January 16, 2015
3 min read

Excessive blinking may indicate ocular surface disease in children

Allergic eye disease and evaporative dry eye disease are the two main causes of pediatric ocular surface problems.

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Children are peculiar because they cannot always express themselves in a manner that adults can understand. For example, a toddler who gets headaches often exhibits this as tantrums or head banging. Similarly, there are times when children have a problem with their ocular surface, and instead of just rubbing their eyes, they will develop unusual eye movements and blinking that can be mistaken for neurological ticks. Sometimes these eye movements, and especially the blinking, can be so exaggerated as to cause great concern to parents.

Two causes

There are two main causes for ocular surface problems in children. The first is common: allergic eye disease. A papillary conjunctivitis is sometimes irritating enough for children to rub their eyes and blink often. It is often better to examine the lower tarsal conjunctiva and then the bulbar conjunctiva before everting the upper lids. A word of warning: Explain to the child what you are going to do and tell the child that if he tries to shut his eyes while you do it that it will hurt. Ask the child to look down and employ the parents to reassure the child that it will not hurt as long as he does not try to forcefully close his eyes.

Ken K. Nischal

The second cause, and the one most commonly responsible for the most exaggerated eye movements and forced blinking, is evaporative dry eye disease. In children, this is most commonly seen with meibomian gland dysfunction. Evaporative dry eye disease becomes more of a problem in air conditioned environments or when there is increased dryness in the atmosphere. This condition is far more common in children than originally thought, and several papers have been published demonstrating this. The suspicion that this may be the case is increased if a child has had recurrent chalazia in the past or has chronically red eyes.

Apart from the obvious signs of telangiectasia, posteriorization of the glands, inspissated gland material and incongruity of the lid margins, of which some or all may be present, it is important to look at the tear meniscus. In children under the age of 8 years, the meniscus should be 2 mm. It is also important to look at the noninvasive tear break-up time. While in adults this is said to be normal if it is 12 to 15 seconds, a recent paper has shown that in children younger than 12 years, the normal tear break-up time is around 25 to 28 seconds. This suggests that if an 8-year-old child is seen with a tear break-up time of 15 seconds, it is abnormal. It is also worth using fluorescein to check for punctate epithelial erosions. Sometimes fine punctate epithelial erosions may be seen, which may have an immune reaction component to posterior margin disease in the lids rather than be due to exposure keratopathy or lagophthalmos.


Treating evaporative dry eye disease in children, once the meibomian gland dysfunction is treated, can be challenging. Children hate having eye drops placed in their eyes. If the situation is severe enough, then silicone punctal plugs can be placed. These appear to be effective, and the rates of infection are practically nonexistent as long as the removable type of plugs are used. Most children will allow them to be placed while awake, but occasionally sedation or anesthetic may be warranted.

Figure 1. Image shows telangiectasia and inspissated meibomian glands.

Images: Nischal KK

Figure 2. Image shows poor tear meniscus in a child.


Treatment of meibomian gland dysfunction in children can be difficult, but the use of prolonged drops in a low dose, such as FML (fluorometholone ophthalmic suspension 0.1%, Allergan), has been reported to be safe as long as the epithelium is intact. In cases in which there is corneal involvement, it is often paracentral and not peripheral, as seen in adults. Under such circumstances, it is worth treating the inflammation topically and systemically and then arranging an exam under anesthesia, at which stage squeezing of the eyelids can rid the lids of marked inspissated material and allow placement of punctal plugs, usually in the lower lids first.

In summary, children, especially those younger than 12 years, may present with ocular surface disease with unusual signs and symptoms, including exaggerated rolling of the eyes and forced eye blinking. It is worth ruling out meibomian gland dysfunction, evaporative dry eye disease and allergic eye disease.

Visit UPMCPhysicianResources.com/Ocular to learn more about blinking eyes in children. You can also submit clinical questions or read the most recent questions asked of the UPMC Eye Center’s ophthalmology experts.

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Matafsi A, et al. Br J Ophthalmol. 2012;doi:10.1136/bjophthalmol-2011-300510.

For more information:
Ken K. Nischal, MD, FRCOphth, is a professor of ophthalmology at UPMC and the University of Pittsburgh. He can be reached at Children’s Hospital of Pittsburgh, Children’s Hospital Drive, 45th and Penn Avenue, CHP Faculty Pavilion, Suite 5000, Pittsburgh, PA 15201; email: nischalkk@upmc.edu.
Disclosure: Nischal has no relevant financial disclosures.