Clinical

Childhood Myopia and Dry Eye: Are They Related?

November 1, 2024

By James S. Wolffsohn BSc, MBA, PhD, Professor and Dean of the School of Optometry, Aston University 

Photo Credit: Dreamstime Photos

There is a high incidence of dry eye in children with myopia across the globe,1-4  which is associated with picky eating and eye rubbing in a clinic in China.1 This association can significantly impact children’s educational experience and overall well-being.5 So, is this association just a result of the increasing prevalence of both myopia6 and dry eye7 and the growing interest in these two conditions by eye care practitioners, or is there an actual link between them? Possible links could be neural, structural, nutritional, social/environmental, or treatment-associated factors.

Neural
The parasympathetic nervous system influences the lacrimal8 and meibomian9 glands as well as refractive error development10,11 and could therefore, be a link between myopia and dry eye disease. For example, a link has been found between choroidal thickness and tear stability.12 

Structural
A correlation between corneal thickness and myopia has been reported, with myopes having a thinner cornea,13 but other studies have found no such association.14,15 So, while corneal thickness has been found to be associated with dry eye,16 it is unlikely to serve as a risk factor for myopia development. Corneal thickness correlates with axial length elongation17 and raw axial length in some,18 but certainly not all19 studies.

The high incidence of dry eye in children in a clinic in China was associated with eye rubbing.1 Eye rubbing appears to temporarily alter corneal biomechanical properties, making the cornea softer, especially for myopic young patients.20 In healthy eyes, eye rubbing affects tear stability,21 which, in the longer term, is likely to cause ocular surface disease and dryness symptoms.

Nutritional
Vitamin D deficiency is common22 and is associated with both myopia and dry eye disease.23 The high incidence of dry eye in children in a clinic in China was associated with picky eating,1 but no further details were elicited to understand how this might have impacted refractive error.

Social/Environmental Factors
Myopia has been linked to the increase in reported digital eye strain,24 perhaps due to un- or undercorrected refractive error25 or extensive use of mobile devices causing myopia. A combination of low outdoor exposure linked with more than four hours a day of smartphone use has been found to be associated with greater myopia in Dutch teenagers,26 and a longitudinal study of children (5-15 years of age) from India showed that more than seven hours per day of screen time was associated with more myopia progression than in those using digital screens fewer than four hours per day (odds ratio: 3.5).27 However, several systematic reviews have not been able to find more than a weak link between mobile device use and myopia development.28,29

Rural populations have worse dry eye and meibomian gland health status than those from urban populations, at least in a developing nation.30 Rural populations have also been found to have a higher myopia prevalence than urban populations,31 which may be due to differences in taking breaks and outdoor time.32 

Treatment
Of course, myopia control treatments in the form of contact lenses can disrupt the tear film and induce dry eye, both for soft contact lenses33 and orthokeratology (at least initially).34 A prospective study of 12 months of wear and a retrospective review of medical records both identified that medium- to long-term use of orthokeratology lenses can lead to meibomian gland deformation and impact tear film function.35,36 Topical atropine use for myopia control can result in dryness symptoms,37 but limited impact on the tear film has been measured.38 Ocular surface effects are much more likely if the solution uses certain preservatives.39 

To fully answer the question of whether there is an association between childhood myopia and dry eye, better, large-scale longitudinal studies of young children need to be conducted, following those who develop myopia and those whose axial length growth halts at emmetropia. These trials need to collect detailed information on their ocular biometry, tear film, and associated structures (such as the meibomian glands), nutrition, and social/environmental factors, as well as any treatments prescribed and their use (in the form of compliance) to determine whether there is a true link and if so, what are the causes.

 

Prof. James Wolffsohn, a Professor of Optometry at Aston University since 2000, formerly Deputy Executive Dean for Life Sciences and then associate Pro-Vice Chancellor, is the Dean of the School of Optometry and also Head of the Department of Audiology. Professor Wolffsohn was a Clinical Research Fellow at the University of Melbourne in Australia, following an Optometry degree at the University of Manchester (UMIST), a training period at Moorfields Eye Hospital, and a PhD at Cardiff University. His main research areas are the development and evaluation of ophthalmic instrumentation, myopia management, contact lenses, intraocular lenses, presbyopia and the tear film. He is a National Teaching Fellow, has published more than 345 full peer-reviewed papers, and presented at numerous international conferences. He is the academic Chair of the British Contact Lens Association, having previously been President and chair of the BCLA Contact Lens Evidence-based Academic Reports (CLEAR); he is on the Executive board of TFOS, was a harmonizer and sub-committee chair for TFOS DEWS II & TFOS Lifestyle reports; he is the International Myopia Institute’s Chief Scientific Officer and was joint-Chair of their white papers. He holds the BCLA Medal (2021) and the AAO Glenn Fry (2022) and AAOptom CCLRT Founders (2024) awards.

 

 

 

References

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