The Impact of Screen Time on Pediatric Dry Eye and Meibomian Gland Dysfunction.

Maintaining ocular stability is critical for clear vision, comfort, and overall eye health. Ocular stability relies on lubrication from healthy tear film to protect and nourish the ocular surface. A healthy ocular surface ensures a smooth refractive finish and clearer vision. Healthy vision relies on tear film’s 3 layers: meibomian-produced lipid (prevents evaporation), lacrimal gland-produced aqueous (hydrates), and goblet cell-produced mucin (ensures adhesion). A dysfunction of any of the 3 layers can lead to dry eye disease (DED). DED is commonly linked with prolonged digital screen use.DED is generally categorized into 2 subtypes: aqueous deficient dry eye (ADDE) and evaporative dry eye (EDE). Insufficient tear production due to lacrimal gland dysfunction leads to ADDE. It is commonly linked to autoimmune conditions such as Sjögren syndrome, collagen vascular diseases, or vitamin A deficiencies. On the other hand, EDE is caused by increased tear evaporation leading to a disruption of the outer lipid layer. This can be from meibomian gland dysfunction (MGD) or poor blinking habits. MGD or poor blinking decreases tear oil content, causing faster evaporation. Although the subtypes share overlapping symptoms and risk factors, they require distinct diagnostic approaches and treatments.Modern lifestyle factors have led to a significant rise in DED. The surge in pediatric DED cases has been linked to increased screen time via smartphones, tablets, and computers as a key risk factor. Prolonged screen use reduces and disrupts blinking, impairing tear distribution. Reduced blinking impairs meibomian gland function and destabilizes the tear film’s lipid layer, promoting increased tear evaporation. Over time, this results in symptoms characteristic of DED such as irritation, burning, blurred vision, and ocular discomfort. Prolonged screen time decreases blink rate (from 20.8 to 8.9 blinks/min during smartphone gaming) and causes incomplete blinking, disrupting tear distribution and impairing meibomian gland function. Once these glands atrophy, they do not regenerate, causing lifelong DED.DED’s complex etiology includes environmental, behavioral, and physiological elements. A China-based population study revealed that 8.7% of children exhibited symptomatic DED. These symptoms include itchy eyes, a burning sensation, and cloudy vision. An Indian cross-sectional study found that 19% of young participants reported moderate to severe DED symptoms. These 2 studies specifically emphasized the correlation between longer device use and increased risk of DED. They also point out protective factors, such as outdoor activities, that reduce the risk of developing DED. Outdoor time promotes distance viewing and blinking, which enhances meibomian oil release and tear stability.Chronic DED reduces quality of life by causing discomfort and impaired vision. In children, untreated DED can affect concentration, hinder academic performance, and increase the risk of serious ocular surface conditions such as corneal erosions and conjunctival inflammation. Although rare, chronic corneal erosions can lead to corneal ulcerations and compromised vision. Longitudinal studies on severe ocular surface conditions, such as chronic corneal erosions, in pediatric DED are limited. Many new studies focus on implementing parameters around screen time usage in children.There are several important management strategies to prevent or mitigate the impacts of both forms of DED. Management strategies include the 20–20-20 rule (looking at something 20 feet away for 20 seconds every 20 minutes). Blinking exercises can be a beneficial treatment, since blinking rates decrease from a normal 15 to 20 times per minute to 5 to 7 times per minute when staring at screens. Blinking exercises alone may not be enough, and additional treatments may be required. Supplementary interventions could include the application of warm compresses, manual expression of meibomian glands, and using artificial tears with lipid components. Warm compresses both unclog oil glands and improve tear production to mitigate symptoms. Artificial tears with lipid components provide symptomatic relief by providing lubrication and helping to keep the tears on the cornea for a longer time.Treatment strategies for dry eye disease differ for ADDE and EDE. In ADDE cases, the objectives are to enhance tear production and reduce inflammation. For patients with mild to moderate dry eye, pediatricians may recommend over-the-counter artificial tears to be applied 3 to 4 times per day and a warm cloth compress for 5 minutes 1 to 2 times per day. Patients should be advised to avoid topical antihistamines because they can make dry eye symptoms worse. If this