Continuing Education

Fitting Kids With Contact Lenses

Considering adding kids to your contact lens practice? This article can help prepare you for what to expect and what to do.

By PAULINE CHO, PHD, FAAO, FBCLA, & SIN WAN CHEUNG, MPHIL, FAAO

For children under the age of 13 years old, the question is, "To fit or not to fit contact lenses?" Traditionally, practitioners would play it safe and say 'no' to contact lenses for kids. But advanced technology, globalization, and rapid expansion of communications and telecommunications have improved the quality of life, and the lifestyles of both adults and children have changed.

Surely, the time has come for us to review our scope of practice with respect to the ever-changing society that we live in and to explore the potential for expansion. This is not to say that we should abandon traditional wisdom in contact lens fitting, but rather that we update our scope of fitting in light of technological advancements and improved quality of life.

The answer to the question, 'To fit or not to fit kids?' is not a simple 'yes' or 'no' because it is patient- and practitioner-dependent. Our goal in this article is not to provide a convincing or compelling argument for or against fitting kids with contact lenses. Our purpose is to present information from research reports and from clinical experience to help you decide for yourselves whether you want to include kids in your contact lens practice.

Research Findings

Clinical research is essential to providing evidence-based clinical care, but it's important to remember that subjects who participate in clinical studies may not behave in the same way as patients who pay for their contact lens services. The former are aware that they are taking part in a study, and this may influence their behavior, usually making them more compliant (Hawthorne effect).

In a research study the researchers pose a question and then design and implement a protocol to answer the question. Many of the major questions that practitioners have about whether to fit contact lenses to children are similar to those that researchers have posed and answered. Following are some of these questions paraphrased and a brief overview of the studies and their results.

Are children more challenging or burdensome to fit with contact lenses compared to teenagers? (Walline et al, 2007a) The Contact Lenses in Pediatrics (CLIP) Study compared contact lens fitting and follow up between a group of 84 8- to 12-year-old children and a group of 85 13- to 17-year-old teen-agers. Fitting, lens handling and care, and follow-up care were the same for both groups. Corneal and conjunctival reactions were low and the same for each group after three months. It took a mean of about 12 minutes longer to train the children in lens handling and care, but this was done by ancillary personnel. The practitioners' chair time was approximately the same for each group. The study's conclusion was that because neither group experienced significant problems, practitioners should consider prescribing contact lenses for children as young as 8 years old for correction of ordinary refractive errors.

Do corneal reshaping contact lenses slow myopia progression in children? (Cho et al, 2005; Walline et al, 2009) Anecdotal evidence suggests that they may. Another question is whether corneal reshaping lenses slow eye growth/elongation. If so, this would confirm the slowing of myopia progression.

The Longitudinal Orthokeratology Research in Children (LORIC) study addressed this question. Thirty-five children 7-to-12 years old underwent overnight ortho-k and were compared with 35 children who wore single vision spectacles. Researchers compared the changes of axial length (AL) and VCD between the two groups. At the end of 24 months, the increases in AL were 0.29mm ±0.27mm for the ortho-k subjects and 0.54mm ±0.27mm for the control group. VCD increased 0.23mm ±0.25mm and 0.48mm ±0.26mm for the ortho-k and control groups, respectively. The researchers concluded that ortho-k can have both a corrective and preventive control effect in childhood myopia. However, there are substantial variations in changes in eye length among children and there is no way to predict the effect for individual subjects.

The Corneal Reshaping and Yearly Observation of Nearsightedness (CRAYON) study, of which an update recently published, indicates that corneal reshaping lenses do slow eye growth/elongation. Forty subjects 8-to-11 years old with −0.75D to −4.00D of myopia and less than −1.00D of astigmatism were fitted with corneal reshaping contact lenses and 28 completed the two-year study. They were age-matched to soft contact lens wearers from another study.

Researchers performed A-scan ultrasound at baseline and annually for two years. Refractive error and axial length were similar at baseline between the two groups. The corneal reshaping group had a significantly smaller annual rate of change of 0.16mm versus 0.30mm for the soft lens wearers as well as a similarly smaller vitreous chamber depth (VCD) mean annual change of about 0.13mm versus about 0.23mm for the soft lens wearers.

Although there were a number of limitations to the study as described by the authors, it does present noteworthy data.

