KIDS & CLS
Contact Lenses and Kids: Seize the Opportunity
Fitting kids with contact lenses may not be an easy task, but it's not difficult. And think of the rewards.
By Jeffrey J. Walline, OD, PhD
We fit children with contact lenses for numerous reasons, from correcting refractive error to vision therapy to being an alternative treatment option when others fail. In this article, I'll point out the many opportunities we have to fit kids with contact lenses.
Age Doesn't Always Matter
The most common reason for children older than six or seven years to wear contact lenses is to correct refractive error. Those who elect to wear contact lenses to correct their refractive error should be able to independently care for their lenses. Therefore, I generally don't provide children who are younger than six or seven years with the option of contact lens wear.
However, children mature at varying rates and some six-year-olds may be responsible for their lens care, whereas some 13-year-old children aren't conscientious enough to wear lenses. Unfortunately, we don't have any strong indicators of successful adaptation to contact lens wear, but anecdotal indicators such as a child's reaction to discomfort, his independence and parental involvement may help you decide whether he's likely to wear contact lenses successfully.
Contact lenses often provide a more convenient mode of correction for young, active children who participate in a variety of sporting activities. Glasses don't fit well under football, hockey or baseball helmets, and they often fly off children's faces during gymnastics, cheerleading or playground antics. Parents often bring young children back to their eyecare practitioner because the child loses his glasses or bends them into an impossible form. For some parents, contact lenses may well be a cost-effective means of correcting their child's refractive error.
For moderate to high hyperopia, contact lenses may be cosmetically more appealing than glasses and they are likely to be more comfortable. A wide variety of contact lens options are available for hyperopic children, including all modalities of soft and GP contact lenses. However, daily disposable and continuous wear soft contact lenses are not available for hyperopia greater than +6.00D.
Daily disposable and continuous wear lenses are available for nearly all myopic prescriptions, and low to moderate myopic children can wear corneal reshaping lenses. Just decide what modality best fits each child's personality, maturity and lifestyle.
You can fit children with many contact lens
Match the Lens to the Environment
The most appropriate correction modality for each child depends on his motivation for contact lens wear, his contact lens experience and the type of contact lenses, if any, his parent(s) wears. If the child wants to wear contact lenses only during sporting activities, then soft contact lenses are the best option because with part-time wear, it's difficult to adapt to GP contact lenses. Soft contact lenses may also be a better option for children who play sports in dusty environments, such as softball, horseback riding and gymnastics (when they use powder on their hands).
However, continuous wear contact lenses may not be the most appropriate modality for this age group because they won't have the experience of applying and removing contact lenses regularly, which prepares them in case they experience any sudden-onset trauma that requires them to remove their contact lenses in a less-than-optimal environment.
Controlling the Refractive Error
Adults may regard spectacles as trendy and fun, but children don't always have the same sentiment. Therefore, you must know the contact lens options for controlling different types of refractive error, as described in the following sections.
Myopia Myopic parents are often concerned about controlling their child's myopia, and GP lenses are the only contact lens option that may slow myopic eye growth. Most studies indicate that alignment-fit GP lenses affect myopia progression, but scarce data exist regarding the effects of corneal reshaping lenses on the progression of myopia.
Corneal reshaping contact lenses are excellent for active children who don't want to wear vision correction during sporting activities. Instead, they wear corneal reshaping contact lenses at home under their parents' supervision, where they're also less likely to lose their lenses.
Amblyopia Young amblyopic children don't like to have the vision of their sound eye occluded with an eye patch -- or they may not like to wear a patch for cosmetic or comfort reasons. These children must use some sort of penalization to improve the vision in their amblyopic eye. Children as young as two weeks may wear a contact lens to treat amblyopia.
Charlotte Joslin, OD, says, "The occluder contact lenses provide an alternate treatment option for dense amblyopia." An occluder contact lens is beneficial for approximately one-third of children who were unsuccessful with standard patching therapy. One-third of the children (from a case series of 13 subjects) were initially successful with the occluder contact lens, but they eventually learned to dislodge the lenses from the eye, and one-third of the children were never able to wear a contact lens for vision therapy because they were noncompliant.
Dr. Joslin suggests ordering high-plus contact lenses to improve lens handling and she says, "The occluder contact lenses are available in four-packs, which is handy because these young patients often lose or tear their contact lenses."
