KIDS AND CONTACT LENSES
Achieving Vision Correction…and More
Latest data show that contact lenses can boost kids' self-confidence in addition to improving their vision.
By Amber Gaume Giannoni, OD, FAAO, & Jeffrey J. Walline, OD, PhD
Dr. Giannoni is a clinical associate professor at the University of Houston College of Optometry. Contact her at (713) 743-1935 or firstname.lastname@example.org
Dr. Walline is an assistant professor at The Ohio State University College of Optometry, where he conducts studies of pediatric contact lens wear. He is also a consultant or advisor and has received research funds from Paragon and Vistakon.
In a series of rigorous clinical trials over the past several years, we have been investigating the feasibility, risks, and benefits of contact lens wear in children. There is now a significant body of research showing that children benefit from lenses in a number of ways, just as teenagers and adults do. (Additional references are available on the references page at www.clspectrum.com/references.asp) Based on the data we and our co-investigators have collected, we believe that practitioners should present contact lenses as an option earlier than many have in the past.
The most recent data we have reported is from the Adolescent and Child Health Initiative to Encourage Vision Empowerment (ACHIEVE) study, which builds on earlier research by looking at whether contact lenses affect how children feel about themselves. Nearly 500 ethnically diverse 8- to 11-year olds were randomized to either contact lenses (n=247) or spectacles (n=237) and followed for three years. All subjects had been wearing glasses for correction of myopia prior to enrollment in the study.
The children were tested with the Self Perception Profile for Children, a validated scale for understanding self-esteem and self-concept. In the field of psychology, it is considered the gold standard instrument for these measures. We found that children in the contact lens group felt significantly better about themselves compared to spectacle wearers in three specific areas: athletic competence, social acceptance, and physical appearance.
This doesn't mean that children actually performed better after they began wearing contact lenses; rather, it means they felt more competent and confident about their performance in those areas.
But perception often becomes reality, says Mitchell J. Prinstein, PhD, professor and director of clinical psychology at the University of North Carolina at Chapel Hill and an investigator in the ACHIEVE trial.
“Children's sense of self-concept can alter their whole course of development,” he says. “Kids who feel more confident about sports or social activities are more likely to engage in those experiences, which further builds their skills and makes them more open to similar experiences in the future.”
By contrast, he says, “Kids who perceive themselves as unattractive or not socially accepted by their peers tend to be at higher risk for depression, disordered eating behaviors, and other negative adjustment outcomes.”
Psychologists have long known that changing children's self-perceptions is difficult, even with therapies that specifically target such changes. “So it is pretty exciting to learn that a relatively simple change, such as contact lens wear, can have such a positive effect on self-perception,” Dr. Prinstein says. “Until now, we haven't really thought about vision correction as an important variable in children's self-concept.”
For many eyecare practitioners and parents, the connection between vision correction and self-esteem is an intuitive one.
“Early in my career, I realized that pediatric fitting isn't just about vision and eye health—it's about the whole child,” says Christopher H. Cooper, OD, a private practitioner in Memphis, Tenn. A mom in his practice recently asked to have her 5-year-old fitted with contact lenses. The little girl was very active, and, most importantly, the mother remembered being ridiculed herself as an awkward young girl with thick glasses—and she didn't want her daughter to go through the same experience.
“There is a reason we have the phrase, ‘myopic personality,’” says Andrea P. Thau, OD, FAAO, FCOVD, a SUNY College of Optometry associate clinical professor and private practitioner in New York City. “I can't count the number of times I've seen a formerly shy, withdrawn child come in with a huge smile on his face at the first follow-up exam. Their perception of the world changes completely when you remove the physical barrier of glasses,” she says.
In the ACHIEVE study, we saw gains in athletic, social, and appearance self-perceptions with contact lens wear regardless of whether children liked wearing glasses at the outset of the study or not. But those children who initially disliked spectacles also made gains in their own perceptions of academic performance over the three-year study.
Those children who most disliked wearing glasses may have removed them more frequently in class, affecting their ability to see the chalkboard or the teacher. With a form of vision correction that they didn't want to remove, the children became more confident about their schoolwork.
Another interesting finding was the contact lens modality that parents overwhelmingly chose for their children. When given the choice between a two-week disposable hydrogel lens (Acuvue 2, Vistakon) and a daily disposable lens (1-Day Acuvue, Vistakon), nearly everyone (93 percent) opted for the single-use lenses. Of course, cost was not a factor because the lenses, lens solution, and spectacles were all provided free of charge to the study participants.
However, when the actual costs were explained, more than six in 10 said they would still choose the single-use lenses. This is an indication that daily disposable contact lenses are probably underutilized in typical practice. Doctors' assumptions that this modality is too expensive for their patients may simply not be accurate.
Very importantly, there were no differences in either ocular health or the rate of myopic progression between the spectacle and contact lens groups over the course of this study.
The Right Fit
Among children, the best candidates for contact lenses are those who desire to wear them and are mature enough to take care of them. Parents are typically most concerned about whether their children can keep the contact lenses clean, so reasonably good hygiene practices are also important.
“Eight or 10 year olds are actually much more compliant than teenagers are,” points out Dr. Cooper. “I think by initiating contact lens wear at a young age, we can instill good eyecare habits early and build a lifetime of compliance.”