Do soft contact lenses increase the progression of myopia in children? (Walline et al, 2008a) Practitioners have reported on "myopic creep" for many years. But is this a true myopia increase or only a change of corneal transparency, which is often transitory?

To investigate this, about half of 484 8- to 11-year-old children were assigned to wear spectacles for three years and the other half wore soft contact lenses. The researchers measured refractive error, corneal curvature, and AL on an annual basis. In the contact lens wearers, myopia progression was 0.06D per year greater than for the spectacle wearers or 0.18D over three years, which is not clinically or statistically significant. There was no difference between the two groups for AL or steepest corneal curvature; that is, there was no difference in true myopia progression between the two groups.

How do children feel about other children who wear eyeglasses? (Walline et al, 2008b) The Children's Attitudes about Kids in Eyeglasses (CAKE) study explored this by having 80 6-to-10 year olds compare a series of 24 pairs of pictures of other children, some of whom wore eyeglasses and some of whom did not. Researchers asked questions about the children in the pictures. In general, the subjects felt that the pictured children who wore spectacles appeared to be smarter and more honest.

Do contact lenses significantly improve the quality of life for children and teens? (Walline et al, 2007b) The CLIP study used the Pediatric Refractive Error Profile (PREP), which is a pediatric quality of life survey that was completed by 169 subjects while wearing eyeglasses and again following silicone hydrogel lens wear for one week, one month, and three months. The overall PREP score increased about 15 points for both children and teens when wearing the lenses. The study concluded that contact lenses significantly improved the subjects' quality of life, their feelings about their appearance, and their participation in activities.

Patient Selection

With the recent research indicating that some children can successfully wear contact lenses, the next step is to decide whether to incorporate fitting children into your practice and how to get started.

At what age can kids be fitted with contact lenses? Aside from cases in which contact lenses are a visual necessity, many practitioners prefer not to fit contact lenses to correct ordinary refractive errors before age 13. We would venture to suggest that if contact lens wear is indicated, parental support is confirmed, and necessary precautions and care will be taken, there is no minimum age. After all, vigilant practitioners have successfully fitted babies for many years in aphakic cases.

Some practitioners are concerned about maturity related to handling contact lenses. As we mentioned before, Walline et al (2007a) have shown that kids aged 8-to-11 years can handle soft lenses as well as teens aged 13-to-17 years. Our experience shows that about 75 percent of children can apply and remove ortho-k lenses by themselves; the rest may need some assistance from their parents. For daily wear contact lenses, kids must be able to apply and remove lenses themselves as they may need to remove the lenses when they are at school or when their parents are not around.

In the case of ortho-k, parents may apply and remove the contact lenses for the kids as the lenses are only worn at night at home. In most cases, the parents take care of ortho-k lenses as they are relatively more expensive and require good care. Parents are also more concerned about the cleanliness of contact lenses that are worn overnight. Children can of course learn to do the cleaning and disinfecting procedures if they are mature and responsible enough to take care of their own lenses, but even so they should do it under parental supervision. With daily wear contact lenses, daily disposables would eliminate the need for care procedures.

As in adults, motivation is the key factor in successful contact lens wear for children. Although children are likely to feel good with glasses-free vision, peer influence may not be as important among children as it is for teens. The major reasons for discontinuation of lens wear are reported to be price of contact lenses in teens and preference for glasses in kids (Jones et al, 2007).

Motivation for kids to wear contact lenses and for parents to seek contact lenses for their kids varies among different cultures. For example, in the Chinese community where myopia is prevalent, contact lens wear in kids for normal vision correction is not common. However, in recent years an increasing number of kids have been fitted with specially designed contact lenses — such as ortho-k lenses — for myopia control, as parents are worried about myopia progression (Cho et al, 2002; Cho et al, 2003). Today's multicultural societies will include patients with a wide variety of backgrounds and practices. So, as practitioners, we must not fail to adapt to our patient population.

Safe lens wear requires careful monitoring of lens fitting and ocular response. However, young children may not be able to follow instructions properly during tests. These include eyelid eversion during slit lamp examination, air-puff non-contact tonometry, and application of diagnostic eyedrops. Poor fixation may also affect photo documentation in biomicroscopy and the accuracy of corneal topography. Consultations may therefore take more time or more visits with young patients. Do not fit and dispense lenses to children until you have examined them properly.

