Dry Eye Disease (DED) has been defined by the Tear Film and Ocular Surface Dry Eye Workshop II (TFOS DEWS II) as “a multifactorial disease of the ocular surface characterized by a loss of homeostasis of the tear film, and accompanied by ocular symptoms, in which tear film instability and hyperosmolarity, ocular surface inflammation and damage, and neurosensory abnormalities play etiological roles” [1]. Tear film instability is the hallmark of the disease, inducing a variety of symptoms and/or visual disturbances, and potentially leading to ocular surface damage [2]. The prevalence of DED in adults varies widely, ranging from 5 % to 50 %. This condition becomes more common with age and is particularly more prevalent in women [3,4]. Patients report an array of symptoms including but not limited to ocular dryness, redness, stinging, burning, photophobia, foreign body sensation and visual disturbances; these symptoms may have an impact on the quality of life (QoL) of patients [[5], [6], [7]]. DED can be categorized into aqueous deficient dry eye (ADDE), evaporative dry eye (EDE), or a mixed type. EDE is the more common type, accounting for 35 %–45 % of cases. It is predominantly due to meibomian gland dysfunction (MGD) and reduced meibum secretion that results in tear film disruption, which promotes tear evaporation. However, ADDE is caused by a lack of aqueous tear secretion by the lacrimal glands. It is primarily triggered by an inflammation or obstruction of the lacrimal gland, refractive surgery, contact lenses and certain medications [1].

DED significantly impacts the adult population, with recent studies reporting a notable prevalence (10 %–44 %) even among the pediatric population [[8], [9], [10]]. Pediatric cases are increasingly identified due to modern lifestyle changes primarily associated with prolonged use of electronic and digital devices, worsened by the Coronavirus Disease 2019 (COVID-19) pandemic. Other potential risk factors include inflammation, allergies, inadequate nutrition and diabetes [[11], [12], [13], [14]]. In recent years, ophthalmologists have been closely observing this pathology, raising questions about whether its incidence is increasing. Young patients with DED seem to exhibit a similar symptom profile to that of adults [11,13]. However, there is a notable scarcity of references and clinical evidence specifically addressing the pediatric population [3]. Current diagnostic and management protocols for DED have been developed and studied for adults but lack specificity and validation for children, highlighting a crucial gap in pediatric ophthalmic care [12]. It is important to recognize that pediatric dry eye is frequently misdiagnosed as an infection, irritation, or trauma. In many cases, these manifestations are mistakenly attributed to isolated events, rather than accurately identified as episodes of an underlying chronic disease [15]. These challenges result in variations in diagnostic approaches across different centers and contribute to significant delays in achieving accurate diagnoses in both developed and developing countries [16]. This study aims to identify the challenges and uncertainties encountered in the diagnostic and management process from the perspectives of expert physicians.

Although recommendations from international expert ophthalmological societies offer valuable guidance to ophthalmologists for diagnosing and treating diseases, they may not always address situations where physicians struggle to establish a diagnosis in real-world clinical practice within the limitations of their facilities. The heterogeneity of pediatric patients with DED, combined with the limitations of diagnostic tools, complicates the accurate diagnosis of this condition. Here, we outline the findings of a European study, by the pediatric DED (PeDED) Delphi group, aimed at developing expert consensus-based opinions for understanding and managing PeDED, addressing the urgent need for age-appropriate treatment algorithms for eye care practitioners. By gathering expert insights, our results provide a comprehensive understanding of the unique characteristics of PeDED. In addition to identifying current trends, this study allows the anticipation of future practices, ultimately guiding the development and improvement of products tailored for pediatric use to improve patient outcomes.