Article Date: 4/1/2008

Safety Check

Safety Check

How much risk is involved in fitting children with contact lenses? A new study debunks old myths.

Mile Brujic, OD: Only about 2% of practitioners routinely prescribe contact lenses for children ages 10 and younger, and only 38% have ever prescribed contact lenses for those between ages 10 and 12, according to a 2006 survey by Johnson & Johnson Vision Care, Inc. A 2007 J&J survey found that doctors consider 10 the youngest age for beginning contact lens wear, and 13 seems to be the average age.

Why are so many young patients missing out on an opportunity to benefit from contact lenses? And what can we do to change this situation?

To answer these questions, we have assembled optometrists who routinely prescribe contact lenses to children of all ages. Among those joining us are Mary Lou French, OD, FAAO, MEd, and Christine W. Sindt, OD, FAAO, as well as Marjorie J. Rah, OD, PhD, FAAO, and Jeffrey J. Walline, OD, PhD. Drs. Rah and Walline co-authored the Contact Lenses in Pediatrics (CLIP) Study.1 We will discuss the major findings of this landmark study, including safety and health issues.

PRACTITIONERS' CONCERNS

Dr. Brujic: First, let's discuss why the CLIP study was needed. Why are practitioners reluctant to fit children in contact lenses?

Christine W. Sindt, OD, FAAO: A lot of practitioners are afraid to talk to children. They're afraid of managing the risk, not only of contact lens wear, but of children not communicating problems with their lenses. Also, children have long lives during which problems can develop.

Jeffrey J. Walline, OD, PhD: I agree that some doctors are risk averse. Practitioners may think children require too much chair time or the children are not mature enough to manage contact lenses.

Mary Lou French, OD, FAAO, MEd: Of course, all of us here today know these are gross misconceptions, especially if you have a well-trained staff that supports your contact lens fitting efforts. Kids between 8 and 12 years old are the ones who listen and usually do the best in my practice, where I fit kids almost exclusively all day.

Dr. Brujic: The CLIP Study was designed to provide evidence of this success. Drs. Walline and Rah, can you tell us more about the study?

CLIP STUDY DESIGN

Dr. Walline: We enrolled two groups — 84 children (8 to 12 years of age) and 85 teenagers (13 to 17 years of age) — at the University of Houston School of Optometry, the New England College of Optometry and the Ohio State University College of Optometry. The study subjects met the following criteria:

■ No history of contact lens wear

■ Noncycloplegic refractions between +5.00D and –9.00D (spherical) and less than 2.25D cylinder

■ Good ocular health.

"Kids between 8 and 12 years old are the ones who listen and usually do the best in my practice, where I fit kids almost exclusively all day."

Mary Lou French, OD, FAAO, MEd

Marjorie J. Rah, OD, PhD, FAAO: The patients were fitted with ACUVUE® ADVANCE™ (85% of patients) and ACUVUE® ADVANCE™ for Astigmatism (15% of patients) Brand Contact Lenses. We performed testing, application and removal training, and follow-up visits at 1 week, 1 month and 3 months. At each visit, patients completed a quality-of-life survey that was specific to their experiences with eyeglasses and contact lenses.

Dr. Walline: We timed all of the standardized protocols, including fitting, teaching application and removal, and follow-up visits. All patients had to be able to apply contact lenses themselves before they were permitted to take the lenses home.

KEY CLIP STUDY FINDINGS

Dr. Walline: We recorded impressive results.

■ Only three adverse events were reported, and all of them resolved completely.

Kids, Contact Lenses and Chair Time
Dr. Walline: The Contact Lenses in Pediatrics (CLIP) Study found that total chair time was an average of 130 minutes for 8- to 12-year-olds and 115 minutes for 13- to 17-year-olds. Most of the extra time spent on the younger group was devoted to application and removal training, which can be delegated to staff.
Dr. Rah: Chair time was longer in the study than it would typically be in clinical practice. The study's standardized protocol required time-consuming logMAR visual acuity testing and prolonged contact lens settling that a practitioner might not perform during every visit in a busy practice.
Dr. Walline: The median difference in chair time recorded for these two groups is only 5 minutes, not 15 minutes. A few outliers in the younger group required a lot of extra time.
Staff members typically handle the application-removal training in a separate room. Therefore, the idea that fitting children with contact lenses decreases productivity of the office was exposed as a myth.
Dr. French: In my practice, I don't think we spend even an extra 5 minutes on the younger age group. But you have to manage your time well to succeed. Once I've recommended a lens, my staff works with the patient and dispenses the diagnostic lenses.
When I'm ready to examine the lens fit, I test acuities and perform a slit lamp examination and a refraction. As I'm removing the lenses, I'm talking to the child and the parents about the lens modality I'm recommending and the lens care. This allows me to use my time more efficiently. My advice: Build a competent staff that understands contact lenses, and you won't add to chair time.

