may already be starting to fail, has been hiding in plain sight.

The evidence is clear. A 2025 systematic review and meta-analysis of 48,479 pediatric participants estimated the overall prevalence of dry eye disease among children at 23.7%.¹ The researchers also compared prevalence before and after COVID, and found that the post-COVID prevalence was 44.1%—more than double the prepandemic rate of 18.7%.¹ These are not outlier numbers, but rather they represent a converging body of literature that suggests we need to rethink how we approach the pediatric eye exam and, equally important, how we educate the parents.

Why We Keep Missing It

With meibography being utilized more frequently as a screening tool, the structural meibomian gland changes we are identifying in pediatric patients can often be surprisingly extensive and provides noninvasive, objective findings for the provider and the parent of the child. However, most practices are still basing the diagnosis on symptoms and slit lamp findings alone, and this is where the disconnect occurs. Children are classically poor historians of ocular symptoms. A 7-year-old may not describe fluctuating vision or ocular fatigue the way a 40-year-old does. Instead, they rub their eyes, squint, or blink repeatedly trying to clear their vision. It becomes easy to attribute these findings to allergies or benign ocular irritation, particularly when these patients don’t fit our classic dry eye demographic. Another common scenario is the child with recurrent styes whose parents are told it’s simply pink eye or a recurring infection. Lubricants or medications can be prescribed to address acute symptoms, but the underlying structural meibomian gland changes often go unaddressed.

Research out of Duke University found that 41% to 42% of asymptomatic pediatric subjects aged 4 to 17 had some degree of meibomian gland atrophy on meibography.² Nearly half of children presenting for routine eye care were already showing structural gland loss, despite not having complaints of dry eye symptoms.² This is significant because meibomian gland atrophy is permanent and irreversible. The child with moderate gland loss at age 10 becomes the adult with severe evaporative dry eye at 35, long after the window for meaningful intervention has closed.

Understanding the Contributing Factors

Pediatric meibomian gland dysfunction (MGD) does not develop in isolation. Several converging forces are accelerating gland dysfunction in children, and most of them are modifiable.

Screen time and incomplete blinking. The average American child spends 4 to 8 hours daily on digital devices. During all reading tasks, including focused screen use, their spontaneous blink rate may drop by up to 60%, and a significant proportion of those blinks are incomplete.³ Research by Cremers and colleagues found that 86% of children with severe meibomian gland atrophy engaged in more than 4 hours of daily screen time, and approximately 50% exceeded 8 hours.⁴ The physiology is straightforward: The blink is the delivery mechanism for meibum. It is the pump that pushes oil from the glands onto the tear film. Less pumping means stagnant meibum, which thickens, inspissates, and eventually obstructs the ducts. The acini atrophy from disuse. The glands are lost, quietly, years before a patient is ever diagnosed with DED.

Diet and the omega-3 deficit. The standard American diet, particularly in kids and teenagers, is often heavily weighted toward omega-6 fatty acids and processed foods, which promote proinflammatory signaling. Children who subsist on processed foods with minimal fish, nuts, or seeds may be deficient in the omega-3 fatty acids that support the lipid layer of the tear film and modulate meibomian gland function. Not surprisingly, studies have also demonstrated that higher BMI percentile in children is independently associated with increased gland tortuosity.⁵^-⁷ As childhood obesity continues to rise, we should expect a corresponding increase in pediatric MGD severity.

Ocular allergy is another consistent risk factor for dry eye disease in the pediatric literature.⁸ The chronic inflammatory environment it creates directly destabilizes the tear film and disrupts the ocular surface epithelium, accelerating disease progression. These are conversations we can begin having with parents today.

The Broader Impact: Academic Performance and Daily Function

Comfortable, efficient reading requires a stable tear film. In a child with a reduced tear break-up time whose blink rate during screen use has already collapsed, the visual system is working hard against a constantly degrading optical surface. Although the result may be discomfort, more often it is fluctuating vision, increased visual effort, accelerated fatigue, and difficulty sustaining attention. These symptoms are difficult for a child to articulate to a teacher or parent, so they may simply stop reading, avoid the task, or be misidentified as having an attention problem. Beyond the classroom, there are many environments where children rely on clear, stable vision to excel: the baseball player tracking a pitch, the soccer player reacting to a fast-moving ball, the young musician reading sheet music under stage lights. When we reframe DED and MGD not merely as a comfort issue but as a condition that actively interferes with how a child reads, concentrates, and performs, the discussion around treatment shifts considerably.

