KIDS AND CONTACT LENSES

Fitting Children Into Contact Lenses

Children as young as 8 years old can gain many benefits as a result of being fit with contact lenses.

	Dr. Bennett is assistant dean for Student Services and Alumni Relations at the University of Missouri-St. Louis College of Optometry and is executive director of the GP Lens Institute. You can reach him at ebennett@umsl.edu.
	Dr. Henry is currently a clinical professor and director of Clinical Operations and Residencies at the University of Missouri-St. Louis, College of Optometry. Currently she serves as the chair of the Association of Contact Lens Educators (AOCLE).

By Edward S. Bennett, OD, MSEd, FAAO, & Vinita Allee Henry, OD, FAAO

When we were young, it was common to hear that you had to be a certain age to wear contact lenses (typically 14 to 16 years old). Of course, contemporary studies by Dr. Jeff Walline and colleagues (Walline et al, 2004; Walline et al, 2007; Walline et al, 2009) have found otherwise. The goal of this article is to provide pearls on working with young people and to show how contact lenses can, in fact, be life-changing for them.

Why Contact Lenses?

All children today are encouraged to have active lifestyles, and contact lens wear can be a great incentive to participate in athletic activities. Spectacles can compromise children’s ability—not to mention their motivation—to participate in sports due to the restrictions imposed by both the lenses and the frames. How many times have you seen a young spectacle-wearing child incur facial lacerations from their glasses when hit in the face with a soccer ball or basketball? It is often unnecessary. Spectacle wear has also been associated with shyness, introversion, and a less outgoing nature socially (Terry and Stockton, 1993; Terry, 1989). This is consistent with the results of The Adolescent and Child Health Initiative to Encourage Vision Empowerment (ACHIEVE) study, in which 8-to 11-year-old myopic children were randomly assigned to wear spectacles or soft contact lenses for a three-year period (Walline et al, 2008). The results indicate that contact lenses significantly improve how children feel about their physical appearance, their ability to play sports, and their acceptance among friends. Furthermore, although it will not be discussed in this article, the future for overnight orthokeratology and maybe even soft bifocal lenses in slowing the progression of myopia in young people is very promising.

At What Age Can Children Wear Contact Lenses for Cosmetic Purposes?

Studies indicate that children as young as 8 years old are capable of wearing GP (Walline et al, 2004), soft (Walline et al, 2008), and overnight orthokeratology (Cho et al, 2005; Walline et al, 2009) contact lenses. Results of the Contact Lenses in Pediatrics (CLIP) study show that the total chair time for children 8 to 12 years of age was only 15 minutes longer than that for adolescents 13 to 17 years of age. It is also apparent that young people 8 years of age and older are typically mature enough to independently care for their contact lenses while experiencing few adverse effects (Walline et al, 2007). Certainly, if we emphasize proper contact lens care and compliance to young people, there is no reason why they should experience complications at a greater frequency than would adults.

You may want to let young people handle a contact lens prior to the fitting.

What Are Other Important Factors for Fitting Young People Into Contact Lenses?

In addition to age, several factors are important for successful fitting of young people into contact lenses (www.aoa.org/childrenandcontactlenses, 2010). These include interest and motivation, maturity, ability to independently take care of lenses, personal hygiene habits, sports, prescription requirements, self-esteem, and pre-existing medical conditions.

Children’s motivation to wear contact lenses often comes from the challenges of spectacle wear during athletics and other activities. Cosmesis is also a very strong motivating factor. But pay attention to children’s nonverbal communication when performing your examination. If they do not react positively to drop instillation or to anyone touching their eyes, it may indicate that the motivation for the contact lenses is coming solely from a parent. In such cases, consider delaying contact lens wear until the children exhibit more interest in being fit into lenses.

Figure 1. Proper lid retraction for application of a contact lens.

Children typically have a high enough level of maturity to be fit with contact lenses and to properly handle and care for them when they can converse easily, appear open to new experiences, and have a good track record in other areas (i.e., activities, schoolwork). How young people conduct themselves during the examination and, in particular, their hygiene (i.e., hair combed, cleanliness, neatness) can be a good indicator of how well they will care for their contact lenses. Young people who cannot master lens handling are likely not ready for contact lens wear.

GP or Soft Lenses? The Decision-Making Process

Both GP and soft contact lenses are often good options for young people. The correct choice depends on several factors.

1. Astigmatism Young people who have, at minimum, 0.75D of astigmatism have the option of GP or soft toric contact lenses. You can decide between them based on several factors. For children involved in sports, soft contact lenses would be advantageous. However, if the corneal astigmatism is .2.50D, a bitoric GP lens design would be recommended for optimum vision.

2. Sports Soft contact lenses—especially daily disposable lenses—are the obvious choice for stability of fit. However, other increasingly popular options are corneo-scleral GP lenses for both stability and vision benefits as well as overnight orthokeratology lenses so that a child does not need to wear the correction during sports activities.

3. Overnight Wear Both GP and silicone hydrogel lens materials (those approved for overnight wear by the U.S. Food and Drug Administration [FDA]) would be acceptable if a young person is a good candidate for overnight lens wear.

4. Myopia Control FDA-approved GP lens designs for overnight orthokeratology would be indicated if slowing the progression of myopia is desired. However, center-distance soft bifocal lenses have demonstrated some ability in this area as well (Aller, 2006; Anstice and Phillips, 2011; Sankaridurg et al, 2011; Walline et al, 2011).

Fitting Young People With Contact Lenses

When fitting GP lenses, it can be beneficial if you or a staff member could demonstrate lens application and removal to reduce anxiety. Tell patients that there will be some initial awareness caused by the lid feeling the lens edge as it moves on the eye. The use of a topical anesthetic is beneficial in both decreasing initial awareness and also increasing the wearers’ positive perceptions about adaptation and success. In addition, empirically fitting young people will allow them to immediately experience the primary benefit of GP lenses—good vision—which then may reduce their anxiety about the initial awareness. GP lens designs in common use today are well manufactured, typically ultrathin with consistent edge designs, which has helped decrease initial awareness.

