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The selection, choice and follow-up care of eyeglasses chosen for children has
challenges, rewards and pitfalls. Navigating the gauntlet of these factors
while simultaneously pleasing both the child and the parent requires knowledge,
skill, intelligence, compassion and even humor. Dispensing to children is
really done almost to a completely different rulebook than normal dispensing.
GETTING TO KNOW YOU
We will use an age ceiling of
approximately 12 years old to define children. When approaching a child
coming in for glasses, a good overall dispensing approach centers on remaining
low key. A low-key approach will help reduce the intimidation and fear a child
will naturally have when entering a new place for the first time. Start out by
addressing both the child and the parent with a friendly hello. State
your name and inquire how they both feel about getting glasses for the first
time. I have found that discovering how the child/parent would like to begin
the selection process is important. In some cases (and depending on the age of
the child), one is best advised to address the concerns, both spoken and
unspoken, of the parent first.
Many mothers are often
overwhelmed by the prospect of their baby having to get glasses. Remember
that young parents (mid 20s) still grew up in a time where eyeglasses had much
more of a negative connotation and they may feel despondent at having to be at
this junction with their child. Reassure them that, in general, getting glasses
at an early age (under five) does not mean a life-long dependency on them. On
the contrary, most young children and infants require glasses under age five
for simple anatomical reasons.
In other cases, having the child
initiate the selection process by beginning to look at, try on and play with
frames can help allow the child to really feel they are a part of the process
and not just a passenger. At all times, encourage the child to view eyewear as
fun. First, you may have to help clear up some parental confusion as to why
their baby needs glasses in the first place. Never assume the parent completely
understands the reasons that require children to need glasses.
WHY DOES MY BABY NEED GLASSES?
There are many possible causes
requiring young children to wear glasses. These are the most commonly
encountered reasons corrective eyewear is dispensed to children under five
years old:
Anatomical Because all children are physically small, their eyeballs
are too. In addition, when an eyeball is smaller than is ideal, light
will come to a focus behind the retina; the result is farsightedness.
Therefore, it is important to convey to the parent that all children are born
farsighted because the eyeball or globe is small. Nevertheless, since most
childrens eyes are able to compensate (accommodate) for this state, they
usually do not need any visual help. In cases where a childs eye cannot
completely compensate for their normal farsightedness, a weak eye muscle may be
the cause. Tell parents at the first visit that the glasses are there as a
helper to allow their childs eyes to develop normally.
Ask the parent when the first
follow-up is scheduled.You will often discover that the doctor wants to see
them in a period that ranges from six week to three months. Inform the parent
that their childs progress with the help of the eyewear requires much more
frequent follow-up at first (unlike an adults normal exam recall) and the
frequency of these follow-ups does not mean their child has a grave condition
needing tremendous attention. Just some tender loving care and eyeglasses.
Neurological The
proper neurological development of a childs visual system requires both eyes
to work together. As learned in anatomy, there is a linked relationship between
the eyes close focus, or accommodation, and the need to turn in, or converge.
As a childs eye attempts to compensate for their farsightedness, this linking
can manifest itself as an obvious turning-in of the eye (accommodative
esotropia). The tendency of the childs eye to turn-in can be compounded by
weak eye muscles that normally control the eyes position. In either situation,
in order for the neural pathways of each eye to develop properly, the brain
must be able to receive a useable signal (image) from each eye and be able to
merge these images stereoscopically.
Tell the parent the prescribed
glasses are there to help a childs eye avoid turning independently from its
companion eye. In this way, their childs brain will not favor the image from
one eye over the other. If left unattended, the child could become amblyopic
(little useable vision) in the eye with the poorer vision, the greatest turn-in
or both.
Congenital conditions
Conditions present at birth, such a severe myopia, cataracts and nystagmus (a
rapid, uncontrolled oscillation of the eye), although less often encountered in
most practices, are seen occasionally. In these cases, the optician should
inquire from the parent about the specifics of their childs condition, but
offer no speculation in response to questions from the parent. These questions
are best answered directly by the responsible physician.
