Succeeding with Kids and Contact Lenses
By keeping the process simple, you can succeed with children in any age group.
Renee E. Reeder, O.D., F.A.A.O. and Valerie Kattouf, O.D., F.A.A.O., Chicago
Very little is as rewarding as successfully fitting children in contact lenses. The faces of infants and toddlers, in particular, light up at their suddenly clear view of the world, and their change in demeanor and interaction with their surroundings as a result is truly remarkable.
Meanwhile, elementary school children, tweens and teens not only appreciate the clarity of their lenses, but also their appearance with lenses, their ability to participate in social situations without feeling self conscious and in activities, such as sports, unencumbered by spectacles.
Through our experience in fitting contact lenses in children of all ages, we've found that successful wear is contingent on the KISS philosophy. That is, you have to Keep It Simple to Succeed.
Here, we discuss this philosophy as it pertains to the various age groups of children.
Infants and toddlers (newborns to age four)
The actual insertion process and the time constraints of parents caring for these children are the primary issues with this age group. As a result, keep it simple with your infant and toddler patients by planning for the contact lens exam ahead of time and prescribing a pediatric weekly extended wear or disposable lens.
Infants and toddlers have slightly steeper corneas than older patients. Therefore, fit these patients in a pediatric extended wear lens that's in the middle base curve range. If, however, the patient's prescription is within the range of a disposable extended wear lens, choose the steepest base curve available in the patient's power.
In terms of planning for the contact lens exam ahead of time, have the parents of these patients schedule the exam during the child's nap. This facilitates retinoscopy, pupillary distance measurement and keratometry. For newborns and infants up to three-months of age, have the parent sit in your exam chair, and swaddle the baby. If, however, the child presents conscious or wakes up just prior to or in the middle of the exam, have the parent tightly swaddle the younger infant to keep him still. For older infants (older than three months of age) and toddlers, have the parent partially recline in the exam chair with the sleeping child on her lap. For the conscious older infant or toddler, have the parent hold the child in the partially reclined exam chair with her legs crossed around the child's legs and her arms secure around the child's arms. Or, have the patient lay on the floor with his parent pinning his feet and arms.
Once the patient is secure, hold his upper lid with your index finger, and pull down his lower lid with your thumb. Then, slide the lens under the upper lid and under the lower lid with the index finger of your other hand. During both the patient positioning and insertion process, explain to the parent exactly what you're doing and why, so the parent can successfully accomplish the fitting process at home.
Because the parents of infants and toddlers are especially strapped for time, keep contact lens wear simple for them by prescribing a weekly extended wear lens. Have these parents remove the lens Saturday evening and reinsert it Sunday morning. Also, simplify the cleaning regimen by prescribing an all-in-one solution. You can prescribe liquid enzymatic cleaner as needed.
Elementary school children (ages five to nine)
The primary issues of this age group are short attention spans, small palpebral fissures, evolving dexterity and the time constraints they place on their parents due to their evolving list of activities.
To deal with these patients' short attention spans, keep the exam process simple by employing an autorefractor/autokeratometer. This will obtain accurate prescription data in the least amount of time. The most recent devices obtain the horizontal visible iris diameter measurement as well.
Because these patients' eyes have small fissures, lens insertion is challenging. To keep the insertion process simple, select a small diameter lens for this age group.
Keep in mind that these patients are still developing their dexterity. Therefore, you must train their parents in proper lens insertion and removal. To simplify this role for these time-challenged parents, recommend orthokeratology or extended wear silicone hydrogel or gas permeable (GP) lenses. Also, educate these parents that while their child may not be able to insert the lens, he can be trained to remove it — a fact that will alleviate their concerns regarding their child experiencing lens irritation while at school, for instance. In fact, give these children an extra starter kit to keep in their backpacks or cubbies at school, and have them take their glasses with them, should they experience irritation while not accompanied by their parent.
Should the patient opt for extended wear lenses, GPs, in particular, can be beneficial to this group, as they are small and made of rigid material, enabling easy removal and handling. Further, should a minor prescription change be necessary, GPs can be modified in a fairly short time, which fits nicely with this age groups' evolving activity schedule.
When an anisometropic patient presents, keep it simple by only fitting the eye that has the higher prescription. By putting the spherical difference between the two eyes into one contact lens, you can incorporate the prescription of the eye that has the best visual acuity, and any remaining prescription of the eye with decreased visual acuity in a pair of polycarbonate spectacles. In so doing, you provide the patient with motivation to wear that protection through enhanced vision. Many of these patients require greater than +6.00D to −10.00D correction in the eye that has the higher refractive error. By placing a portion of the correction in the spectacles, you reduce the contact lens power needed to within the power range of most silicone hydrogel extended wear disposable lenses, thus, opening a wider range of options for your patient.