Figure 2. A generic contact lens education brochure is a great way to emphasize important contact lens care tips.

The fitting process for soft lenses in children is similar to that for adults. You may want to let young people actually handle a lens to experience how soft it is before the fitting. Explain that they may feel a “tickling” sensation when the lens is applied, but it is not much different than a big drop of water touching the eye.

With both empirically fit GP lenses and inventory fit soft lenses, emphasize the benefits of visual freedom (i.e., to play sports, see the blackboard, etc.).

Patient Education

Traditionally, one of the reasons that young people were not fit into contact lenses was a concern about their ability to both master care and exhibit good compliance with contact lenses. Of course, as stated earlier, the work of Dr. Jeff Walline and others has shown that the great majority of children as young as 8 years old are successful with a variety of soft and GP contact lens types. In addition, Sindt (2011) has reported that children may be able to remove lenses as early as ages 4 to 5 years, apply lenses at ages 6 to 8, and clean and care for the lenses at 10 to 12 years of age depending on such factors as maturity and motivation.

Handling In addition to letting young people handle lenses to see what they feel like as well as to experience having the lens on the finger, start by instructing them on the importance of proper hand washing prior to applying the lenses. A staff member can demonstrate and then have the young person wash his hands.

For application of GP and soft lenses, proper lid retraction is essential. The middle finger of the opposite hand (as eye) should be positioned over the upper lashes, pinning them back; the middle finger of the same hand (as eye) should pin the lower lashes against the sclera (Figure 1). This is especially important for soft lenses and scleral GP lenses in children because a larger-diameter lens is being applied to a relatively smaller eye in many cases. Removal is similar for GP lenses regarding proper lid retraction with the only change being that both the middle and forefingers of the same hand (as eye) grasp the lower lid. The lids can then be pulled temporally or vertically to eject the lens.

Care Instructions Once patients have demonstrated proficiency with lens handling, present the instructions on care and cleaning. This includes cleaning the lens upon removal (unless it is a daily disposable lens) in the palm of the hand and then placing it into a clean, empty case, which is then filled with the appropriate disinfecting solution. After application with the proper wetting solution, instruct young patients to rinse the case with saline, wipe it dry with a clean cloth and then allow it to air dry upside down with the caps off. Young people or at least the parent(s) should then be able to repeat the instructions. Once this has been accomplished, it’s a good idea to reward success by allowing children to select something from a “parent-approved” treat drawer (Sindt, 2012).

Wearing Schedule A daily wear schedule would minimize the risk of complications, but this decision is based upon both patient and practitioner preference. For young people who want to wear the lenses on an extended wear schedule, they should first wear the lenses on a daily wear schedule to gain proficiency in handling and caring for the lenses. One recommended schedule is to wear the lenses for six to eight hours the first day and for 10 hours the second day, followed by wear for all waking hours (Sindt, 2011). Emphasize the importance of adhering to the recommended wearing schedule. In addition, if they are wearing the lenses on a daily wear schedule, removing the lenses approximately one hour prior to bedtime will minimize the risk of becoming tired and falling asleep while wearing the lenses.

Proper Care Solution Use Children can be very compliant with solution use if they both understand why a particular solution is used (i.e., and why a bottle that has a red top can cause harm to the eye if the solution is put directly into the eye) and are provided with a large supply of lens care solutions initially such that they can become accustomed to using the same care solutions during the first several months.

Emphasize that children should avoid allowing tap water and saliva to come into contact with the lens. As the FDA has recommended that contact lenses should not be exposed to any form of water (i.e., swimming pool, hot tub, shower), children should not allow direct exposure of their lenses to water and, if possible, should shower prior to lens application (or after removal) or, at minimum, should keep their eyes closed when water from the shower may get into their eyes.

Other Important Factors Young people and their parents should be aware of symptoms that could be representative of such complications as corneal abrasion and infection. Typically this pertains to acquired discomfort, redness, and blurred vision. Provide young patients and their parents with the office phone number and emergency off-hours phone number to call if this occurs. Also encourage young people to have back-up spectacles to wear early in the morning, at night, and whenever their lenses feel dry or uncomfortable. If they are wearing frequent replacement lenses, both patients and parents should be aware of the replacement schedule (i.e., put on the calendar to replace the lenses on the 1st of every month, the 1st and 15th of every month, etc.).

Reinforce your care instructions by highlighting and reviewing several important instructions in a brochure designed for this purpose (Figure 2). In addition, there are several websites that are very beneficial and consumer-friendly with contact lens care instructions, videos on how to handle lenses, and important tips for safe contact lens wear (Table 1).

Follow-up Care

After fitting young people with contact lenses, the most important visit is the one-week follow-up visit. At this time, question patients as to how lens handling is going (i.e., does it need to be reinforced or retaught?), confirm proper lens care solution use and cleaning, and ensure that they are complying with the recommended wearing schedule. Poor habits can develop quickly, especially if a parent wears contact lenses and is not optimally compliant. Emphasize that contact lenses are healthcare devices regulated by the FDA and, therefore, young patients need to promptly adhere to the recommended lens care and handling instructions as well as to the replacement schedule and the follow-up visit schedule.

Summary

Young people are often great candidates for contact lens wear and have demonstrated that they can be successful with both lens handling and lens wear even as young as 8 years of age. If they appear motivated to wear contact lenses, prescribing them can make a difference and positively change a young person’s life. CLS

To obtain references for this article, please visit http://www.clspectrum.com/references.asp and click on document #204.