PRESCRIPTION ANALYSIS
After the above discussion, the
dispenser should be in a comfortable position with the parent. The next step is
evaluating the exact nature of the prescription. By considering the strength
and type (bifocal or single vision); one can help determine if any type of
frame is better suited. With most of todays lenses available in polycarbonate
and/or aspheric designs, the thickness of the lenses should generally not be an
issue, especially in plus powers. It is during this selection process that a
dispenser should inquire about the recommended frequency of use for the new
eyewear, i.e., only for critical vision (such as classroom) or all the time. In
this way, some frame choices may become favored as superior. If bifocals or
progressives are to be fitted, be sure to note the general fitting
characteristics of the frames tried and deftly eliminate those that may not
have sufficient vertical (B) dimension to allow a usable reading area.
Remember that in pediatric fittings, both bifocals and progressive are often
set at mid-pupil (and above); in order to ensure the child definitely uses the
additional reading area when focusing close.
FRAME SELECTION
Selecting frames with children
and their parents can be a rewarding experience or an outright disaster. Most
of the time, it is the intuition of the dispenser that can mean the difference
between a pleasant experience for all or a three-aspirin event of wailing and
crying. Knowing when to step back is as important as knowing when to lead
with authority. I feel the parent should be encouraged to make an informed
decision and care should be exercised that the dispenser always appears patient
with the selection process. However, if the dispenser is too passive during
frame selection, the time spent can accumulate unproductively.
Therefore, your intelligence,
skill, humor and compassion should be integrated seamlessly. When dispensing, I
try to quickly ascertain what frame I think will work/fit/look best early on
and I try to deftly direct the selection process to these models. Parents will
be looking to the dispenser for authoritative advice and one should be always
ready with a professionally delivered recommendation when asked.
With greater rates of growth
during childhood, the selection process should always be mindful that a child
could grow into a frame during the useful life of the correction. Therefore,
dispensers should recommend frames that are slightly larger than ideal,
in order to permit this growth. Parents are cautioned to avoid selecting frames
that are undersized in order to avoid letting the eyewear dominate their
childs petite face. It should be noted that infants and small children often
have overall facial widths much greater than the anatomical pupillary distance,
especially compared to a teenagers face. With this in mind, some frames
intended for children may be found to be inappropriate. Often choosing from
some of the very small adult styles, which often feature extended end pieces,
will be found to be the superior fitting choice.
Younger-aged children and infants
are often best fit with styles featuring cable wrap around temples. Therefore
each optician working with children should be able to modify and cut any
skull-type temple and add glue-on cable adapters, which are readily available.
For this same age group, special caution must be paid to the choice of either
nose-pads/metal frames or saddle-type plastic frames. In general, infants are
better fitted with saddle bridged plastic frames. These models, however, have
the disadvantage of appearing to dominate the face, and parents will need to be
assured that this type of frame is generally the preferred fitting style.
Certainly, metal frames have the additional risk of their nose pads being
jammed into the shallow bridge (and maybe even the eye) of an infant when they
fall.
Todays frames feature a wide
assortment of colors and you should encourage the child and parent to indulge
their fancy and pick some frames in their favorite bright and happy colors.
Good color choice encourages the child to wear their glasses.
Once past the infant styles, many
childrens frames feature models that closely emulate the latest fashion in the
adult selections. There is no reason a child (or parent) should ever be unhappy
with the broad selection available today.
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For
pupillary distance, measure from outer canthus to inner canthus.
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LENS SELECTION
In childrens dispensing, it is
customary after frame selection to discuss lenses. Of course, only the most
impact-resistant lenses should be offered. Both polycarbonate and Trivex
feature impact resistance six to 10 times greater than conventional CR-39
plastic lenses and these should be the materials of choice for almost all
childrens eyewear. Advise parents that these materials also feature greater
than 99 percent UV protection as standard, as well as a durable
scratch-resistant finish.
It is also important to present
any optional, extra-tough scratch-resistant coatings and premium
anti-reflection lenses. Although the smudgy appearance of typical AR coating
can be viewed as a disadvantage in childrens hands, parents often really
appreciate the reduced glassy-eyed appearance these coating offer. Present AR
lenses in a positive light.