Recognizing It Clinically

Given how nonspecific and how easy it is to overlook these presentations, a structured approach to the pediatric anterior segment exam becomes essential. This exam should include lid margin assessment, meibomian gland expression, tear break-up time, meibography when available, and ocular surface staining. Recurrent chalazia in particular should trigger a comprehensive dry eye workup rather than simply another antibiotic prescription because they are a clinical signal, not just a management problem. It is also worth briefly scanning the lid margins for signs of ocular rosacea. Although precise prevalence data in the pediatric population remains limited, the literature consistently flags children with recurrent chalazia as a group where ocular rosacea should be on your radar.⁹ It can be subtle, particularly in patients with darker skin tones where erythema is harder to detect.

A Treatment Framework for Pediatric Patients

Treatment strategy must be age-appropriate, practical for families to execute, and escalated according to disease severity. Unlike adult dry eye management, where we may move quickly to in-office procedures, the pediatric approach is grounded in behavioral intervention first and escalation is based on clinical findings and response.

Lid hygiene and warm compresses remain the foundation of pediatric MGD management. Warm compresses applied consistently at a temperature that is sufficient to melt inspissated meibum— approximately 40° to 45° C sustained for at least 4 minutes—followed by vertical lid massage are effective when performed correctly. It is worth noting that compliance can be a persistent challenge in this population. A structured handout with clear instructions, a chairside demonstration, and follow-up accountability go a long way in improving adherence, but managing parental expectations around consistency is equally important.

Omega-3 fatty acid supplementation at appropriate pediatric dosing is safe and supported by evidence. General guidelines suggest approximately 900 mg daily for children aged 4 to 8, and 1,000 to 1,200 mg daily for those aged 9 to 13. Teens require up to 1,600 mg daily. It is worth noting that North American children may be at a significant deficit for EPA and DHA if their diets do not have sufficient levels. A food-first approach is always the preferred starting point: fatty fish, walnuts, chia seeds, and flaxseed are excellent sources of omega-3 fatty acids. The challenge, as any clinician who has tried to get a 10-year-old to eat sardines regularly can appreciate, is that these are not exactly foods most children gravitate toward. When dietary modification inevitably falls short, a quality supplement becomes the more realistic and reliable path.

Preservative-free ocular lubricants are well-tolerated in children and appropriate for symptom relief and surface protection. In children with significant MGD, lipid-containing formulations help compensate for the compromised lipid layer. While dosing is guided by clinical judgment and disease severity, a reasonable baseline recommendation is morning and bedtime instillation at minimum. It is important that parents understand that ocular lubricants are a supportive therapy: Consistency is key, but they are not a curative step and should be viewed as 1 component of a broader treatment plan.

Topical anti-inflammatory therapy is an important part of the treatment conversation when ocular surface inflammation is significant, evidenced by staining, conjunctival injection, or clinical assessment. A short course of a topical steroid with a favorable safety profile, such as loteprednol etabonate, can be as effective as induction therapy to quickly reduce acute inflammation. Steroid use in children should be limited to short courses with appropriate monitoring, and transitioning to a topical immunomodulator for longer term inflammation management is a logical next step.