conservative treatment does not relieve the patient’s symptoms, they should be referred to a comprehensive ophthalmologist.Although artificial tears remain the primary treatment, patients with moderate to severe symptoms, classified as gritty eyes, tearing, blurry vision, itchiness, and pain, may benefit from input from ophthalmologists for prescription medications like cyclosporine eye drops. These drops reduce inflammation in the lacrimal glands by inhibiting T-cell activation, thus improving tear production. Cyclosporine formulations in chondroitin sulfate emulsion have shown significant improvements in helping tear production and improving ocular surface health. Another option is lifitegrast, which reduces the infiltration of inflammatory cells into the ocular surface.The management of EDE is primarily focused on the lipid layer of the tear film and treating meibomian gland dysfunction. Although reducing daily screen time to less than 2 hours is commonly recommended, promoting outdoor activities to combat extended digital device usage is also often encouraged. Warm compresses and artificial tears with lipid components are common approaches to alleviate symptoms quickly. For better long-term results, advanced treatments recommended by ophthalmologists—such as intense pulsed light therapy or meibomian gland expression—can be used. Meibomian gland expression is typically performed in-office by an ophthalmologist and involves either manually squeezing the eyelids or using thermal pulsation devices like LipiFlow and TearCare, which apply controlled heat and pressure to unclog the glands. Although these interventions are helpful, they may be uncomfortable and less well tolerated in children.Special attention is needed for individuals on systemic medications, which can exacerbate DED. Examples include antihistamines, selective serotonin reuptake inhibitors, acne treatments like isotretinoin, vitamin D, seizure medications, and acetylsalicylic acid. These medications reduce tear production by disrupting lacrimal or reflex secretion. Screening for relevant risk factors in pediatric populations is essential for implementing targeted interventions.Future studies should investigate the specific effects of different devices and examine the relationship between the length of screen time and the severity of DED/MGD. Long-term studies can be beneficial to better understand causal mechanisms and assess the influence of other factors such as nutrition, environmental elements, and systemic illnesses. Moreover, researching customized treatments for ADDE and EDE in young patients could provide a practical understanding for better treatment outcomes. Exploring innovative technologies, such as wearable devices that monitor blinking or mobile applications designed to promote healthy blinking habits and regular screen breaks, may also be helpful for pediatric and other groups.In addition, public health campaigns in which school districts, teachers, parents, and health care professionals collaborate could be effective in raising awareness about DED in children. Related research should concentrate on developing policies that promote and provide guidelines for structured outdoor activities and digital device usage, as well as easily accessible eye care services, to address rising pediatric DED rates.Comments: I found this In Brief fascinating information for pediatricians on the increased development of dry eye in the pediatric age population and the association with the harms from increased screen time, so prevalent in those of all ages. Perhaps I missed this in my medical school classes, but I was not aware of the importance of blinking, tear production, and meibomian gland dysfunction. This In Brief gives another reason for parents to supervise and limit the amount of screen time, as some of the dysfunction mentioned is irreversible and can lead to long-term problems of dry eye. This In Brief prompted me to review the most recent AAP guidelines on screen time. While quality of the media material and time duration suggestions were made, I didn’t see mention of the increased risk of dry eye with increased screen time. This may be another aspect that parents should consider when deciding on optimal screen time use for their children and in their households. Seems like a winning strategy to encourage outdoor activities that will result in reduced screen time but also more distance viewing, which increases blinking. However, not all children have safe neighborhood outdoor environments in which to play, so creative strategies to limit screen time and substitute it with activities to increase blinking are warranted. And, as the authors mention, this is an important example of why public health measures are important in our society.Janet R. Serwint, MDEditor Emeritus, In Brief