PEDIATRIC CL PRACTICES
Pediatric-Focused Contact Lens Practices
Considerations in developing a pediatric contact lens specialty.
By Kassaundra Barlow, OD, & Amber Gaume Giannoni, OD, FAAO
Dr. Barlow is a clinical assistant professor at the University of Houston College of Optometry and is credentialed at TIRR Memorial Hermann Hospital. Her interests include pediatric and special needs populations as well as brain injury vision assessment and rehabilitation.
Dr. Gaume Giannoni is a clinical associate professor at the University of Houston College of Optometry and is the director of the Dry Eye Center at the University Eye Institute. She also sees patients in a private practice setting and has received authorship honoraria from Bausch + Lomb.
Technology is expanding to younger populations every year. A study performed in 2010 found that 69 percent of 11- to 14-year-olds and 31 percent of 8- to 10-year-olds have their own cell phones (Davis, 2012).
Many eyecare professionals are not following this trend of offering contact lenses to younger patients, despite evidence that they are safe and can help expand this niche within their practices. Several studies have demonstrated that children as young as 8 years old can successfully wear a variety of contact lens modalities and be mature enough to independently take care of their lenses without parental intervention (Walline et al, 2006).
These same studies also found no significant long-term consequences for patients fit as children compared to those fit as teenagers (Walline et al, 2013). Additionally, fitting some children at an earlier age can provide specific benefits, a topic which will be discussed later. With all of this published information, why aren’t more of us fitting our pediatric patients in contact lenses? Currently, only 3 percent of new contact lens fits in the United States are on kids ages 6 to 12 years (Efron et al, 2011).
Where Do I Start?
Many children require vision correction at an early age. For example, the need for myopic refractive error correction occurs in approximately 16 percent of school-aged children (Kleinstein et al, 2012). Moderate hyperopic and astigmatic refractive error tends to occur even earlier; however, these children may not be symptomatic until age 6 or 7, when visual demands increase (Walline et al, 2007). While contact lenses are not suitable for every child, the need for vision correction, at a minimum, represents an opportunity for us to consider them. Additionally, overnight corneal reshaping lenses are another management option for myopic children. With research suggesting that orthokeratology may slow natural myopia progression, we may see a rise in their use among practitioners.
Most patients choose contact lenses for elective reasons; however as practitioners seeing children, we must remember the potential vision benefits associated with correcting certain refractive errors with a contact lens. In high myopia, for example, spectacles increase image minification. A simple switch to contact lenses could actually improve acuity (Efron et al, 2011). In cases of significant anisometropia, which occurs in approximately 3 percent of children, image sizes differ between the two eyes, and this disparity will be greater in spectacles (Tong et al, 2006). Contact lenses are a great first option in these cases. By making the image sizes more equal, children have a better opportunity for improved vision, stereopsis, and binocularity. Contact lenses can also be utilized as a partial prescription to decrease the weight of spectacles and to improve visual function and cosmesis.
A great example of those who might benefit from such a combination are accommodative esotropes. These patients typically have high hyperopic refractive error and may need additional plus at near to maintain ocular alignment. Contact lenses can be prescribed to correct the majority of a patient’s distance vision, while the remaining prescription, including near add, can be placed into spectacles. A similar system can be employed for aphakic children, as they are dependent on optimal refractive correction at all distances (Figure 1).
In addition, children who are fitted with heavy-framed glasses to address both high sphere and high astigmatism, or those who may be experiencing poor cosmetic appearance related to magnification/minification effects that these lenses cause, are often noncompliant spectacle wearers. These children may benefit from being fit into spherical contact lenses and astigmatic spectacles over the contact lenses. The glasses over the contact lenses would be cosmetically appealing, and their vision would not be compromised due to the potential rotational instability of toric contact lenses. When considering such combinations, it is important to thoroughly discuss the importance of wearing both optical devices. Obviously, if such children wear contact lenses only, they will be at a visual disadvantage.
Figure 1a. Our 7-year-old patient wearing +16.50D round-seg bifocal aphakic spectacles. Her mom stated that she was shy and typically avoided eye contact. The patient complained that her glasses were heavy and would slip down her nose.
Figure 1b. Our patient wearing spherical contact lenses with bifocal spectacles. Her mom said that she instantly became more outgoing and requests to wear this combination every day. The patient liked the ability to choose a more “stylish” frame.
As mentioned before, several studies have shown that children and adolescents can be successful soft, GP, and orthokeratology lens wearers. Children’s eyes are basically the size of adults’ by the time they are 2 years of age, so the fitting process should be comparable to that of your older patient base.
As practitioners, we have many options at our disposal; however, the choices can be overwhelming if you are new to fitting this age group. Table 1 shows several of the pros and cons to consider when getting started. For example, the small diameter of a GP lens might be beneficial for patients who have narrow palpebral fissures. Also, in younger patients, or those who have reduced dexterity, GP lenses can be easier to handle because of their stiffer material. Making the process easier will decrease the number of application and removal attempts, which could potentially reduce the risk of infection because of decreased contact time with children’s fingers.