Topical cyclosporine is the most commonly used option in this role, though clinicians should be aware that Restasis and Cequa are technically off-label in patients under 16. Verkazia, approved for vernal keratoconjunctivitis in children 4 and older, represents a labeled pediatric option that is worth considering where appropriate. Although robust pediatric dry eye-specific trials are lacking, clinical evidence from related inflammatory ocular surface conditions, including pediatric blepharokeratoconjunctivitis and ocular rosacea, supports the use of topical cyclosporine in this population with a favorable safety profile.^10,11

For cases that require systemic intervention, oral azithromycin is a reasonable option. Oral doxycycline is another consideration, though it is generally not recommended for prolonged or repeated courses in children under 8 years of age due to potential effects on developing teeth and bone. For children 8 and older, it can be an effective tool, but parents must be clearly counseled on the risk of photosensitivity. Phototoxic reactions are a well-documented risk, with reported incidence varying widely depending on dose and sun exposure.¹² Broad spectrum sun protection is essential for any child on doxycycline, and this conversation needs to happen explicitly at the time of prescribing 

Additionally, given the impact of prolonged antibiotic use on the gut microbiome, the concurrent use of a quality probiotic is a reasonable and practical consideration that is worth discussing with parents.

Advanced treatments. For pediatric patients who may benefit from in-office intervention, low-level light therapy (LLLT) represents the most appropriate and accessible option. LLLT works through photobiomodulation and delivers low-power LED light across therapeutic wavelengths to the periorbital region to improve meibomian gland function, reduce inflammation, and promote tissue repair. It is entirely noninvasive, requires no contact with or near the eye, and newer treatment protocols can be completed in as little as 7 minutes. Its favorable safety profile and minimal risk of adverse events make it a particularly suitable option in this population.

It is worth noting that LLLT is not currently FDA approved for dry eye or MGD in any age group, which makes any clinical use off-label. This is, therefore, a conversation that should happen with patients and parents prior to treatment. While formal pediatric-specific studies are still emerging—notably, the Illinois College of Optometry is currently conducting the first randomized clinical trial of LLLT specifically for MGD in children—the adult evidence base is encouraging and the disease process in children is the same.^3,13

For patients 18 and older, IPL, radiofrequency (RF), and other thermal-based treatments become additional options that are worth discussing. FDA clearance for IPL in MGD is currently designated for patients 22 and older, and clinical trial enrollment for RF has similarly used age 22 as the minimum threshold, meaning use in patients aged 18 to 21 is off-label for these modalities as well. Patients and parents must be clearly informed of this prior to proceeding.

The Role of Parental Education

Parental understanding and education are at the foundation of any pediatric dry eye treatment plan. This is often one of the most underestimated dimensions of managing this disease in children and is also where many of our best clinical intentions break down. Often, parents are bringing their child in for a routine exam or to update their glasses or contacts, and the discussion of a disease process such as dry eye can come as a surprise. This is because, like many, parents associate dry eye with someone older than their 10-year-old. Our job is to shift that mindset and clearly connect the dots between what they already know—extensive screentime, poor diet, recurrent styes—and how that relates to their child’s ocular health.

Effective parent communication in the exam room should cover several key areas:

1. Explain why meibomian glands matter in relatable terms.
2. Address the potential permanence of gland loss and how that could impact their child in the future.
3. Validate their concerns about screen time with specific clinical information.
4. Provide guided information on at-home treatments and nutrition.

Practical Steps for Your Practice

Just as optometrists have taken the lead and are at the forefront of dry eye treatment in adults, we are uniquely positioned to lead in the pediatric population as well. We see children at ages when meaningful intervention is still possible, before significant gland atrophy has occurred, before symptoms emerge, and before visual performance begins to suffer. Pediatricians do not examine meibomian glands. School nurses do not image the lid margin. We are the authority on this issue, and it is time we embraced that role in the pediatric space.

Integrating pediatric dry eye care into your practice flow involves only a few simple steps:

1. Add a brief screen time question to your pediatric intake form and make lid margin evaluation a standard component of every pediatric exam rather than only for symptomatic patients.
2. Treat recurrent chalazia as a diagnostic signal that requires a full workup rather than a standalone management problem.
3. Get comfortable explaining the pathophysiology of MGD and dry eye in simple, relatable terms that both the child and parent can understand. Showing a parent a meibography image of their child’s glands alongside a healthy comparison is one of the most powerful ways to drive parental compliance.

