Oculoplastics
Not just little adults

Getting the drops in

No one said it’s easy to get kids to take medicine. And eye drops have a disadvantage over oral medicine in that they cannot be converted to a better tasting liquid. Additionally, children often do not realize the importance of following their eye drop regimen.
Short of using handcuffs, there are a few tricks to helping parents get the eye drops in—or avoid the conditions triggering eye drop use in the first place, said Drs. Buznego and Sheppard.
1. Prescribe a more potent agent that the child will use less frequently
2. Have parents remind children to not scratch or rub an itchy eye, as this only makes the condition worse
3. Encourage proper hand washing in children. This can avoid the spread of bugs transmitted when children do eventually touch their eye. Parents can turn hand-washing compliance into a game
4. Chill drops. This helps with pain and can soothe the eye

Pediatric dry eye, allergies, and infection raise different issues than adults

A child with congenital corneal opacity and dry eyes
Source: Abhay R. Vasavada, M.D.

Dosing frequency and systemic side effects are two areas of concern that prompt ophthalmologists to take a slightly different approach when treating dry eye, allergies, or infection in children.
Although ophthalmologists say the actual medications they use for these conditions are usually the same for children and adults, getting the medicine in the eye while avoiding systemic side effects are more challenging in children.
“We usually aim for a more potent agent infrequently versus a less potent agent more infrequently,” said John D. Sheppard, M.D., professor of ophthalmology, microbiology, and immunology, Eastern Virginia Medical School, Norfolk, Va.
Here’s a look at treatment plans used by a number of ophthalmologists when they work with pediatric patients.

Targeting dry eye

Common symptoms associated with dry eye and lid margin disease in children include blinking, tearing, photophobia, red eyes, recurrent chalazia, and some corneal involvement, said M. Edward Wilson, M.D., director, Albert Florens Storm Eye Institute, Medical University of South Carolina, Charleston, S.C.
That said, treating dry eye in children and teenagers can be problematic because they are not the most compliant patients, and they often do not have the time or interest in intensive treatment, Dr. Trattler said.
Abhay R. Vasavada, M.D., director, Iladevi Cataract & IOL Research Centre, Raghudeep Eye Clinic, Ahmedabad, India, advises lid massage with erythromycin eye ointment. If the dry eye is more severe, Dr. Vasavada also recommends the use of preservative-free artificial tears. “The advent of preservative-free tear substitutes and lubricants allows the surgeon to use these drops more freely without the risk of side effects,” he said.
Dr. Wilson agrees that lid hygiene and warm compresses are good starting points for pediatric dry-eye patients, Dr. Wilson said. “Antibiotic drops or ointment helps sometimes because Staph aureus and Staph epidermis are often involved when the cornea gets involved,” he said. “Doxycycline or tetracycline orally works well directly on the oil and also on the microflora.”
However, children under age 8 cannot use the latter because the medications can stain dental enamel, Dr. Wilson said. Although erythromycin orally can be used in children under age 8, it typically does not work as well as doxycylcine or tetracycline, he said.
“I think that cyclosporine is safe, and I use it for both chronic allergies as well as dry-eye related problems [in children],” said Esen K. Akpek, M.D., associate professor of ophthalmology, and director, Ocular Surface Diseases and Dry Eye Clinic, Wilmer Eye Institute, Johns Hopkins University, Baltimore. Dr. Akpek will also use cyclosporine in children for blepharitis-related corneal problems.
Ophthalmologists interviewed said they will use steroids if necessary but that they are very cautious in doing so, due to possible cataract formation.
Pediatric patients with dry eye related to conditions such as Riley-Day syndrome may require topical steroids as well as punctual occlusion, Dr. Sheppard said.
It is also important to determine if dry eye is caused by other medications the child may be using, said Carlos Buznego, M.D., voluntary assistant professor of ophthalmology, Bascom Palmer Eye Institute, Miller School of Medicine, University of Miami, Miami. For example, asthma or allergy medications such as Benadryl (diphenhydranine, Pfizer, New York) can have a drying effect, he said. Accutane (isotretinoin, Genentech, South San Francisco), used in teenagers for acne, can slow down meibomian gland dysfunction, Dr. Buznego has said.

