pediatric and teen cl care

Successful Fitting Involves More Than Just An Office Visit

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

A 5-year-old girl presented to the clinic for contact lens fitting for aphakia. Her mother reported a history of uveitis secondary to rheumatoid arthritis resulting in band keratopathy and a posterior subcapsular cataract in the right eye. Uncorrected visual acuities were counting fingers at 3 feet in the right eye and 20/50 in the left eye with her spectacles. Manifest refraction of +10.00D in the right eye and –1.75D in the left eye resulted in visual acuities of 20/100 and 20/40, respectively. Due to the high amount of anisometropia, we recommended a contact lens for the right eye.

The Initial Fitting

We first applied a diagnostic monthly soft disposable contact lens to the right eye to determine the potential visual acuity with a contact lens. The best visual acuity with the soft lens was 20/70. When we applied a diagnostic GP lens to the eye, the best visual acuity was 20/50.

For initial patient comfort and ease of viewing the fluorescein pattern, we instilled one drop of 0.5% proparacaine before applying the GP lens. Both the soft and GP lenses fit well, but due to the potential for better visual acuity, we ordered the GP lens.

Although our patient was apprehensive about wearing a contact lens, especially the GP lens, her mother successfully applied and removed the lens during the training session. She began wearing the contact lens at home for the first few days, but was having difficulty with adaptation.

Because of the difficulty with adaptation, her mother called the office to see if we could prescribe anesthetic drops to help with adaptation. She remembered how the drops had helped in the office during the fitting process. Although using one drop of anesthetic at the fitting and again at the dispensing visit can improve initial adaptation, it's not in the patient's best interest to prescribe them for use at home.

After further education, the patient continued to gradually adapt to the lenses. Once the girl was able to wear the lenses to school, another issue arose. Rewetting drops were necessary for her to comfortably wear the lenses throughout the entire day; however, the school nurse was reluctant to allow the eye drops without a note from our office.

Get More Involved

Fitting a child with a medically necessary contact lens involves more than just office visits. Often, visual acuity is reduced and preferential seating is necessary to optimize academic performance.

Additionally, rewetting drops or medications may be necessary along with providing proper documentation to the teachers and school nurse. A letter to the school detailing the child's needs is an important addition to the fitting process. In this case, our patient was able to move closer to the teacher in the classroom and we sent a note to the school nurse and teacher detailing her contact lens and rewetting drop regimen.

Although we weren't able to prescribe anesthetic drops, we were able to involve the school to help her adjust. She is now adapting to the lenses and enjoying improved vision. 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 and advisor and has received research funds from Paragon and Vistakon.