Kids, Contacts and Quality of Life
By Linda Conlin, ABOC, NCLEC
Release Date: August 1, 2019
Expiration Date: August 1, 2022
Upon completion of this program, the participant should:
- Identify common vision conditions in young children.
- Understand the special considerations for fitting infants and children with contact lenses.
- Understand the evaluation techniques, instrumentation and the role of caregivers in pediatric contact lens fits.
Linda Conlin, ABOC, NCLEC
This course is approved for one (1) hour of CE credit by the National Contact Lens Examiners (NCLE). Technical Level 1 Course CTHJHI102-1
The past two decades have seen a marked increase in how often eyecare professionals (ECPs) fit children with contact lenses. ODs and physicians prescribe contact lenses for children more frequently partially because of improvements and adaptations in the contact lenses themselves. The other part is that kids need them. Eyeglasses are impractical for infants making contact lenses the better choice for correcting pediatric vision disorders.
If vision disorders are not corrected before age 5 it can lead to permanent vision impairments such as refractive errors (myopia, hyperopia, astigmatism and anisometropia), amblyopia (lazy eye) and strabismus (lazy eye, misaligned eyes). But when these disorders are detected and treated early many can be corrected. According to the Centers for Disease Control (CDC), approximately 7 percent of children younger than 18 have a diagnosed eye and vision condition. Amblyopia accounts for about 3 percent of that number. The statistics, however, represent only the tip of the pediatric vision care problem, and as ECPs, we should be concerned with a few more.
For example, 25 percent of school-age children have vision problems, according to Prevent Blindness America. Among children with special healthcare needs, approximately 6 percent have unmet vision care needs. These statistics do not just represent fitting opportunities.
They represent roadblocks that these children will face over their lifetimes if they do not receive vision correction at a young age. For example, statistics show that children with visual conditions frequently face additional challenges.
- Juvenile offenders have high rates of undiagnosed vision problems.
- More than 50 percent of children who have a vision screening and are recommended to have an eye examination do not get one.
- Vision screenings detect only 5 percent of all vision problems.
- Only 57 percent of youth with visual impairments have attended postsecondary schools.
- The incidence of some form of visual impair ment in children with a learning disability is about 10 times higher than in the general population.
- Vision problems are the fourth most prevalent class of disability in the United States and one of the most prevalent conditions in childhood.
- In the youngest children, studies have found retinopathy of prematurity occurs in up to 43 percent of premature births, depending on gestational age and birth weight.
- Astigmatism is present in up to 28 percent of children ages 5 to 17 years.
- In preschoolers, the incidence of amblyopia is 3 to 5 percent and 2 to 4 percent for strabismus.
- Approximately 5 percent of toddlers should wear corrective lenses.
- Approximately 75 percent of children with myopia are diagnosed between the ages of 3 and 12 years.
IDENTIFYING THE PROBLEM
Infants, very young children and some children with disabilities frequently do not respond to questions or cooperate well with the ECP during a typical eye exam and contact lens evaluation. At the same time, children usually become anxious about procedures, so an ECP must be more flexible and creative when dealing with children. Try to make the procedures fun.
Even though the child’s parent will have supplied the history and chief complaint, the ECP must establish a rapport with the child. How? Reviewing the history and clarifying information with the parent before taking a young child into the exam room can help reduce stress. After all, she will spend what she may perceive to be a long time in a dark, perhaps scary room. Begin the evaluation while walking with the child to the exam room. Talk to the child about herself in a friendly manner and in a language she will understand. Look for obvious defects like nystagmus or strabismus and unusual posture or head tilt that may indicate vision problems.
Remember that children have short attention spans, so it’s important to work quickly and efficiently. You may have only one chance to evaluate each part of the test. Start with the simplest tests, such as motility in which the child can track a toy or video on a smartphone and progress to the more complex as the child becomes more comfortable with the procedures. If your electronic chart system is compatible with it, a movie, rather than shapes or letters should hold the child’s attention long enough to perform a distance retinoscopy. Similarly, children’s videos played on an iPod or tablet are helpful with evaluating near fixation.