As with adult patients, it is important to build rapport with children and their parents. It is important to explain the procedures properly and in detail. For example, some kids are very averse to people touching their eyes or instilling dye/drugs into their eyes. Such kids should not be fitted until they are comfortable with you examining their eyes as necessary, as it can be a very traumatic experience for some kids.

Indications and Contraindications

In addition to general indications and contraindications for contact lenses that apply to all ages, a few factors need special attention in young patients. Children generally have better ocular health than adults do. They have better skin (e.g. eyelids and conjunctiva), less conjunctival redness, and clearer corneas, but corneal staining, follicles, and papillae are not uncommon. Trichiasis is one of the main causes of corneal staining in Chinese kids, and epiblepharon is a common cause. While these children are contraindicated for orthok lenses, daily disposable lenses may be an option for them as bandage lenses. Other conditions associated with corneal staining include incomplete blinking and allergic rhinitis. The presence of follicles and papillae may be related to extrinsic factors such as air pollution or intrinsic factors such as systemic allergic responses. The exact causes are unclear; however, contact lenses and lens care solutions may trigger further reactions.

Today, allergies such as eczema, asthma, and rhinitis are more common in kids than in adults. In mild cases these conditions may not affect contact lens wear, but in severe cases the allergic conditions and the medications that treat them are likely to cause problems in the ocular tissues such as corneal staining, follicles, and papillae.

Young kids tend to rub their eyes a lot, probably because of mild ocular allergies or trichiasis. Eye rubbing should be avoided in lens wear as it may introduce microorganisms from the eyelashes into the eye and the lashes may scratch the cornea in kids who have trichiasis. In overnight ortho-k, rubbing the eyes may dislocate the lenses. It is therefore important to teach children not to rub their eyes.

When parents consider contact lenses for their children, they need to be realistic about the treatment including the usage, the effect, and the cost. It is not advisable to fit a child if both parents do not agree about contact lens wear for the child or if the parents have unrealistic expectations in the treatment. This is particularly important in ortho-k lens wear as the risk of severe complications is higher than with daily wear lenses (Morgan et al, 2005; Stapleton et al, 2008; Dart et al, 2008).

In Hong Kong and some Asian countries such as Singapore and Taiwan, contact lenses for kids are usually initiated by parents for myopia control. It is important to help parents understand the limitations of the lenses or treatment and that myopia control effects have not yet been confirmed in randomized clinical trials.

Choice of Lenses

Both soft and GP lenses may be considered for children depending on their needs, as with adults. However, to minimize complications, daily disposable lenses and lenses with a higher Dk (e.g. silicone hydrogel, high-Dk GP) are preferred. It is important to strongly warn children against napping or sleeping while wearing their lenses. However, in reality some kids do nap whenever they can. Therefore, it is prudent to fit young children with the highest-Dk lenses possible.

Informed Consent

Wearing contact lenses increases the risk of corneal complications that can, in the worst case, lead to loss of vision. It is therefore important for you to provide adequate information to your young patients and their parents before and after commencing the treatment.

Children and their parents should be appropriately informed about the treatment, the pros and cons, potential and foreseeable risks associated with lens wear, and the alternatives available. This is particularly important when the child is enrolled into overnight ortho-k, as overnight lens wear increases the risk of complications. Information provided should include your duty of care to the patient as well as the patient's responsibilities with respect to lens care, maintenance, and aftercare visits. It is not possible to try to incorporate all information in the consent form. You can prepare information separately for distribution to patients/parents for reference.

It is prudent to give the parents sufficient time to read the information they have been given and to consider whether they really wish to proceed with the treatment.

Signed informed consent is important for the following reasons:

1. Better educated patients/parents are less likely to be discontented with the course of lens wear because of reduced unrealistic expectations.
2. You must comply with the laws that require you to give patients/parents the information necessary for an informed consent.
3. You will be in a better position to mount a legal defense if anything should go wrong during lens wear (White, Cho, 2003).

You must go through all forms/instructions/advice that you provide to kids/parents to ensure that they have understood the content and to allow them the opportunity to ask questions. Do not allow potential refusal of treatment to stand in the way of properly informing the patients/parents, as they must be able to make informed decisions. You should therefore be careful not to make unrealistic or misleading claims.

In the case of ortho-k, because the lenses are worn at night it is important to provide a telephone number where patients can reach you in case of emergency. The telephone number may be written or typed on a card that the patient can easily access, and should not be buried in one of the information or instruction handouts.

