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Contact Lenses for Kids (aside from myopia control!)

2 CPD in Australia | 1G in New Zealand | 30 October 2017

By Kate Gifford

There is a wealth of scientific data indicating that paediatric contact lens wear is safe and beneficial beyond simple correction of acuity. When armed with the appropriate information, and empowered by confidence, optometrists are well placed to start a conversation with parents and children that has the potential to change the child’s life.

From 2005 to 2013, the Sydney Eye Study found the overall prevalence of myopia in 12-year-old children had increased from 12 per cent to 19 per cent, with those of East Asian ethnicity increasing from 39 per cent to 53 per cent prevalence.1 Add to this the 9 per cent of children who have anisometropia greater than 1D,2 and the fact that around 15 per cent of the same age group have hyperopia over +2D, and a picture forms of the volume of ametropic children who could benefit from contact lens wear. Since almost one in four of these children do not bring their glasses to school,3 discussing contact lens correction as part of comprehensive management of your paediatric patients becomes a clinical necessity.

Barriers to paediatric contact lens fitting can exist in the minds of the practitioner, patient and parent in equal measure. However, there is much more that contact lens wear offers to the ametropic child than just acuity correction – binocular vision, visual development, physical and psychological benefits are also part of the package. While the hot topic in paediatric contact lens fitting right now is myopia control – using soft multifocal, novel daily disposable and orthokeratology designs – there are numerous other opportunities to offer contact lens correction to your paediatric patients. With increased understanding comes practitioner confidence to open the conversation with parents and children about the benefits of contact lens wear.

This article combines scientific review and clinical experience in paediatric contact lens fitting and management to help you with this conversation. Clinical indications are described with cases from practice, and practitioner barriers such as time, cost, compliance and safety are discussed with recommendations provided for communication in practice. The names of the patients in the case studies have been changed for privacy.

Amblyopia, High Ametropia  and Anisometropia

Samuel’s Story

When I first spoke to Samuel about wearing contact lenses, he wasn’t interested at all. It was his third appointment before I discussed contact lenses again with him and his parents, and this time I had a little more success. Samuel suffers from Marfan Syndrome – a genetic disorder that affects the body’s connective tissue – along with his father and younger sister. A shy and quiet boy, he made little eye contact through his R -8.50/-3.00x87 and L -8.00/-1.50x50 spectacles, with which he achieved best corrected acuity of R 6/15 and L 6/12 due to lens subluxation. When we discussed the contact lens options, his parents had misconceptions about whether Samuel’s vision would be worse through contact lenses – I explained that in fact, it was more likely be the opposite due to removal of spectacle minification. He was 15 at the time and began excitedly pacing the room when he put thought to how his life might look without thick glasses.

After six months of wearing monthly disposable toric lenses, Samuel said he felt his vision was much better with contact lenses than with spectacles. He was comfortable wearing his contact lenses for 12-13 hours per day. His acuity improved slightly at his first review; after six months he achieved R 6/12- and L 6/9- and after 12 months achieved 6/9+ in each eye. Samuel strides much more confidently into the consulting room now and declares at each appointment that he loves being a contact lens wearer.

Refractive amblyopia can be improved by at least two lines, and in some cases resolved, through full optical correction in young children.4 Due to Samuel’s age and congenital condition, improvement in his amblyopia would not have been expected, but the benefits of increased image magnification provided by contact lens wear delivered this. Interestingly, children with non strabismic anisometropic amblyopia have been shown to improve with treatment regardless of their age, indicating that the conventional sensitive period of seven to eight years may not apply and these children should be managed comprehensively with full refractive correction and patching at any age.5 Consistent correction may be easier to achieve with contact lenses.

Ava’s Story

Ava was nine when she presented with a history of recurrent herpes simplex keratoconjunctivitis in her left eye. She also had similar recurrent skin infections on her face and back, which were due to virus exposure at birth. While the infections had been controlled with daily oral anti-viral medication to a reducing frequency of only a handful of mild flare-ups a year, Ava had spent many of her first years of life with a sore, infected left eye. This meant she exhibited mild amblyopia of L 6/9. Her refraction in this eye has remained stable at L +1.50/-0.50x82, while her right eye was stable for three years at R -0.50 until it progressed to -1.25 and then -2.00 only three months later.