■ We found no obvious differences in ocular health between the two groups. Biomicroscopic evaluations showed increased signs of corneal and conjunctival staining as well as bulbar and limbal redness from baseline to 1 week to 1 month. But the signs decreased to below baseline by the 3-month visit, indicating normal adaptation to lens wear.

■ Fitting time was about 11 minutes more for children, but this was mostly due to outliers who required more than one visit to learn to apply the lenses. (See "Kids, Contact Lenses and Chair Time" above.)

■ After 3 months, 92% of children and 94% of teens continued to wear contact lenses.

■ Most of the subjects preferred contact lenses over spectacles.

ADDRESSING RISK: AGE VS. EYE HEALTH

Dr. Walline: These findings are significant because they encourage doctors to set aside their fears about kids and contact lenses, allowing them to offer a better variety of treatment options for young, active children.

Dr. Sindt: We know that contact lenses involve some risk. However, risk is determined by eye health and what patients do while wearing lenses, not age. Children are generally healthier, without eyelid disease. They tend to do very well in contact lenses because they aren't as susceptible to getting red eyes or dry eyes.

I always advise parents of the risks of wearing contact lenses. But I also emphasize that, with proper care, the risks are not any greater for children than for teens or adults. When I establish this fact, parents' interest really perks up.

"Data show that children are particularly susceptible to ultraviolet (UV) damage because they have large pupils and spend a lot of time outdoors."

Mile Brujic, OD

CHOOSING THE SAFEST MODALITY

Dr. Brujic: How do you choose the modality that you feel is safest for each individual child?

Dr. Rah: If a parent is concerned about lens care and compliance, I discuss daily disposable lenses, and the parents usually seem relieved. I start with this modality in most cases.

Dr. Sindt: I have the same experience, even though we don't have data to show daily disposables are safer. Parents like the convenience and the fact that their children won't be responsible for cleaning.

Dr. Walline: In one study2, we offered complimentary lenses and asked parents to choose 2-week lenses or 1-day disposables. Not surprisingly, 96% of them chose the 1-day disposable. When costs were explained to the parents, 63% said they would pay the extra cost for daily disposable contact lenses.

Dr. Sindt: Daily disposable power ranges are limited, compared to those of other modalities, so I talk to parents and children about the options available in their power range. As we all know, a –0.75D or a –1.00D lens can be more difficult to handle — less so in some brands than in others — so I may base my choice on whether or not I believe a child will be able to handle the lens.

Dr. French: I usually offer patients a 2-week lens, training them to discard their lenses on the 1st and the 15th of the month. For the higher prescriptions, I recommend a daily disposable. However, I find the cost difference is a factor, even though the 1-day offers convenience.

UV PROTECTION

Dr. Brujic: Here is another issue: Data show that children are particularly susceptible to ultraviolet (UV) damage because they have large pupils and spend a lot of time outdoors. What's more, they experience lifetime exposure to UV rays, which are becoming increasingly hazardous because of ongoing ozone depletion.3–6 How do you present UV information to parents?

Dr. Sindt: Choosing the contact lens that's best for my patient's overall ocular health is my responsibility. Therefore, I choose a lens based on power, the patient's needs, physical fit, corneal physiology and UV protection. I take time to explain the importance of UV protection to parents.

Dr. French: I, too, bring up the need for UV protection when discussing vision correction options, including the need for sunglasses.

CONSIDERING ALL FACTORS

Dr. Brujic: The consensus seems to be that we need to consider a variety of factors — ocular features, refraction and individual needs — before determining the best lenses for our young patients. CLS

REFERENCES
  1. Walline JJ, Jones LA, Rah MJ, et al. Contact Lenses in Pediatrics (CLIP) Study: Chair Time and Ocular Health. Optom Vis Sci. 2007;84:896–902.
  2. Walline JJ, Jones LA, Chitkara M, et al. The Adolescent and Child Health Initiative to Encourage Vision Empowerment (ACHIEVE) study design and baseline data. Optom Vis Sci. 2006;83:37–45.
  3. Winn B, Whitaker D, Elliott DB, Phillips NJ. Factors affecting light-adapted pupil size in normal human subject. Invest Ophthalmol Vis Sci. 1994;35:1132–1136.
  4. Weale RA. Age and the transmittance of the human crystalline lens. J Physiol. 1988;395:577–587.
  5. Gaillard ER, Zheng L, Merriam JC, Dillon J. Age-related changes in the absorption characteristics of the primate lens. Invest Ophthalmol Vis Sci. 2000;41:1454–1459.
  6. Young S, Sand J. Sun and the eye: prevention and detection of light-induced disease. Clin Dermatol. 1998;16:477–485.


Contact Lens Spectrum, Issue: April 2008