Ask the parent to hold a small child on his or her lap in the exam chair. If the child is unwilling to sit in the exam chair, let him sit where he wishes, and get on his level, even if it’s the floor. Use instruments such as a handheld auto-refractor and keratometer while a parent holds the child. Make the process more like playtime and less like a clinical procedure. For example, play “peek-a-boo” when you cover each eye with the occluder. Animated cartoons or mechanical toys with sound make excellent fixation targets for distance, while handheld toys work well for near. Play the “Match Game” with children who do not speak. Ask the child to match the pictures on the cards you or a parent show them to the same pictures on the distance screen.
Children who are too young to match pictures can reach for a small object held at near and retrieve a toy they see across the room. Observe the way the child approaches the toy for more clues to vision problems. Teller acuity cards are another option. Because children prefer to look at patterns rather than solid color fields, the cards have a striped pattern on one half and are blank on the other. The stripes become progressively smaller, and the child will stop responding to the cards when he can no longer see the pattern. For infants, observe their interest in looking at objects around them. Watch how they react to light, movement and color. The Bruckner test is another indicator of refractive error. Use a direct ophthalmoscope to illuminate both pupils and observe the red reflex when light reflects from the retina. Inferior crescents indicate myopia and superior crescents indicate hyperopia.
The next step is to determine the prescription for corrective lenses. Streak retinoscopy works well for children who cannot respond to subjective tests. The practitioner flashes a light beam horizontally across the retina and observes the red reflex. The reflex moves either with or against the horizontal motion. Movement in the same direction as the light indicates the need for plus power, while movement in the opposite direction indicates minus power.
Instead of a phoropter, use progressively stronger handheld trial lenses of the indicated plus or minus power in front of the eye and repeat the test until the movement is neutralized. When corrected for working distance, the power that neutralized the movement becomes the prescription.
INFANTS IN CONTACT LENSES
Once you have a prescription, you can begin fitting the lenses. Let’s start with a look at contact lenses for infants. Congenital cataracts occur in 1 to 3 of 10,000 births in developed countries and can be bilateral or unilateral. Causes include genetics, metabolic disorders, birth trauma, and maternal infection during pregnancy. Intraocular lens (IOL) implants used to replace an adult crystalline lens is controversial in infants younger than 7 months of age, but are more common in children aged 2 years and older. However, when an implant is contraindicated, other correction is needed to protect visual development.
Eyeglasses on infants are impractical, which makes contact lenses a good alternative correction for pediatric aphakia. Because the first year of life is critical to visual development, ECPs usually fit contact lenses seven to 10 days after surgery, with soft lenses as the most common solution to restore aphakic vision. Keeping in mind that a new baby’s world is close up, add 2D to 3D to the final prescription to enhance near vision. Avoid tight-fitting lenses because the child will spend a great deal of time sleeping with them.
Fitting infants with contact lenses for any vision problem presents some logistical challenges. Infants cannot be told to sit still or look at a target. They do, however, respond to voice recognition, touch and smell. Try to spend some time holding and speaking softly to the baby before beginning the fitting procedures. Instead of a slit lamp, use a penlight and magnifier or a lighted magnifier to evaluate the lens. Work quickly when inserting and removing the lens to help keep the child calm. Remember that this is an emotional time for parents who may react poorly to the baby’s cries.
Make sure that the parents understand the importance of follow-up exams. Generally, a follow-up visit is scheduled for 24 hours after the initial lens insertion, then every 1 to 2 weeks afterward for lens removal, cleaning and disinfection. Parents must know how to apply lens lubricant every morning and night. Advise parents to look for redness, discharge and the infant rubbing or reaching for his eyes. Show parents how to identify a decentered lens and the methods to recenter it. Provide them with written information on key points and a 24-hour phone number for assistance.
After about 4 to 6 weeks, instruct the parents in lens care, insertion and removal. Whenever possible, provide a spare pair of lenses. Subsequent follow-up visits depend on the specific medical issues but keep in mind that the corneal curvature quickly becomes flatter during the first year and may require one or more base curve changes from the original fit.