It was difficult to achieve good compliance with Ava’s glasses when her right eye was only mildly myopic, so her left amblyopia persisted. Part-time spectacle wear could also have contributed to myopia progression, as under-correction to a blur level of 6/12 has been shown to potentiate axial growth in myopic children.6 However since her myopic shift, Ava has worn an orthokeratology lens for myopia control in her right eye and a daily disposable in her left eye. She achieves R 6/5 and L 6/6- contact lens acuity and manages well with glasses whenever she has a recurrence in her left eye and needs to cease contact lens wear.

Binocular Vison in Contact Lenses

Brooke’s Story

Brooke has worn spectacles full time since she was six, and a small reduction over the ensuing years sees her prescription now at age 15 being R +4.75 and L +5.00. She’s been lucky enough not to suffer amblyopia or esotropia as many of her similarly hyperopic counterparts do – with her distance refraction she exhibits a moderate exophoria at near. She was first fitted with daily disposable lenses for tennis when she was 12, worn twice a week. An increase in schoolwork demand saw her convergent (base-out) fusional reserves reduce, which are required to keep an exophoria in check, and as her confidence increased she was keen for more full-time wear of her contact lenses. In comparison to single vision spectacle lens wear, Brooke’s exophoria decreased and her convergence improved in contact lens correction, leading to both a better aesthetic and binocular vision result in contact lens correction.

When a hyperope wearing spectacles looks at a near target, their convergence away from the optical centre of the lenses creates base-out prism in each eye, with the base being the thicker part of the lens at the centre. This base-out prism moves the image inwards and so decreases the convergence demand. When this hyperope then switches to contact lens wear, they have to converge more by themselves, which if they are capable, will result in an esophoric shift.7 In Brooke’s case, fitting her with contact lenses improved her satisfaction with her correction as well as her binocular vision function – symptomatic convergence insufficiency has been associated with reading behaviours of avoidance in children.8

In contrast to Brooke’s experience as a hyperope, the myope reading through their spectacles experiences base-in prism at near, moving the image further away. Looking away from the optical centre of the lens also reduces the power, effectively reducing the accommodative demand. When this myope changes to a single vision distance (SVD) contact lens correction, he or she must increase their accommodation, which is why the early presbyopic, moderate to high myope always needs an add in their contact lenses before they do in their spectacles – and the high myopes can sometimes survive presbyopia without ever needing progressive spectacles. Back to our myopic kiddies though, while they must increase accommodation demand, they will show an exophoric shift in contact lenses as they lose the base-in spectacle correction.9 This can be beneficial to moderate-to-high myopes where the spectacle-to-contact lens effect will be greater, specifically for those exhibiting esophoria in spectacles, which has been associated with a higher rate of myopia progression.10

Sienna’s Story

Sienna first presented to my practice at age 16. She had progressing myopia and complained of unstable distance vision when wearing her glasses. Cover testing quickly revealed the problem – she had a significant divergence insufficiency esophoria, breaking into an intermittent tropia, which was worse at distance than at near.

Sienna was keen to get rid of her -4.50 glasses and move into full-time contact lens wear. In her case, as with Brooke’s, contact lens wear served a double benefit – it met her needs for refractive correction as well as partially remediating her binocular vision problem. Additional management was required in the form of vision training and over-specs for the classroom until her eye control improved. Four years later, Sienna is now studying at university and sometimes wears prism spectacles in very large lecture theatres to give her binocularity the support required, but otherwise is thrilled being a full-time daily disposable lens wearer with no myopia progression noted in that time.

