Pediatric and Teen CL Care

Scleral Contact Lenses in Pediatric Patients

BY CHRISTINE W. SINDT, OD, FAAO

I most commonly use scleral lenses in pediatric patients to protect the ocular surface or in cases of severe irregular astigmatism from trauma in which a corneal GP lens is difficult to fit. The astounding therapeutic benefits of scleral lenses in the pediatric population make fitting them a skill worth learning.

Does Size Matter in Children?

The answer to this question depends on the reason for fitting. If the goal is to protect the ocular surface, the largest lens possible to cover the greatest area of the globe should be fit. The size of the horizontal aperture will determine the largest lens diameter (Figure 1). In most cases, an 18+mm lens can be applied on children older than age 6 months.

Figure 1. Hold the lens up to the horizontal aperture to determine lens diameter.

Figure 2. Child in the face-down position for scleral lens application.

Changes in Lens Fit

Ninety percent of eye growth occurs in the first year; however, during that year periods of rapid change in fit can occur quite suddenly, even in matters of weeks. Unlike corneal GP lenses, which will start to pop out as the eye grows, a scleral lens will become tight. A tight lens will induce neovascularization quickly, so infants in scleral lenses should be checked monthly. Changes in fit are expected at 6 to 8 weeks of age, 4 to 6 months of age, at 1 year, and at 2 to 3 years of age.

Application and Assessment

Because scleral lenses require a fluid reservoir, they must be applied while the patient is face down. I find it easiest to lay children on my lap, chair, or bed, with their head hanging over the edge (Figure 2). I then slide the lens under the upper lid first, pulling the lower lid down to accommodate the inferior edge. The child’s eye does not have to be open to apply the lens, but lid control is necessary to create a gap under the upper lid (Figure 3). Simply sweep the lashes upward, holding them against the brow bone. Removal of scleral lenses is the same as in adults.

Figure 3. Create a gap under the upper lid.

Figure 4. Portable cobalt light makes it easier to assess fluorescein patterns in infants.

Lens assessment is most easily done with a portable cobalt filter (Figure 4). The desired fitting characteristics are similar to those for adults. CLS

Dr. Sindt is a clinical associate professor of ophthalmology and director of the contact lens service at the University of Iowa Department of Ophthalmology and Visual Sciences. She is the past chair of the AOA Cornea and Contact Lens Council. She is a consultant or advisor to Alcon Vision Care and Vistakon and has received research funds from Alcon. You can reach her at christine-sindt@uiowa.edu.