pediatric and teen cl care

Determine a Patient's Needs Before Choosing a Lens Design

BY MARJORIE J. RAH, OD, PHD, & JEFFREY J. WALLINE, OD, PHD

Our patient was an 11-year-old boy who was first examined in the Cornea service for progressive worsening of his vision. Family medical history revealed that his mother had unilateral keratoconus and that his maternal grandfather also likely had the condition. The patient had no history of atopy, but recently started to rub his eyes. Following evaluation including corneal topography, he was diagnosed with keratoconus greater in the right eye and was referred for contact lens evaluation.

The Initial Lens Fit

Manifest refraction of –0.25 –0.50 × 020 and –0.50 –2.00 × 130 resulted in visual acuity of 20/40 and 20/20-2 in the right and left eyes, respectively. We fitted GP lenses and asked the patient to return for a dispensing visit. Visual acuities with the GP lenses at the dispensing visit were 20/30 in the right eye and 20/30+1 in the left eye, likely due to excessive tearing with no improvement noted on over-refraction. However, the fit was adequate. Following a training session, we prescribed an initial wearing schedule and asked the patient to return for a follow-up visit two weeks later.

When the patient returned for the follow-up visit, he reported that comfort with the lenses had improved and he was adapting well. Over-refraction with the contact lenses resulted in 20/20 vision in each eye. We ordered and dispensed new lenses. The fit of the new lenses was adequate with alignment over the apex, good edge clearance, and good centration and movement of the lens in each eye. Visual acuity was 20/20 in each eye with no improvement on over-refraction.

Fit and Vision Aren't Everything

When the patient returned for follow-up approximately one month later, he reported that both vision and comfort were good with his GP lenses, but that he had not been wearing them much. While in gym class, a contact lens had fallen out during a particularly physical game of soccer. The patient became concerned that this would happen frequently because he is very active in sports and other outdoor activities. Due to his high level of concern, he was wearing the lenses only occasionally, when he was sure that he would not lose them.

After discussing additional options for vision correction, we refit the patient into hybrid contact lenses. We again achieved an acceptable fit with 20/20 vision in each eye, but the patient felt more comfortable with the stability of the hybrid lenses on the eyes. He was more confident that he would be able to enjoy his normal activities without worrying about losing the contact lenses.

Choosing the Right Lens

Once we determine that a child is a good contact lens candidate, it is important to determine which lens to fit. Asking about extracurricular activities, goals of lens wear, and when and how each patient plans to use contact lenses is an important aspect of the contact lens exam. Many children are involved in extracurricular activities that can be physical in nature, involve dusty environments, or have other special circumstances. Knowing this history helps guide you in selecting an appropriate lens modality for each patient.

A GP contact lens was indicated for our patient, but the medical history combined with his social activities made a hybrid contact lens the most optimal choice. This case illustrates the importance of communicating with young patients to determine which lens best fits their individual needs. CLS

Dr. Rah is a staff optometrist at the Massachusetts Eye and Ear Infirmary Contact Lens Service, where she specializes in medically necessary and other advanced contact lens designs. 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.