Aside from the universal attributes of these different lens modalities, it is also important to consider the needs and goals of children. Kids who plan to wear their contact lenses on a daily basis will be great candidates for either GP or soft lenses, while those planning on occasional wear will have a more difficult time adapting to the sensation and comfort of corneal GP lenses. When considering the ocular surface, children who have corneal irregularity can benefit visually from GP lenses due to the creation of a smooth refracting surface between the posterior contact lens and the cornea (i.e., tear layer).
Children who participate in dusty outdoor activities should be fit in soft contact lenses if possible to decrease discomfort and risk for corneal abrasion resulting from debris getting trapped under the lens. Additionally, the ability to control the replacement schedule with soft lenses allows you to further tailor your care to the needs of children and their families. We tend to recommend a more frequent replacement schedule for younger children; daily disposable lenses, in particular, allow for the elimination of cleaning solutions altogether as well as the application of fresh, uncontaminated lenses each day.
Of course, it is of utmost importance to educate both parents and their children to never reuse daily disposable lenses. For this reason, some practitioners refuse to dispense or recommend a care solution when prescribing within this specific category. Alternatively, if a parent or sibling wears a two-week or monthly lens modality, it may actually improve compliance to match the parent’s or sibling’s schedule.
Regardless of the specific lens modality, providing proper education on lens care to both parents and children is imperative. Even if parents wear contact lenses, poor habits are often developed over the years, and this can be a great opportunity for re-education. We recommend that children and adolescents use multipurpose solutions because they are easier to understand and do not pose a risk for ocular surface insult if used improperly.
Patients of any age can fall victim to reduced self-confidence and quality of life from wearing spectacles. Although spectacle wear can be associated with positive perceptions of intelligence, honesty, dependability, and diligence, negative qualities such as introversion, anxiety, and being less attractive are also common (Harris, 1991). Children and adolescents are the most susceptible to altered self-perception, and in these crucial younger years, all primary care providers must consider the whole person. What might be perceived as a simple glasses prescription to adults could actually be a life-changing negative event to teenagers. The Adolescent and Child Health Initiative to Encourage Vision Empowerment (ACHIEVE) study found a statistical difference in the self-perception of children who wore contact lenses versus spectacles, specifically in areas of appearance, athletic competence, and social interaction (Rah et al, 2010). It is worth noting that children didn’t necessarily perform better in these areas, but they perceived that they did. Improved selfperception has the potential to affect self-esteem and confidence, which is crucial for our younger patients as they navigate various social and academic ladders.
Although many of us don’t like to discuss costs, contact lens-related expenses need to be part of the conversation when determining lens types for children, as this is often a considerable factor for parents. A post-study survey from the Contact Lenses In Pediatrics (CLIP) study found cost to be the most common reason for contact lens dropout (Jones et al, 2009). Spherical lenses are typically the least expensive to fit, and patients who have low astigmatism may perform acceptably with spherical equivalent powers. It is important to remember, however, that the visual system in young children is still developing, and precise vision correction is vital for this age group. Spherical GP lenses are generally less expensive compared to a year’s supply of soft lenses; however, if lens loss or damage occurs frequently, replacement costs can quickly add up. For new GP wearers, some practitioners offer a warranty program that provides replacement lenses for a reduced fee during the first year. If soft lenses are worn, silicone hydrogel lenses are generally more expensive than hydrogels are, and lens costs tend to increase proportionally with the frequency of U.S. Food and Drug Administration-recommended disposal.
|Pros and Cons of GP and Soft Contact Lenses|
|GP CONTACT LENSES||SOFT CONTACT LENSES|
Easy to handle
Increased oxygen/does not cover limbus
Corrects irregular astigmatism
Good initial comfort
Often can dispense on same day as fitting
Multiple back-up pairs
Variety of replacement schedules
“No care” option with daily disposables
Greater initial discomfort
Uncomfortable in dusty environments
Rarely have spare pair
No frequent replacement option
Unable to dispense on same day as fitting
Potentially less oxygen/covers limbus
Can be challenging to handle initially
Do not correct irregular astigmatism
Potential for rotational instability with toric designs
Set Your Practice Apart
Although most contact lens fits in children are elective, there will be cases that are medically necessary. Practitioners can set themselves apart from others by being willing to fit these special cases. Judging from personal experience, once you have achieved a successful fit on a complex eye, that individual will be one of your most dependable and reliable patients. For example, visual impairment in children is frequently caused by infantile cataracts (Lindsay et al, 2010), and kids who have aphakia secondary to congenital cataract extraction are at an extremely high risk for developing deprivation amblyopia. Contact lenses are the treatment option of choice for several reasons. A constant clear image is critical in this situation to allow for optimal visual pathway development. Aphakic spectacles are heavy, cosmetically unappealing, and can easily be removed, unlike contact lenses. Contact lenses also often provide improved image quality because children will always be looking through their optical centers. It is important to educate parents that changes to corneal diameter, curvature, and refractive error will occur rapidly over the first year, requiring frequent visits.
|Tips For Developing a Successful Pediatric Contact Lens Practice|
1 Place pamphlets or research papers in your waiting room to inform parents about the possibility of children wearing contact lenses.