Jeremy’s Story

Jeremy was 11 when he first noticed blurred distance vision. With a family history, myopia was initially suspected, however Jeremy had seen an optometrist at the time who had performed cycloplegic refraction and found only R and L +1.50/-0.25 x 90 and best corrected acuities of R and L 6/12. A referral had been provided, which had not yet been undertaken. A year later, his acuity and refraction still presented a puzzle, and there appeared to be no eye health abnormalities on biomicroscopy, optical coherence tomography or topography. Jeremy’s binocular vision assessment soon revealed the story – he could barely clear +1.00 or -1.00 at near, and both his convergence and divergence reserves were reduced – profound accommodative and convergence infacility. This inflexibility of his visual system rendered Jeremy 6/12 at distance and N8 at near, significantly impacting his visual comfort and efficiency for school work. Despite this, Jeremy was on an academic scholarship at his new high school, and a star basketball player.

Both non-cycloplegic and cycloplegic retinoscopy revealed a similar refraction to that of the previous optometrist – Jeremy needed a full-time correction, even if a low power, to attempt to relax and normalise his system, along with vision training. This was unlikely to be successful in glasses, as the refraction did not improve acuity and therefore did not offer much incentive for compliance. It was also likely that his refraction would increase with time as his visual system relaxed, rendering contact lens correction the first choice from a compliance and cost perspective. After a month in R and L +1.00 daily disposables, Jeremy’s vergence system showed better flexibility while his accommodation remained similar. After another month, where his prescription was increased to +1.25 for half of the time and then +1.50 for the other half, his acuity improved to R and L 6/7.5 alongside an improvement in both binocular systems. Jeremy remains in full-time contact lens correction and once his refraction is stable, back-up glasses will be dispensed for him.

Safety, Compliance and Comfort

It is understandable that contact lens safety in children is a primary concern for practitioners and parents alike. However, a 2017 study has demonstrated that the risk of microbial keratitis in paediatric contact lens wear is no greater than that in adults, and in younger children (aged eight to12), the risk appears to be markedly lower. This is likely to be due to better compliance and parental supervision.11 This study has been published as open access, which means it can be downloaded freely and can even be provided to academically inclined parents to allay safety concerns. Prescribing daily disposable contact lenses to children, where possible, minimises the risk of microbial keratitis and other infiltrative events. Poor case hygiene risk is additionally eliminated with daily disposable prescribing. Extended wear should be prohibited.12

Observation of the potential paediatric contact lens wearer for signs of poor hygiene, and discussion with parents on their expectations of their child’s competence, will help the practitioner to select suitable candidates. In addition to a strong safety profile, there is more good news for parents, in that children and teens demonstrate higher levels of compliance with lens disinfection and hand washing than their adult counterparts.13,14 Children may require more reinforcement of lens care and maintenance instructions than teens – a small drop in the percentage of children answering contact lens care questions after three months of wear has been observed compared to their teenage counterparts.15 For parents or practitioners unsure of the ideal age of commencement, data has shown that after 10 years of contact lens wear, no difference in the frequency of adverse events and objective assessment of ocular health has been found between those fitted as children compared to those fitted as teens.16

Only a minimal percentage of children  are likely to suffer dry eye symptoms  (4 per cent) compared to 56 per cent in adult contact lens wearers.17 Teens may be more likely to report contact lens related dry eye than younger children,18 and consideration should be given to any systemic medications which could exacerbate dry eye symptoms, such as acne medications and those taken for anxiety and depression.19 It is yet to be shown whether the digital lifestyle of children and teens today may lead to an increase in dry eye complaints, as may be the case for adults20 – consideration should be given to the best lens material, with high water content, novel water gradient and/or high oxygen transmissibility designs employed to optimise comfort and encourage ongoing successful wear through the years. Otherwise, the most common comfort consideration is likely to be allergy, either in reaction to contact lens wear or secondary to the growing incidence of childhood allergy, where around 10 per cent of children suffer allergic rhinitis (hayfever), which has a 90 per cent association with ocular allergy.21 A history of allergic rhinitis though, isn’t necessarily a contraindication to contact lens wear. A small study of 10 adults with confirmed allergic sensitivity to grass pollen showed reduced symptoms of burning and stinging, reduced duration of symptoms and reduced bulbar hyperaemia, corneal and conjunctival staining when daily disposable lenses were worn as a barrier to environmental allergen exposure.22 There may be a role for daily disposable lenses in providing lubrication and a barrier function in patients with ocular allergy, which can be considered  and communicated to parents in the case  of the potential paediatric contact lens wearer with this history.