CONTACT LENS PROCEDURES FOR YOUNG CHILDREN
Contact lenses frequently are a good choice for correcting vision in young children. In correction following surgery for congenital cataracts and in aniseikonia, contact lenses reduce differences in image size between eyes and improve peripheral vision. In amblyopia, an occluder or opaque contact lens is preferable to a patch because it’s easier to keep in place. In fact, contact lenses solve the problem parents have to keep glasses clean, comfortable and in place for many children who need vision correction. Keep in mind that children have larger pupils and are more susceptible to UV, so UV attenuating contact lenses and recommending sunglasses are a must. Consider aspheric lens designs because larger pupils also increase spherical aberration. Another consideration is smaller diameter lenses (13.6, 13.8) for easier insertion when working with younger children who have smaller fissures and tighter lids.
As with the eye exam, be flexible and creative with fitting procedures. Using a handheld keratometer will reduce the difficulty in obtaining corneal curvature readings. When children are too young even for a handheld keratometer, the Bascom Palmer averages of corneal curvature provide a good starting point. The averages are based on age, ranging from birth to 9 years, and the average corneal diameter in infants is 9 to 11 millimeters.
If a child is too young to be held in a parent’s lap for slit lamp evaluation, use a portable slit lamp. In the absence of corneal issues, a penlight and handheld magnifier or a lighted magnifier also may suffice for precorneal and lens evaluation. The lens should equilibrate for 30 minutes first. Usually, the practitioner will need to hold the child’s eyelids open, and a push-up test should show 1 to 2 millimeters of movement. If necessary, use a Burton lamp with the cobalt filter for fluorescein evaluation.
Older children present different challenges. They may have anxiety about the procedures and can be quite good at resisting them. A sympathetic, reassuring approach will help, but avoid being condescending. Explain what will happen in simple terms rather than medical terms. Don’t fudge or fib. Children aren’t as gullible as you might think! Remove the mystery surrounding a contact lens by letting the child hold and touch a disposable trial lens. It may be helpful to demonstrate some procedures, such as lens insertion or instrumentation, on a doll or teddy bear. Praise the child every time she cooperates. Provide rewards like stickers or certificates. Avoid disapproval when she doesn’t cooperate or succeed. Find another approach and ask the child for help by asking her how she wants to accomplish the task. This may provide an idea for a different tack and reassures the child by involving her. You might have to ask the parent to swaddle a completely uncooperative child. Remember though, this is a step of last resort. You may be able to keep the child from moving, but you can bet they will scream and cry.
HANDLE WITH CARE
As with adult contact lens fits, pediatric contact lens fitting has risks. Contraindications for contact lens wear include hypoxic keratitis, corneal issues, allergies, abnormalities or deformities, systemic problems, refractive abnormalities and a history of lens abuse or non-compliance. A study reported in Pediatrics magazine reviewed hospital emergency department visits (ED) associated with medical device-associated adverse events (MDAE). In 2004 and 2005, ophthalmology visits were the largest group of MDAEs for pediatric patients. Of those visits, contact lenses accounted for 23 percent of the MDAE cases, the largest group. Forty percent of all MDAEs for children 11 years of age and older were related to ophthalmic devices and a majority of those cases involved contact lenses. Contact lens-related MDAEs included corneal abrasion, ulceration and conjunctivitis.
ECPs must build a rapport with parents and their children regarding contact lens wear and to adequately educate everyone involved. Both children and parents must be motivated and have realistic expectations about wear, care and cost. Parents must be willing and able to provide appropriate lens wear and care supervision. Beware of “contact lens hostages”—when parents allow or withhold contact lenses as a way to change an unrelated behavior in their child. Keep in mind that younger children like to “follow the rules,” and so may not complain about contact lens problems or may attempt to hide them because they are afraid they have done something wrong or that the lenses will be taken from them. Stressing the importance of follow-up visits with both parents and children, and scheduling the appointments in advance can minimize the risk of contact lens-related complications.