The data is clear: Nearly 1 in 4 children has dry eye disease,¹ and nearly half of asymptomatic pediatric patients show meibomian gland atrophy on imaging.² The downstream consequences of missed early MGD are largely preventable. We have the tools, the knowledge, and the protocols. What this generation of pediatric patients needs most is simple: for us to look.

References

1. Zou Y, Li D, Gianni V, et al. Prevalence of dry eye disease among children: a systematic review and meta-analysis. BMJ Open Ophthalmol. 2025;10(1):e002014. doi:10.1136/bmjophth-2024-002014
2. Gupta PK, Stevens MN, Kashyap N, Priestley Y. Prevalence of meibomian gland atrophy in a pediatric population. Cornea. 2018;37(4):426-430. doi:10.1097/ICO.0000000000001476
3. Wolffsohn JS, Lingham G, Downie LE, et al. TFOS lifestyle: impact of the digital environment on the ocular surface. Ocul Surf. 2023;28:213-252. doi:10.1016/j.jtos.2023.04.004
4. 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;229:63-70. doi:10.1016/j.ajo.2021.03.035
5. Xu Z, Bao L, Wang X, Ying H, Mao J, et al. The role of childhood overweight in meibomian gland dysfunction and dry eye disease in Chinese children. BMC Ophthalmol. 2025;25(1):285. doi:10.1186/s12886-025-04086-9
6. Villani E, Nucci P, Benitez-del-Castillo JM, et al. Expert consensus on pediatric dry eye: insights from a European Delphi study. Ocul Surf. 2025;37:189-197. doi:10.1016/j.jtos.2025.04.004
7. Gupta PK, Venkateswaran N, Heinke J, Stinnett SS. Association of meibomian gland architecture and body mass index in a pediatric population. Ocul Surf. 2020;18(4):657-662. doi:10.1016/j.jtos.2020.06.009
8. Leonardi A, Modugno RL, Salami E. Allergy and dry eye disease. Ocul Immunol Inflamm. 2021;29(6):1168-1176. doi:10.1080/09273948.2020.1841804
9. Arriaga C, Domingues M, Castela G, Salgado M. Pediatric ocular rosacea, a misdiagnosed disease with high morbidity: proposed diagnostic criteria. World J Dermatol. 2016;5(2):109-114. doi:10.5314/wjd.v5.i2.109
10. Rousta ST. Pediatric blepharokeratoconjunctivitis: is there a ‘right’ treatment? Curr Opin Ophthalmol. 2017;28(4):449-453. doi:10.1097/ICU.0000000000000383
11. Özkan G, Gökçe GD, Turhan SA. Pediatric ocular rosacea: clinical features and long-term maintenance therapy with topical cyclosporine. Ocul Immunol Inflamm. 2025;33(9):2077-2082. doi:10.1080/09273948.2025.2553219
12. Goetze S, Hiernickel C, Elsner P. Phototoxicity of doxycycline: a systematic review on clinical manifestations, frequency, cofactors, and prevention. Skin Pharmacol Physiol. 2017;30(2):76-80. doi:10.1159/000458761
13. Stapleton F, Velez FG, Lau C, Wolffsohn JS. Dry eye disease in the young: a narrative review. Ocul Surf. 2024;31:11-20. doi:10.1016/j.jtos.2023.12.001

Shane Swatts, OD is vice president and owner of Eastern Virginia Eye Associates and the Dry Eye Center of Virginia in Chesapeake, Virginia. He is the cofounder of OD Immersion, a national consulting and clinical education platform that helps optometrists implement advanced dry eye, ocular surface disease, and aesthetic services in primary eye care. He is also cofounder of Codesa, a digital platform for specialty dry eye practice management. He is an active key opinion leader, national and international speaker, and clinical investigator. Reach him at drswatts@evea2020.com.

Disclosures: Clarion/Luvo, Codesa, CSI Dry Eye, ESSIRI Labs, Lumenis Aesthetics, Lumenis Vision, Oculus, OD Immersion, ScienceBased Health. Dr. Swatts is also a clinical investigator in a study evaluating the ZogniQ ZPL multiwavelength polarized low-level light therapy device for dry eye disease and ocular surface dysfunction.