Contact Lens Psychology

For  The Patient And Practitioner It’s a sad statistic that spectacle wearing children are 35 per cent more likely to be physically or verbally bullied.23 This data comes from a study of over 6,000 children aged seven to eight years – a reduction of this risk would not be expected in the pre-teen and teen years to come for these children. Pre-teen children aged eight to 11 feel that their physical appearance, athletic competence and social acceptance is improved with contact lens wear.24 While children this age perceive their spectacle wearing peers as smarter and more honest,25 children with lower satisfaction with their spectacles felt their scholastic competence improved with contact lens wear.24

With the multitude of optical, visual developmental and psychological benefits of paediatric contact lens wear, the practitioner must balance the risks and also consider their own barriers to fitting children. Perceived complexity of management, increased chair time and cost to the patient’s parents can be key concerns. The first conversation about contact lens wear can start as a simple explanation to parent and child that contact lenses are also an option for vision correction, and giving examples of situations where contact lens wear is superior to spectacle wear – for example, when playing sport. This is commonly the initial foray into contact lens wear for children, opening the door to consistent part- or full-time wear in future, once experience is gained. Having a contact lens on hand to allow the child to touch and look at, helps to remove a fear of the unknown. When ready to proceed, fitting children (eight to 12 years) compared to teens, will require an extra 10–15 minutes of time spent on contact lens application and removal instruction, which if delegated to a staff member, does not increase the eye care practitioner’s chair time.15 However, as a key hurdle to contact lens success, the practitioner may prefer to spend this instruction time with the paediatric patient, to encourage persistence and enhance the relationship of trust between practitioner, parent and patient.

Regarding ongoing contact lens wear, parents of teens are more likely to continue purchasing contact lenses than parents of children.18 This is likely due to concerns about young age and long term duration of contact lens wear – these misconceptions are easily countered with the evidence described above. Part-time wear is more common in children than in teens according to large prescribing surveys.26 Practitioners can also share parental concerns about cost, particularly in view of daily disposable contact lens wear. This conversation with the parents can include discussion of how often they are replacing glasses for their child, how this may be different with the introduction of part- or full-time contact lens wear, and citation of research that spherical daily disposable lenses attract less cost-per-wear than reusable lenses up to three days per week of wear, and for toric daily disposable lenses this holds for up to four days per week of wear.27

Communication in practice about the benefits of contact lens wear for children and teens starts with the practitioner. Each parent and child will hold different attitudes and misconceptions about contact lens wear, particularly related to age suitability and safety. There is a wealth of scientific data indicating that paediatric contact lens wear is safe and beneficial beyond simple correction of acuity. This data can be useful when educating patients and their parents in practice. Providing 'social proof', that is, discussing other successful cases with your patients, as well as research results will help to reassure the parent when they are making the right decision for their child’s visual and personal development. 

 
 

 
Kate Gifford BAppSc(Optom)Hons, GCOT, FBCLA, FIACLE, FCCLSA, FAAO, operates an independent practice in Brisbane, Australia, with special interests in contact lenses, binocular vision and myopia control. Graduating from Queensland University of Technology (QUT) in 2003 with First Class Honours and a University Medal, Ms. Gifford is currently completing a part-time PhD by clinical research. She is a fellow of the BCLA, IACLE, CCLSA and AAO and is the Immediate Past President of Optometry Australia. Ms. Gifford is an award-winning clinical supervisor and visiting lecturer at QUT, holds 38 peer reviewed and professional publications, and has presented over 80 lectures at conferences in Australia and internationally. Ms. Gifford and her optometrist husband Dr. Paul Gifford have developed www.myopiaprofile.com and www.mykidsvision.org to assist practitioner management and raise public awareness of childhood myopia. Her lectures can be downloaded from www.kategifford.com.au.
Kate Gifford wrote this article on behalf of Alcon. The views expressed are those of the author and do not necessarily represent the views of Alcon. NP4 Number # :A21709695817

 

References
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' This article combines scientific review and clinical experience in paediatric contact lens fitting and management to help you with this conversation '