Tweens (ages 10 to 12)
Emerging allergies, challenging attention spans, busy schedules, accommodative insufficiency or convergence excess and novice insertion and removal are the major issues of this group.
Seasonal and perennial allergies are on the rise in this age group. As a result, be sure to evert these patients' lids, so you can simplify the lens selection process.
Although this age group is more attentive than elementary school children, they still tire and get bored easy. Therefore, simplify the exam process by once again making use of your automated equipment.
Because these children are more independent than elementary school children, they are given more responsibility (e.g. homework, chores, etc.) and are involved in far more activities, such as sports and clubs. Therefore, as a group, they have the ability to be responsible for the insertion, removal and care of their lenses. That said, their super busy schedules make adhering to a lens wear and care schedule challenging. So, to simplify wear in these patients, recommend daily disposable lenses, as these lenses don't require a care regimen, and provide plenty of spare lenses should the patient tear or lose lenses.
If, however, patient and parent questioning reveal the patient is responsible enough to comply with a lens care regimen, orthokeratology may be a good "fit." Further, if lens handling is an issue for the "responsible" patient, recommend a GP lens. Again, it's all about keeping it simple. (As a brief aside, if the child is going to take full responsibility for his contact lenses, have him indicate this by signing a form that outlines his lens wear and care regimen and explains the outcomes of non-compliance. A written pledge of one's responsibility goes a long way in bolstering successful wear.)
For children who present with accommodative insufficiency or convergence excess, keep it simple by prescribing a soft bifocal lens. Fitting these patients in a single vision lens will just increase their accommodative demand and symptoms.
Keep in mind that regardless of the type of lens you prescribe, these patients are likely to be nervous regarding lens insertion and removal. After all, sticking something in your eye can be nerve-wracking. To facilitate the learning process, first teach these patients how to hold and control their lids to insert an eye drop. Others may achieve success by working on lens removal by first rolling the lens down with their index finger into the outer corner of their eye before plucking it off the surface. Having these patients look for the wrinkled-up contact lens in the mirror helps them realize they have the lens off the cornea. If the patient expresses frustration trying to re-insert the lens, do it for him, so he can master removal. Mastering even one part of lens handling on the first sitting is a real patient confidence booster. If needed, train the parent to insert the lens if the child can only remove it. In another sitting you can then focus on insertion. Training sessions should be limited to 30 to 45 minutes. By keeping the sessions short, you minimize ocular redness. Parents and patients often become agitated when they notice the eye becoming irritated by repeated attempts at lens application and removal. Additionally, you are limited by the patient's attention span. Too long a session only results in patient frustration and failure.
Teens (ages 13 to 19)
This age group's primary issues are busy schedules and the perception that they're invincible. Therefore, to keep it simple to succeed with these patients, prescribe daily disposable lenses. Prescribing daily disposable lenses gives the teen the responsibility of lens care and wear with the simplicity of a regimen that will provide parents with peace of mind. When prescribing these lenses isn't possible, however, prescribe an extended wear lens. You want peace of mind that when these patients over wear and sleep in their lenses (and they will) that their eyes will be at minimal risk for complications.
In the case of colored contact lens wear, be sure to educate patients that as is the case with regular contact lenses, colored contact lenses are medical devices, and sharing them could put both the patient and their friends at risk for infection.
For teens who have astigmatism greater than two diopters of cylinder and are unhappy with their vision in soft toric lenses, recommend back surface toric GPs. If the patient finds a standard diameter GP uncomfortable, prescribe a corneoscleral lens. These lenses can be empirically designed with the patient's contact lens data. Finally, offer orthokeratology to your low-to-moderate myopic patients.
When it comes to lens care, select an all-in-one solution regimen to further enhance compliance. As is the case with tween patients, have your teen patients sign a pledge that they understand how to care, wear and replace their lenses, as it reinforces their responsibility.
To instill compliance with their wear and care schedule, recommend technology, such as talking lens cases, smartphone applications and web-based applications to make it simple.
Contact lens wear can have an enormous positive impact on the lives of children of all ages. After all, they provide freedom from spectacle wear and clarity of vision, among other quality-of-life-improving attributes. That said, each age group has its various challenges. Therefore, to ensure successful wear for your child patients of all ages, it's essential you follow the aforementioned KISS tips. OM
|Dr. Reeder is the chief of the contact lens service at the Illinois College of Optometry. E-mail her at firstname.lastname@example.org.|
Dr. Kattouf is the chief of the pediatrics service at the Illinois College of Optometry. E-mail her at email@example.com, or send comments to opto firstname.lastname@example.org.