Application and Removal

Keep application and removal sessions short (e.g. 30 minutes) as performance is less likely to increase with repeated failures. Trying again after a break or in the next visit is more likely to be successful.

If a child has difficulty learning how to apply contact lenses, use the 'Eyedrop' exercise with the following instructions:

1. Place a small drop of artificial tears (instead of a lens) on the index finger.
2. Hold the eyelids and eyelashes firmly and place the drop of artificial tears gently on the cornea.
3. Refrain from blinking after touching the drop to the cornea. Be careful to avoid touching the cornea with the index finger.
4. Look down and let go of the eyelids.

These procedures can be repeated several times before switching to a contact lens. This exercise is particularly helpful for kids who are initially afraid to place contact lenses on their eyes. You can instruct children to practice this exercise at home (with parental supervision) or it may be carried out in your office. It allows the child to practice 'application' while avoiding any potential irritation from improperly applied lenses and it also prevents lens contamination.

Care Instructions

There is no evidence demonstrating whether kids are more or less compliant than are adult patients. In any case, kids are kids, and they will always need a certain amount of supervision. You need to do your part, but parents have to agree to take on the responsibility of monitoring compliance at home and bringing their child back for regular follow up. Hence, you should provide instructions on lens handling as well as normal and abnormal signs and symptoms in contact lens wear to both kids and parents. Kids whose parents cannot comply with these instructions should not be fitted with contact lenses.

With daily disposable lenses, the amount of instruction that you need to provide to the parents/children is greatly reduced. If you prescribe non-daily disposable contact lenses, instruct young patients on lens usage as well as on the care of contact lenses and accessories, as with adult patients. The only difference is that you need to provide the instructions to the parents as well.

On-site demonstration of how to care for the lenses is necessary, and the importance of compliance cannot be over-emphasized (Claydon, Efron, 2004). Place special emphasis on the care of lens accessories, as these have been identified as the most frequently and severely contaminated items (Boost, Cho, 2005, Cho et al, 2009).

Some steps are frequently omitted in the instructions provided by practitioners. For instance, you should instruct young patients to take proper care not to contaminate their hands after washing them; for example, the lens case should be opened before (not after) washing the hands. Very often, a kid's idea of washing hands is a quick rinse under the tap water. It is therefore important for you to demonstrate proper hand washing to children and parents. It is also important to stress the need to dry hands thoroughly with a clean towel or tissue after washing and before handling lenses.

Particular attention has been paid to contact lens cases in recent years due to reports of high contamination of this device. Using solutions (multipurpose or saline) to rinse the lens case before air drying is most frequently recommended, but this procedure results in a deposit of salts on the surface of the case. Figure 1 shows the right well of a new lens case that has been rinsed with MPS and air dried three times. A layer of salt deposition is clearly visible.

Figure 1. Salt deposition inside the well of a new lens case after rinsing with MPS and air dried.

This deposition may adversely affect disinfecting performance and lens comfort when lenses are stored with fresh MPS in the case, as the solution would contain a higher level of electrolytes. High electrolyte levels favor the survival of some organisms; for example, microbiologists use an increased salt concentration in media to select for Staphylococcus aureus. We suggest wiping the rinsed lens case with clean facial tissue to remove the remaining MPS, leaving a clean, smooth surface (Figure 2). After cleaning and drying, the case should be stored in a cool, dry place — not the bathroom. Another frequently omitted instruction is how and when to disinfect the lens case. Disinfection can be carried out weekly by soaking the cleaned case and its lids in a cup of hot (just boiled) water (covered) for 10 minutes. Lens cases are recommended to be replaced monthly.

Figure 2. The salt deposition from Figure 1 was removed by wiping the rinsed lens case with clean facial tissue.

A common step usually ignored or missed involves one of the most basic procedures in contact lens use: lens application. Specifically, it is important to instruct patients to hold the eyelashes clear of the eye during application (Figure 3). Poor application technique (Figure 4) can result in particles or organisms on the eyelashes being transferred onto the lens and into the eye. Emphasize proper lid hygiene and provide clear instructions on proper lens application to parents and their kids.

Figure 3. Patients must pull the eyelids apart and make sure that the eyelashes are not touching the lens during application.

Figure 4. Microorganisms from the eyelashes may be introduced into the cornea from the lens with poor application technique.