Fitting an older child of parents who wear contact lenses usually has the bonus of a positive attitude toward contact lens wear, eliminating the hurdle of explaining the benefits of contact lens wear versus the cost in time and money. But there can be a downside. The reality is that if Mom or Dad is noncompliant with contact lens wear and care, little Johnny will be, too. Note the child’s personal hygiene. Lack of good grooming may predict poor contact lens care. Good candidates for contact lenses are children who frequently break or lose their glasses, active children, and spectacle wearers who show a loss of confidence or withdrawal.
An older child should be able to insert and remove the contact lenses himself before taking them home. Resist parents who insist they can do it for the child, or show him how to do it. It may be best for you and your patient to have parents and siblings wait in another area during instruction.
Videos are a good introduction to the process. If the method you show the child isn’t working after a few minutes, be flexible. Ask him how he’d like to do it, and work with his method as long as it’s safe. It’s better to work over a table than the sink, and it may be easier for the patient to insert the lens by looking down instead of straight ahead.
Don’t take foreknowledge of contact lens wear for granted.
Inform the parents and child about the treatment, risks, care and alternatives in the same way that you would for a patient entirely new to contact lenses. This is an opportunity to remind parents about the care they should be taking of their own lenses. It is possible that parents will recognize and correct their own noncompliant behaviors when they view them in light of the outcomes they want for their child.
TWEENS AND TEENS
For this age group, it’s important to present a balance between benefits and responsibilities. Teens will easily see the benefits of vision, cosmetics, convenience and flexibility with activities. However, they must also see the responsibilities of good habits, awareness of eye health and honest reporting of issues. At this point in life, teens are becoming more independent and want to do things their own way. They are also avoiding direct parental supervision, making decisions that risk their eye health more likely. At every visit, it’s important to review good contact lens habits by asking about wearing times, frequency of disposal and cleaning procedures if applicable.
Teens and tweens are more aware of contact lens options than ever before. Individual websites and social media are providing information and incentives geared toward teen and preteen contact lens wear, including competitions for the best stories about the relationship between healthy vision and sports performance. Professional athletes are telling their stories too. Social media sites are giving teens advice about talking to their parents about contact lenses as well as information parents can access.
ECPs must also be aware of companies that sell cosmetic contact lenses illegally and target teens. Many young people believe that what they find on the internet is true. Websites falsely claim that lenses are FDA approved or are “safe,” and orders may include non-FDA approved solutions. They offer online insertion, removal and cleaning instruction, but post disclaimers of liability for injury. It’s our responsibility to ensure that parents and teens are aware of those practices.
THE FUTURE IS IN THEIR EYES
Technological advances in lens materials and easier care systems allow children to begin wearing contact lenses at younger ages. According to the American Optometric Association, studies have shown that contact lens wear improves the quality of life for many children not only by correcting vision but by improving self-confidence. Contact lenses also are preferred for most sports because they provide better peripheral vision and don’t dislodge the way glasses do. According to the 576 optometrists who participated in the American Optometric Association (AOA) Research and Information Center Children & Contact Lenses study, 71 percent already prescribe lenses to children 10 to 12 years old, usually daily disposable lenses. Twenty-one percent said they are more likely to fit children 10 to 12 years old than they were a year ago. And a study of children ages 8 to 11 years who were fit with daily disposable contact lenses found that 90 percent of the children could insert and remove the lenses without help. This means that ECPs must be ready for a larger, younger pediatric patient population. We now have earlier identification of vision problems, improved lens choices and care methods, children’s interest in contact lenses at a younger age, greater parental acceptance and interest in contact lenses and manufacturers targeting a younger market. With all of that progress, the minimum age for fitting children with contact lenses is virtually nonexistent.
For all of its challenges, pediatric contact lens fitting comes with unique rewards. Eighty percent of early learning development is visual, and as the statistics show, uncorrected and undetected vision problems can have a long-term impact on a child’s life. The most important investment we can make in our future is providing the best care and education for our children. Vision care is a critical part of that plan.