Mary Lou French, OD, FAAO, MEd, a private practitioner in Orland Park, Ill., finds that kids who are very active in sports and/or need an astigmatic correction are particularly appreciative of the opportunity to try contact lenses. “The greatest myopic change occurs between the ages of 8 and 12, so this is an ideal time to get kids in a vision correction method they are comfortable with,” she says.
“The ACHIEVE study findings really validate my experience over 32 years in clinical practice,” continues Dr. French, “I think practitioners who are used to fitting teenagers will quickly become more confident about fitting pre-teens as they start to hear the feedback from children and their parents.”
One of those parents, Sheli Thoss, recently brought her 12-year-old daughter to Dr. French, who fit her with contact lenses. “I was probably most concerned about the cost initially,” she says. “But contact lenses turned out to be less expensive than I thought.” She was also surprised at how easy it is to care for modern lenses, because she remembers her friends dealing with “cookers” and multiple bottles of solutions.
“My daughter spends at least 10 hours a week in dance classes and performances, so she is constantly in front of mirrors. I think she is really pleased with her appearance in contact lenses, and I know she likes the peripheral vision and not having glasses sliding around on her face,” says Ms. Thoss.
In their household, the two-week wearing schedule gets marked on the family calendar just like dance recitals and the dog's medications. But for patients who find it harder to remember when to open fresh contact lenses, a service such as Acuminder (www.acuminder.com), which offers free reminders via e-mail, text messaging, desktop widget, or Face-book, can be helpful.
The Business Benefits
The conventional wisdom about pediatric contact lens fitting is that it is too time-consuming, but some practitioners believe that younger patients are actually among their least challenging (See “Tips for Pediatric Lens Fitting,” below). The Contact Lenses in Pediatrics (CLIP) study proved that the only additional chair time involved in fitting 8- to 12-year olds is a few extra minutes in application and removal training, which staff typically handles.
|Tips for Success with Pediatric Lens Fitting|
|• Be sure the child wants contact lenses, not just the parents.|
• Hire staff members who enjoy and are good at working with children.
• Consider prescribing single-use lenses, especially when parents have concerns about compliance or cleaning.
• Don't rush kids through application and removal training. Schedule the training at a time when the staff has time to work with them.
• Teach the kids application and removal without coaching or assistance from their parents. Children must be able to remove lenses independently before leaving the office.
• Consider training two or more children at once, so they can learn with their peers.
• Schedule the first follow-up visit within two weeks.
• See pediatric patients more frequently to reinforce good wearing habits and to check for progressing myopia.
• Require that children have a back-up pair of spectacles.
• Don't use age as a criterion for fitting children with contact lenses.
Moreover, argues Dr. French, there is much less chair time involved in finding a comfortable lens. “Children don't suffer from dry eye; they don't drop out due to discomfort or presbyopia; they don't abuse their lenses like college students and young adults often do; and they reliably return every year. In many ways, they are the ideal patients,” she says.
Over time, all of those repeat visits can add up to additional revenue for the practice. Most practitioners who fit lots of children insist on back-up spectacles, and kids need to replace those often either because of damage or vision changes. “It is so critical for them to have glasses in case they run out of contact lenses or get an eye infection,” says Dr. French. “We offer families a ‘value pack’ to make sure they purchase both.”
In addition, as the ACHIEVE study suggests, parents are more likely to invest in higher-cost lenses if they perceive a health benefit for their children from those lenses.
Dr. French plants the seed about contact lenses early, so that families know that they will have that option in the future. Not infrequently, this opens the door to educating parents about changes in contact lens technology, and may lead to a contact lens trial for others in the family.
“It's always a good practice-building strategy to increase awareness about the importance of good vision and vision correction options for children,” agrees Dr. Thau. She almost always fits children with spectacles first. “When kids go into vision correction for the first time, it can have a profound impact on how their eyes work together as a team. I like to see them back after six weeks for a follow-up visit and that is usually when I first mention contact lenses.”
There is no question, she says, that pediatric contact lens fitting has brought financial gains for her practice. “When you do a good job with adult patients, you're lucky if they refer one or two patients to you,” she explains. “But when I do a good job with a child, it's not unusual to get 10, 20, or even 50 referrals from that one patient. The next day at school, everyone wants to know, ‘Where are your glasses?’ The other kids at school go home and tell their parents and the phone starts ringing. Pretty soon, the parents have shared the details with everyone they know at soccer practice, ballet class, and the weekend birthday party. They educate each other,” she says.
And the emotional payoff for the practitioner may be even greater. “Contact lenses give children the tools to feel better about themselves socially, to do better in school, perhaps to improve their performance in sports,” says Dr. Thau. “You can change their life forever, in a way that rarely happens with adults.”
No one should take the CLIP and ACHIEVE study results to mean that every child who needs vision correction should automatically be fit with contact lenses—or that contact lenses will turn around every child's self-esteem.
But what these studies do tell us is that children of all ages derive significant visual, quality-of-life, and self-esteem benefits from contact lens wear and should be given the opportunity to wear contact lenses when appropriate.
There is no magic age for initiating contact lens wear. A child's maturity, motivation, and hygiene, along with parental support, are much better indicators of readiness for contact lens wear than any arbitrary age is. CLS
For references, please visit www.clspectrum.com/references.asp and click on document #170.
The authors served as co-investigators on both the CLIP and ACHIEVE studies, which were sponsored by Vistakon, Division of Johnson & Johnson Vision Care, Inc.