Regular Aftercare

Aftercare schedules vary with the lens type prescribed. Once patients have adapted to daily lens wear, it may be prudent to recommend three- or six-monthly aftercare visits or to schedule an aftercare visit before ordering the next supply of lenses — whichever comes first. This would allow you to not only check the ocular integrity, but also to confirm that the prescription is still valid. With ortho-k lenses, we suggest quarterly aftercare. It is also important to schedule early morning visits after the first overnight and first week of ortho-k lens wear to ensure that there are no hypoxia-related problems (Cho et al, 2008).

In general, kids, like adults, tend to get complacent with lens care procedures. However, they are easier to re-educate compared to adult patients; the former being more willing to listen, to learn, and to please. Take the opportunity to review care procedures at every aftercare visit. Getting the kids/ parents to demonstrate how contact lenses and accessories are cared for and re-educating them (if necessary) will help reinforce what they need to do.

Patients, particularly soft lens wearers, are notoriously bad at returning for aftercare consultations, especially after a few months of contact lens wear. It is advisable for you to arrange automatic recalls for aftercare visits, particularly in ortho-k practice. It is not a good idea to let parents decide whether or not their children should come in for follow up. In the event of complications, it would be to your advantage to be able to demonstrate that reasonable steps have been taken to fulfill your duty and that any harm resulting from future use of the lenses can be defended by citing the patient's noncompliance.

Again, we must ensure that parents can be depended upon to help minimize the risks associated with contact lens wear by monitoring compliance at home and noting early warning signs of problems that may arise. Parents must also be able to take appropriate action whenever necessary, but they can do so only if we properly inform/ instruct them. Kids are particularly vulnerable and depend on their parents to consent to contact lens wear. It is therefore essential that information and advice provided to parents are clear and detailed enough for them to safeguard their kids.

Myopia Control with Lenses

Current literature has confirmed that traditional design soft and rigid contact lenses cannot slow myopia progression (Walline et al, 2004; Walline et al, 2008a). The LORIC study has shown that overnight ortho-k has a strong potential for myopia control in children. These results have recently been confirmed by the CRAYON study. Randomized clinical trials on myopia control using ortho-k are now being conducted in different countries.

The potential for myopia control with ortho-k has also evoked new interest in the effect of aberration and peripheral refraction on the development of myopia. Clinical trials using specially designed soft contact lenses for myopia control are also currently underway in different parts of the world.

Practitioner's Attitude

Longer chair time is one of the main concerns of many practitioners when prescribing contact lenses for kids. It has been shown that the chair time may be longer but not overly so, and children are more loyal patients who will not shop around. Good professional services can help to keep younger clients as well as to attract other family members as new patients.

Another main concern in fitting kids is practitioners' perception that the risk of infection or severe complications is higher in kids. There is no scientific evidence indicating higher risk associated with contact lenses in children. This may be because of the relatively small number of kids being fitted to date. However, provided that proper care and strict vigilance are exercised, there is no reason why kids should be more susceptible to contact lens complications compared to adults.

Having said that, our experience indicates that kids do not usually complain. They are not as critical or demanding as adult patients are with regard to their vision, making them easy patients to please. Unfortunately, they also often do not complain even if their vision is not optimal; some just do not like to 'make a fuss.' We should therefore be extra careful not to become complacent with our young patients. This is particularly important with ortho-k patients as myopia reduction may otherwise fall short of the desired target. It is essential to be open minded and remember that contact lenses are an optical correction not only for adults, but also for kids if they are indicated.

To conclude, fitting kids with contact lenses is a decision for each individual practitioner. Maybe the question is not 'To fit or not to fit kids with contact lenses?' but rather 'Are you ready to fit kids with contact lenses?' There are no big challenges in fitting children with contact lenses; all you need is to be prepared. CLS

Dr. Cho is an associate professor of the School of Optometry at The Hong Kong Polytechnic University where she teaches Contact Lens Practice. She has published extensively in optometric and contact lens journals. She is also currently the regional editor (Asia-Pacific) for Contact Lens & Anterior Eye, the journal of the British Contact Lens Association.

Ms. Cheung is currently a research fellow at The Hong Kong Polytechnic University. Her research area focuses on ocular response in contact lens wear and she has published more than 20 articles in international journals. She is also involved in contact lens education for the undergraduate program and continuing education courses for licensed contact lens practitioners in Hong Kong.

To obtain references for this article, please visit http://www.clspectrum. com/references.asp and click on document #165.