Penalization because of optical blur has also been shown to effectively treat amblyopia, so you may prescribe lenses with too much plus power for amblyopia therapy. However, the child must be hyperopic and the blur induced by the lens must be greater than the blur experienced by the amblyopic eye, so if you're going to fit a child with these lenses, he should have only low to moderate amblyopia.
Aphakia Infants may also wear lenses to manage unilateral aphakia because they would suffer from aniseikonia with spectacle correction. Bilateral aphakic children, however, may still wear glasses to correct their vision. Intraocular lenses (IOLs) are also an option for treating congenital cataracts, but using them for infants is controversial because of a child's rapid eye growth and the resulting rapid changes in refractive error. Before fitting an aphakic child with lenses, Louise Sclafani, OD, suggests making sure that the parents understand what's involved in contact lens wear. She says, "I try to meet with the parents before cataract surgery to make sure that they understand the process and that the surgery is only the first part of a long-term treatment for aphakia."
You can fit young aphakic children with either GP or soft contact lenses, and they may wear these lenses either on a daily wear or an extended wear basis. If the parents can apply and remove the lenses daily, then this modality is ideal because the child is more likely to adapt to contact lens wear before becoming an amazingly strong, obstinate two-year-old.
Contact lenses provide an alternate method of patching for the treatment of
Managing Other Conditions
Children may also wear contact lenses for binocular vision therapy. Those who have convergence insufficiency or accommodative insufficiency or infacility may benefit from bifocal lenses. These children may benefit from either GP or soft lenses. If they need a high reading addition to alleviate symptoms because of near-point esophoria, then translating GP bifocals may be the most appropriate option, but most children will benefit from any type of bifocal lens.
A few children may present to your practice with nystagmus caused by any number of etiologies and anecdotal reports of decreased nystagmus following lens wear do exist. The proposed mechanism of effect centers around a biofeedback loop that dampens the movement of the eyes, and GPs were supposed to be the most effective. But other reports have stated that soft lenses also work, which indicates that improved visual input may be the primary reason for dampened nystagmus. Even if the lenses don't decrease the nystagmus, prosthetic lenses may conceal some of the eye movement and improve the cosmesis.
Some children refuse to wear glasses because they don't like their appearance with glasses, because their peers tease them or because they feel that wearing glasses is uncomfortable. These children are excellent candidates for lens wear. They may benefit not only from constantly wearing vision correction, but they may also receive a boost in self esteem.
Children may wear contact lenses for a large variety of reasons, and they're capable of wearing nearly any modality. Parents are vital for contact lens wear until the child becomes seven or eight years old, at which time the child may be able to independently care for his contact lenses. You should inform every child who requires refractive error correction about the option of contact lens wear. Even children who don't need correction may benefit from contact lens wear if you're comfortable with the available options.
Finding Appropriate Lenses for Child's Play
Around the age when children become active and ambulatory, their eyes are approximately at the level of tabletops and other objects. Children also like to play rough, and they don't realize their own strength. Therefore, ocular injuries are relatively common for toddlers. When asked what are the most difficult pediatric contact lens fittings, Dr. Sclafani immediately replied, "Two-year-old children who have traumatic eye injuries."
Depending on the trauma, you may fit a lens to improve vision or to improve cosmesis. Experts typically recommend GPs to improve vision following trauma because of irregular astigmatism. The parent might find it easier to apply and remove GP lenses from a two-year-old's eyes, but it may also be easier for the two-year-old to dislodge them from his own eye. If trauma results in disfigurement of the eye and improved cosmesis is the goal of the lens fitting, then you'll typically want to prescribe soft lenses. A number of cosmetic lenses are available that you can use for children or adults. If the visual prognosis is guarded, then a prosthetic lens with an opaque pupil may be indicated to maximize cosmetic outcomes.
Benefitting From a Younger Population
Once you become familiar with fitting children with contact lenses, you'll find that they're excellent referral sources and you'll learn to determine how capable each child is of handling the responsibility of contact lens care. You'll also realize how much fun you can have working with children who may become loyal contact lens-wearing adult patients in the future.
To obtain references for this article, please visit http://www.clspectrum.com/references.asp and click on document #102.
Dr. Walline is a research scientist at the Ohio State University College of Optometry and he is the principal investigator of the Children's Overnight Orthokeratology Investigation.