letters to the editor

Glasses or Contact Lenses for Young Patients?

As a parent of three grade school children and an optometrist for almost 20 years, I am outraged about the clinical judgment used with the child in the December 2008 Pediatric and Teen CL Care column "Noncompliant Eyeglass Wearer A Good Fit for Contact Lenses," by Marjorie J. Rah, OD, PhD, and Jeffrey J. Walline, OD, PhD.

My background includes three years as a clinical and research assistant with one of the world's foremost experts in contact lenses as well as clinical practice in both optometric and ophthalmologic settings. I found in the very early years of practice that I needed to create professional and personal guidelines to follow when certain clinical situations presented themselves — and then to stick to them. For instance: when do you initiate glaucoma therapy when everything is normal except for an elevated IOP — and then what IOP? When do you fit contact lenses on a high-diopter patient who has lost his glasses and has no intention of replacing them? What age is appropriate to fit a child with contact lenses? The list goes on; and after 20 years of practice, and after seeing what I have seen, I'm glad I have stuck to my guns in these situations.

In this case presentation, the 8-year-old girl with –2.25 –1.00 × 165 and –2.50 –1.00 × 35 did not have amblyopia, and I find it hard to believe that with an uncorrected distance visual acuity of about 20/300 that she would not appreciate the visual benefits of her glasses. I'm sure she is going to wear her contact lenses every waking hour and will never wear her glasses; she will continue to become myopic, and the parents won't buy new glasses that she won't wear. I would not like to see her cornea in a few years, nor have to prescribe her –6.00 –1.75 glasses in four-to-five years because she has a terrible infiltrative keratitis — and then spend 30 minutes on a follow-up visit explaining shape and size magnification as they pertain to Knapp's rule and how psychophysics intertwines in her dissatisfaction with her new glasses.

I recently have had three or four young patients for whom the parents inquired about contact lenses because they "won't wear their glasses." I tell parents right in front of their children that we are not going to reward such negative behavior with contact lenses and become "enablers." When children can prove a level of maturity and wear their glasses for six months to a year, we can revisit the contact lenses question. I ask parents whether their children brush their teeth every day, clean their room, and pick-up after themselves without being told? The answer is always no. I explain that contact lenses are a medical device with potentially serious ramifications, exacerbated by misuse. I rarely have had an issue after explaining my concerns, and the children wear their glasses when they realize that they won't get their way this time.

I realize they may be able to go to another practice to get contact lenses; I am still in shock that our educators and researchers are pushing contact lenses for such a young age for non-medical reasons. I am an advocate of pediatric contact lens use only for medical reasons.

Andrew Walkowiak, OD
Whitingham, VT

Dr. Rah and Dr. Walline's Response

Dr. Walkowiak believes that professional guidelines are best for treating patients, but we believe that patients should be judged and treated as individuals. Treatments that work well for some may not work well for others. For example, the patient from our December column sincerely attempted to adapt to spectacles, but she was visually uncomfortable and could not wear them. She has benefitted greatly from contact lens wear for the past five years, with no ocular health complications.

There is no scientific evidence or clinical substantiation to indicate that fitting children with contact lenses before the teen years will lead to ocular problems. We have managed hundreds of ‘tweens’ with contact lenses through many years of follow up, and they have experienced no more problems than an adult population. We do not advocate contact lens wear for all children, but we believe that judgments based on sound clinical evidence rather than on rigid, unsubstantiated guidelines serve our patients best in the long run.