2 Provide verbal and written information on contact lens care. Consider adding a “Kids Corner” to your office website.
3 Utilize technology to demonstrate proper lens care and reduce staff time (i.e., LUMA Contacts [Eyemaginations]). This will appeal to kids and demonstrates to parents that your practice is state-of-the-art.
4 Consider having children and parents sign a lens care contract to demonstrate the importance of adhering to your recommendations and to reinforce that lens wear is a privilege that they have to earn each year.
5 Find staff members who love to work with children. If staff members dislike kids, it will show in their performance.
6 See younger patients every six months, and consider having them take a lens care quiz. This will reinforce compliance and identify areas in which they need re-education.
7 Require the purchase of back-up spectacles to reduce wear time and for instances when a child must temporarily discontinue contact lens wear.
We occasionally see children who have aniridia, albinism, or who have abnormal iris or corneal structure secondary to injury or infection. These patients are great candidates for prosthetic lenses to decrease photophobia and address cosmesis, which ultimately has the potential to improve visual function and selfconfidence. Depending on the severity of the condition, patients may benefit from modalities ranging from simple opaque frequent replacement lenses to custom hand-painted lenses. Custom prosthetic lenses can be ordered with either clear or opaque pupils if vision is noncontributory in the affected eye. Prosthetic fits are often covered by medical insurance; however, prior approval is usually required.
Patients who have nystagmus can usually find a position at which eye movement is at its lowest frequency and amplitude (null point). Visual acuity in children who have moderate-to-high refractive error may be greatly reduced in spectacles if their nystagmus is dampened in any position other than primary gaze because of distortion and prismatic effects produced by off-axis viewing. Contact lenses will allow children to constantly look through the optical center of their correction in any head or eye position, maintaining optimal potential acuity.
Contact lenses for patients who have amblyopia offer another option for occlusion therapy when children are noncompliant with other methods. Contact lenses can be over-plussed to cause blur in a child’s better-seeing eye, or alternatively opaque pupils can be used to serve the same purpose as patches. In either case, contact lenses would be more difficult for children to remove and therefore could help increase compliance.
As previously mentioned, overnight orthokeratology is a potential treatment option for children, whether to provide an alternative mode of correction or in an attempt to retard natural myopia progression. Regardless of the reason, these lenses are as safe as other overnight modalities (Stapleton et al, 2008) as well as safe for children (Walline et al, 2004). In terms of slowing down myopia progression, it has been hypothesized that corneal reshaping lenses cause peripheral myopic defocus, which dampens the signal for the eye to elongate (Walline et al, 2009). Recent studies have demonstrated an average of 0.50D to 0.75D reduction in myopia over a two-year time span (Walline et al, 2009). Fitting patients in corneal reshaping lenses would not only expand your options for correcting myopic refractive error, it is yet another way to set your practice apart.
What Is the Risk?
What is the risk/benefit balance in fitting younger children with contact lenses compared to fitting adolescents, the age at which most individuals feel relatively comfortable? Many practitioners believe it will take more chair time and will increase liability. The CLIP study looked at the amount of chair time used when fitting soft contact lenses on 8- to 12-year-olds compared to 13- to 17-year-olds. Researchers concluded that there was only a 15-minute increase in total chair time among the younger group, and that difference was largely spent on application and removal training (Walline et al, 2007). It is important to note that most offices utilize staff members for this task, so practitioners would not likely spend any extra time fitting a patient in either age group. Additionally, the CLIP and ACHIEVE studies did not find any increase in adverse contact lens-related events in younger patients; therefore, the notion of increased liability is an unproven concern (Walline et al, 2007).
Fitting children in contact lenses can be extremely rewarding for you, your office staff, and most certainly for your patients. Most children and adolescents seeking contact lenses do so as a cosmetic option; however, some benefit from the potential for improved selfperception, visual acuity, binocularity, and stereopsis.
Despite these facts, many practitioners nevertheless refuse to fit young patients in contact lenses for a variety of reasons. However, by opting to develop a pediatric contact lens practice, word-of-mouth referrals will quickly occur. Children who play on sports teams are some of our biggest referral sources.
Although the need for specialty contact lenses in this age group is not as common, the ability to take on these challenges is a great way to set yourself apart and meet the needs of any patient who walks in your door, regardless of age. So the next time your 8-year-old patients present for their 10th frame adjustment in three months and you discover that they have better phones than you do, as their cutting-edge eyecare provider, it might just be time to share your advanced knowledge of contact lenses with them. CLS
For references, please visit www.clspectrum.com/references.asp and click on document #216.