Fitting Children with Corneal Refractive Therapy
BY JEFFREY J. WALLINE, OD, PHD
Most eyecare practitioners have fit children with contact lenses, but few routinely present contact lenses as a primary treatment option for myopic children as young as eight years old. Myopia typically develops and progresses in children at this age, and those who develop myopia require visual correction throughout the day.
Children in this age group may frequently lose or break their eyeglasses or contact lenses during rough play on the playground, in the park or at home. However, as you might expect, children rarely admit to losing their contact lenses. They typically recite the proverbial "the dog ate my contact lenses" excuse.
CRT to the Rescue
This excuse is no longer necessary for children treated with overnight corneal refractive therapy (CRT) using Paragon CRT (Paragon Vision Sciences) contact lenses. While these children participate in sporting activities, recreation or school, the lenses are tucked safely away in their plastic cases at home.
CRT lenses are a relatively new modality of contact lens wear and parents should get involved in the fitting and dispensing process as well as CRT contact lens application, removal and care training. While parental involvement is necessary, make sure you caution parents to avoid getting overly involved. Conscientious parents will remind children to wear their contact lenses nightly and will make themselves available to answer questions, provide encouragement and put out fires, especially during the first two weeks of wear.
On the other hand, parents should not apply, remove or clean contact lenses for their children unless a child becomes exceedingly frustrated. Parents must also be tolerant. During the first two weeks, children wearing CRT lenses must adopt a new routine that requires extra time to apply contact lenses before bedtime and remove contact lenses before school. We all know what a challenge it can be to change a child's morning routine!
Starting a New Routine
During the first two weeks of a child's wear of CRT lenses, parents should awaken the child at least 20 minutes earlier than normal to give him sufficient time to remove and clean his contact lenses without additional stress caused by time constraints.
If possible, parents should also provide new contact lens-wearing children with their own private counter space and a compact mirror to allow them to use the mirror during contact lens application and removal without the hassles of brothers and sisters vying for bathroom time. Teasing from an older brother, pestering from an older sister or questions from a younger sibling can prove troublesome.
After two weeks of contact lens wear, I am always happy to hear a parent say something along the lines of, "I don't know how my child is doing when it comes to applying or removing contact lenses. I never see or hear anything about it." This is almost always a sign that the child is successfully applying and removing his contact lenses.
Learning the Ropes
Instructing children about care and handling of CRT contact lenses typically requires less than 45 minutes. Children are capable of independently wearing and caring for contact lenses.
We typically require children to apply and remove both of their contact lenses at least once before dispensing them. Allow one hour for the first dispensing visit. If a child has not applied and removed both lenses in that time, schedule another dispensing visit and do not dispense the contact lenses. After an hour, children and their parents (not to mention the instructor) are typically frustrated; a second visit will improve everyone's attitudes and ultimately decrease the overall time necessary for contact lens handling education. Before the second dispensing visit, give children some exercises to help them become comfortable with touching their eyes. When children return for the second visit, they are usually able to apply and remove the contact lenses in a short time.
If patients are not able to independently apply and remove the lenses after 30 minutes of concerted effort during the second visit, then you may place a drop of anesthetic into their eyes. Children should then be able to apply the lenses within the first four or five attempts. If a child can't, he may not be a good contact lens candidate at that time.
Children can apply CRT contact lenses in a manner similar to the way they would apply traditional gas permeable (GP) contact lenses. Instruct children to place the contact lens on the index finger of the dominant hand. They should use the other hand to hold the top lid open by pinning the eye lashes to the eyebrow. The middle finger of the dominant hand should gently pull down the margin of the bottom eyelid to the cheekbone. Instruct children to then apply the contact lenses while looking into a mirror placed on the counter, making sure they look with their opposite eye to ensure that the eyes point straight ahead.
Removal of CRT contact lenses is different from removing traditional GP contact lenses. The larger diameter of the CRT contact lenses can make it difficult to remove them from the eye by pulling the lateral canthus and blinking. Instruct children to instead use the two-handed method in which the nondominant hand holds the contact lens in place with the top lid and the dominant hand on the bottom lid pushes under the contact lens to dislodge it from the eye.
Caring for CRT Lenses
Patients should clean their CRT contact lenses upon removal -- not before application. It's like washing dishes: it's easier and more efficient to clean the dishes right after eating than to clean them the next time you are ready to use them. If you wait until the next morning, the food is dried on the plate and difficult to remove completely.
Instruct patients to rub the contact lenses with the "cup side up" for 10 seconds vertically across the palm of the hand and 10 seconds horizontally across the palm of the hand using a cleaning solution such as Unique pH (Alcon). As soon as the first contact lens is clean, patients should place it in the case with fresh solution and one drop of a liquid enzyme protein remover such as SupraClens (Alcon). Once the first lens is in the case to rest, patients should remove, clean and put the second one to rest. To avoid switching the contact lenses on the eyes, patients should never have their contact lenses out of both eyes and not in the case.
Looking Out for Complications
Complete your instruction by educating young CRT patients about symptoms that may portend serious visual consequences. Three symptoms are particularly important: red eyes, painful eyes and poor vision, even with optical correction. If any of these symptoms persist for an entire day, patients should discontinue lens wear and call the you for an examination.
Provide both children and parents with a guide to reinforce everything you told them in case they have any questions at home. The sheet we use also contains information for patients who have questions that are not answered in the guide.
All in the Family
We know that CRT successfully corrects children because many parents of our young CRT patients want to wear the lenses, too. Although we wonder why parents use their children as guinea pigs, we often fit entire families with CRT contact lenses. We believe that "a family that CRTs together stays together."
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 (COOKI).