Technological advancements have resulted in the development of contact lens materials that optimise corneal physiology and therefore enable young patients to be fitted with greater confidence and success. Contact lens cleaning systems are efficacious and simple to use, allowing many children to be independent lens wearers.
Paediatric contact lens fitting can be a challenging, but at the same time a rewarding and exciting, area of clinical practice both for the patient and the optometrists
the traditional practice of delaying contact lens wear until secondary school is changing
Despite these developments, the paediatric contact lens market is yet to reach its full potential. Although one in five children aged between 10 and 14 years of age wear spectacles1, an analysis of the prescribing trends by Australian optometrists over the past decade has found that less than six per cent of contact lens fittings were to patients under the age of fifteen2.
The factors reported to underlie practitioner reluctance to promote contact lens wear in children include the potential risk of microbial keratitis,3,4 debate as to the optimal age to commence lens wear and the perception that children may not appropriately manage lens handling and hygiene5.
However, there are now numerous published studies that have confirmed the capacity for paediatric patients to be successful contact lens wearers6-8. As with any therapeutic treatment, the potential merit of contact lens correction for a particular child requires an evaluation of the relative risks and benefits of the treatment.
Essential vs Elective Fitting
Contact lens fitting in children may be undertaken for many reasons that may range from elective refractive error correction7,9 to vision therapy for the management of significant ocular disorders10. Infants as young as a few weeks of age may be required to wear contact lenses for the correction of amblyopia10, aphakia11,12 or anisometropia13. These complex cases are typically managed by paediatric contact lens specialists, owing to the limited range of suitable lens modalities and the necessary clinical expertise.
Most contact lens fitting in children involves correcting lower degrees of refractive error. The potential benefits of this modality in this patient population are now well established. Contact lens use has been shown to improve the vision-related quality of life when compared with spectacle wear14. Children who wear contact lenses tend to have greater self- confidence, an improved perception of their own appearance and demonstrate more active participation in sports6,14,15.
For active children, contact lens correction avoids the risk of breakage of glasses that may occur with sport and leisure activities. Prescriptions can be easily adjusted should the refraction require frequent updates. There is also the added advantage of ultraviolet protection with some soft contact lenses.
Elective contact lens fitting requires the selection of an appropriate lens modality. Numerous studies have reported successful contact lens wear in children and adolescents with several lens types, including gas permeable, hydrogel and corneal reshaping lenses6,8,14-16. Many practitioners have a preference for daily disposables in younger children, primarily to avoid daily lens cleaning and disinfection requirements and the flexibility they allow for convenient part-time wear. However, certain refractive requirements and/or economic limitations may warrant consideration of other lens options. Two- and four-weekly disposable lenses, preferably of silicone-hydrogel material, are available in a range of powers to suit most prescriptions.
Orthokeratology (overnight corneal reshaping) may offer young patients the freedom to experience clear vision, without the need for glasses or daytime contact lenses. This treatment modality is of particular value to children who participate in water-based or contact sports, as it allows them to pursue these activities without hindrance. A further potential benefit relates to a growing body of evidence that orthokeratology may attenuate childhood myopic progression17-19.
To fit… or not to fit?
The decision ‘to fit, or not to fit’ children under thirteen years of age varies considerably between practitioners. A survey conducted in 2010 by the American Optometric Association showed that the traditional practice of delaying contact lens wear until secondary school is changing, with half of optometrists now treating children eight years or younger20. The Contact Lenses in Pediatrics (CLIP) Study found that fitting children between the ages of eight and twelve years was comparable to fitting teenagers in terms of the level of patient satisfaction, compliance and ease of fit21. Younger children are typically accustomed to following directions, making them ideal students for learning optimal lens wear and hygiene habits and potentially guiding good lens practice for life. Studies also show that primary age children are also less likely to have serious adverse effects from contact lenses, compared with teenagers22,23.
Experts recommend that a child’s age be used as a guide rather than the absolute determinant for contact lens suitability24. Age alone should not necessarily be a sufficient factor to contraindicate contact lens correction for a particular child. Three factors that may be more instructive with regard to the appropriateness of contact lenses are: motivation, maturity and the degree of adult support.
Factors Influencing Suitability
Motivation
As in adults, motivation is a key factor in successful contact lens wear in children. There is little to be gained by attempting to persuade an uninterested child of the benefits of contact lenses. A strong incentive for contact lenses may derive from a particular dislike of glasses or when spectacles are an impediment to full participation in sports.
Discussing the reason for undertaking contact lens wear with the child, rather than only the associated adult(s), can be used to gauge their level of interest. This can be particularly important in scenarios when a treatment is in the longer term interest of their child, such as a myopia control, but there is a lack of personal motivation by the child.
Maturity
Maturity is also critical. The optometrist needs to be confident that a child is capable of performing the required care and maintenance to wear their contact lenses safely and successfully. The nature of a child’s personality can often be judged from their behaviour in the examination room. An ideal candidate will cooperate with the techniques required for a thorough ocular assessment, such as slit lamp examination, corneal assessment with fluorescein and eyelid eversion.