Treating allergies

The approach used to treat pediatric ocular allergies is not all that different than what physicians may use in adults. However, children are more likely to suffer greater effects from allergies in the form of conditions such as vernal keratoconjunctivitis (VKC), Dr. Sheppard said.
Dr. Wilson said he prefers to start conservatively with cold compresses and having the child avoid allergen triggers if possible.
He said that second-generation topical antihistamines can help with itching in acute allergic conjunctivitis—Dr. Wilson also says the twice a day dosing for medications such as Elestat (epinastine hydrocholoride 0.05%, Inspire Pharmaceuticals, Durham, N.C.) makes it easier to administer. Otherwise, newer dual-acting agents that contain a mast cell stabilizer and antihistamine, such as Patanol (olopatadine hydrocholoride 0.1%, Alcon, Fort Worth, Texas), Pataday (olopatadine hydrochloride 0.2%, Alcon), Alocril (nedocromil, Allergan), and Zaditor (ketotifen fumarate, Novartis, Basel, Switzerland)are all popular and are approved for children age 3 and older.
Dr. Vasavada prefers a more conservative approach. “I counsel parents that ocular allergy is usually a self-weaning condition and that the child will grow out of it once he gets older. I never use steroids in ocular allergies, not even lower-potency steroids,” he said. However, if ocular allergies are very severe, he will give olopatadine.
If allergies are seasonal and there is no corneal scarring, Dr. Sheppard will try and titrate medication usage to only the time of year when flare-ups are most common. If allergies are not controlled with typical treatment, then Dr. Sheppard will refer patients to an allergist for testing.
“That said, skin tests tend to be more effective for upper respiratory symptoms and less effective for ocular symptoms. Still, we let the allergist decide when to test,” he said.
If a child develops VKC—a condition that Dr. Sheppard said can cause painful-to-watch wheezing, puffy eyes, and a dripping nose—Singulair (montelukast sodium, Merck, Whitehouse Station, N.J.) can provide some relief without any drying effects, Dr. Sheppard said. The typical pediatric dose is 5 mg daily, he said.
Topical cyclosporine is also used by some physicians to treat pediatric ocular allergies, particularly for VKC, Dr. Sheppard added.

Fighting eye infections

Eye infections are notoriously common in children, whether it’s recent contact-lens wearers who present with an infection or a conjunctivitis that has spread through a nursery classroom.
As Dr. Sheppard put it simply: “Kids get everything.” And they are all too willing to share it with their adult caregivers.
Treating eye infections in children differs from adults because you must determine the pathogens that are more common in children, administer the right dosing amount, and be aware of the age for which your medication of choice is approved for usage, Dr. Buznego said.
It is helpful to determine if the infection is viral or bacterial, Dr. Wilson said. “Mostly I see viral infections, and I don’t overtreat with antibiotics if I am convinced the infection is viral,” he said. “Because I use Zymar [gatifloxacin 0.3%, Allergan] or Vigamox [moxifloxacin 0.5%, Alcon] for post-operative prophylaxis, I also use it for a true bacterial conjunctivitis—even though older generic antibiotics may work as well.”
Physicians must consider the pathogens most common in children, such as Haemophilus influenzae, Dr. Buznego said. “Azithromycin has good coverage with this, and it has good dosing.Plus it’s approved in children over the age of 1.” The dosing schedule makes it easier to administer versus drops that have to be used more frequently.
Newer fluoroquinolones such as besifloxacin (Besivance, Bausch & Lomb, Rochester, N.Y.) have somewhat of an advantage because they can be used three times instead of four times a day, Dr. Buznego said.
Ophthalmologists must also consider referring the patient to their primary care doctor if an ear infection is suspected along with the eye infection, Dr. Sheppard said. “The child may have difficulty eating, have a fever, and have the crankiness associated with otitis,” he said.A diagnosis by a primary care doctor is crucial to avoid hearing damage associated with some ear infections, he said.

Editors’ note: Dr. Sheppard has financial interests with Alcon (Fort Worth, Texas), Allergan (Irvine, Calif.), Bausch & Lomb (Rochester, N.Y.), and Vistakon (Jacksonville, Fla.). Dr. Akpek has financial interests with Allergan. Drs. Wilson, Vasavada, and Buznego have no financial interests related to their comments.

Contact Information

Akpek: 410-955-5494, esakpek@jhmi.edu
Buznego: 305-598-2020, cbuz@comcast.net
Sheppard: 757-622-2200, docshep@hotmail.com
Vasavada: icirc@abhayvasavada.com
Wilson: 843-792-7622, wilsonme@musc.edu