As contact lens wear requires regular monitoring of the eye, a child needs to become comfortable with these procedures for ongoing after-care. Difficulty tolerating a routine eye examination may indicate the need to postpone lens fitting; a bad contact lens experience at a young age may affect the acceptance of lenses for life. Children that show poor personal hygiene, are restless or particularly nervous, also warrant careful consideration.
Adult Support
A third integral component is the support a child receives from their adult network, such as parents and guardians. Particularly in the early stages, a child will require assistance with learning how to apply and remove their contact lenses. Involving the supporting adults with examinations and contact lens tuition at the practice will enable them to provide the necessary at-home support to build a child’s competence and confidence with lens handling. As with learning any new skill, positive encouragement and patience go a long way to achieving success.
Patience is Paramount
As the well-known American journalist, Franklin P Jones has been quoted, “You can learn many things from children. How much patience you have, for instance.”
Providing eye care to children can certainly have its challenges, but it also has many rewards. One major benefit is the new ‘life’ that children bring to your practice. Consulting to younger patients provides a refreshing change to the more procedural interaction with adults.
As children have different temperaments and personalities, interaction with them requires flexibility and patience. Children tend to cooperate more if you can come down to their level in speech and mannerisms. Simple examination techniques can evolve into fun ‘activities’, through the use of toys, lights, sounds and animation.
As children require more frequent review visits, you often come to know them, and their families, more closely than you do general patients. The special rapport that can develop with younger patients and their ‘doctor’ over time can be personally satisfying – for instance, when a child begins to feel more comfortable they may confide little anecdotes about themselves.
Contact lenses can be a life-enhancing experience for many children, providing multiple social and psychological benefits. As a practitioner, this highly rewarding specialty of optometric practice is not only professionally satisfying and varied, but rewards your creativity, patience and perseverance each and every day.
Dr. Laura Downie, BOptom, PhD(Melb), PGCertOcTher, DipMus(Prac), AMusA is an optometrist who specialises in contact lenses. She has been published in scientific journals and is a clinical instructor to undergraduate optometry students.
References:
1. The Australian Institute of Health and Welfare Report, Eye health among Australian children, Canberra, Australia 2008.
2. Efron N, Morgan PB, Woods CA. Trends in Australian contact lens prescribing during the first decade of the 21st Century (2000-2009). Clin Exp Optom 2010; 93(4): 243-252.
3. Cruz OA, Sabir SM, Capo H, Alfonso EC. Microbial keratitis in childhood. Ophthalmology 1993; 100: 192-196.
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5. Soni PS, Horner DG, Jimenez L, Ross J, Rounds J. Will young children comply and follow instructions to successfully wear soft contact lenses? CLAO J 1995; 21(2): 86-92.
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7. Walline JJ, Rah MJ, Jones LA. The children’s overnight orthokeratology investigation (COOKI) pilot study. Optom Vis Sci 2004; 8: 407-413.
8. Lipson MJ. Long-term clinical outcomes for overnight corneal reshaping in children and adults. Eye Contact Lens 2008; 34: 94-9.
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15. Walline JJ, Jones LA, Sinnott L,Chitkara M, Coffey B, Jackson JM, Manny RE, Rah MJ, Prinstein MJ and the ACHIEVE Study Group. Randomised trial of the effect of contact lens wear on self-perception in children. Optom Vis Sci 2009; 86(3): 222-232.
16. Katz J, Schein OD, Levy B, Cruiscullo T, Saw SM, Rajan U, Chan TK, Yew Khoo C, Chew SJ. A randomised trial of rigid gas permeable contact lenses to reduce progression of children’s myopia. Am J Ophthalmol 2003; 136: 82-90.
17. Cho P, Cheung SW, Edwards M. The longitudinal orthokeratology research in children (LORIC) in Hong Kong: a pilot study on refractive changes and myopic control. Curr Ey Res 2005; 30: 71-80.
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19. Walline JJ, Jones LA, Sinnott L. Corneal reshaping and myopia progression. Br J Ophthalmol 2009; 93(9): 1181-1185.
20. Sindt C. Pediatric prescribing habits. Contact Lens Spectrum; November 2010
21. Walline JJ, Jones LA, Rah MJ, Manny RE, Berntsen DA, Chitkara M, Gaume M, Guame A, Kim A, Quinn N, CLIP Study Group. Contact lenses in pediatrics (CLIP) study: chair time and ocular health. Optom Vis Sci 2007; 84(9): 896-902.
22. Stapleton F, Naduvilath T, Keay LJ, Radford CF, Dart JK, Edwards K, Carnt N, Minassian D, Holden B. Risk factors for microbial keratitis in daily disposable contact lens wear. Invest Ophthalmol Vis Sci 2010; 201051 ARVO.
23. Chalmers RL, Wagner H, Mitchell G, Jansen ME, Kinoshita B, Lam D, Richdale KL, Sorbara L and CLAY Study Group. Age and other risk factors for serious and significant events with contact lens wear in youth. Invest Ophthalmol Vis Sci 2010; 201051 ARVO.
24. Interview with CLIP Study researchers, Contact Lens Spectrum; April 2008