Create a demonstration frame
showing +2.00D or +3.00D aspheric lenses with and without AR. A high-plus Rx
can add to a kids and parents unhappiness with their new glasses.
Polycarbonate aspherics make terrific looking eyewear when the index, density,
flatness and asphericity combine to produce beautiful eyewear. If concerned
about poly and any visual effects of chroma, frames are small and the effects
most often are of little concern.
Many of these premium add-on
coatings offer comprehensive, multiple-replacement warranties for any type of
scratching. Although they add to the cost, parents will appreciate the value
they provide against the inevitable whoops. For the more moderate to stronger
plus power lenses, custom surfacing using aspheric designs will minimize
thickness and magnification effects.
In addition to aspheric designs
and AR lenses, many parents may be receptive to the presentation of
photochromic lens options. Products such as Transitions V are excellent options
for the active, outdoor lifestyle of children especially as they are available
in high-impact poly and Trivex.
DUTY TO WARN
Although the use of polycarbonate
and Trivex materials makes the likelihood of lens shattering almost
non-existent, it is still important to review with parents that these materials
are still not considered 100 percent shatterproof. In addition, most childrens
dress frames do not have to meet any lens-retention standards by law. Be sure
to advise parents that, under extreme impact, the above lens materials will
most likely not shatter. And in the event the lens is separate from the frame,
it will dislodge whole. If the glasses are to be used for any type of sports
(supervised or play), then parents should be cautioned to purchase certified,
sports-specific eyewear.
TAKING THE MEASUREMENTS
Wherever possible, employ a
pupillometer for PD measurements. In some cases, a childs PD may need to be
taken monocularly, especially with an eye-turner. However, many younger
children and infants will not sit still enough for a pupillometer. In these
cases, an anatomical PD approach must be employed. In this technique, a
dispenser measures from the outer edge of one eye to the inner edge of the
companion eye. In some cases, this must be done quickly and with precision. In
difficult cases, your best estimate will most likely be sufficient. Sometimes a
penlight can provide a few seconds of staring by the kid and allows a reflex
PD.
Temple measurements should also
be taken (if possible). When the child is uncooperative, leave the final sizing
to the delivery of the eye-wear. In the meantime, offer the parent a frame to
take home and try on the child. In this way, the drama of acclimation and
familiarization to new eyewear can be reduced or avoided.
FABRICATION AND DELIVERY
Lens retention characteristics
should be given strict tolerances. Children are bound to bend and deform their
frames, and if the lenses do not fit securely when first made, unhappiness and
inconvenience is just around the corner. Lens edge chamfers (or safety bevels) must
be done and verified. Take the lenses out of the frame and carefully run
your thumb over the exposed edges. There should be no sharpness. Touch-up the
chamfer and verify the edges are not sharp, and this will allow your
thumb-check to use more pressure without an issue. When in doubt, employ a 5x
magnifier to inspect the edges before using the thumb-check. In addition, lens
thickness that extends out the rear of the nasal area must be trimmed
back, especially with metal frames. In this way, the natural pressure from the
nose pad arms will not chip the edge of the lenses.
Metal frames should have all
their screws properly cemented or peened-over to prevent them from loosening or
falling out. Plastic frames require the same with respect to trim and temple
screws. In addition, do not forget to secure and tighten those nose-pad screws
(they often come from the manufacturers less than totally secure).
With respect to prescription
parameters, be knowledgeable about and use the most current ANSI standards
available. Put the frame in proper bench alignment and follow any preparatory
notations from the optician involved about adjustments or modifications.
Try to stay seated during the
delivery of the eyewear. This helps reduce any anxiety the child may be
feeling. After adjusting the glasses, be sure to allow the child to put the
glasses on and take them off themselves. You should instruct the child
(and the parents) on the dos and donts of proper care. Its a good idea to
caution parents not to become too concerned with light scratches that are not
in the childs direct line-of-sight. In fact consider advising the parents that
common-sense use of the manufacturers scratch-warranty is best for all the
parties involved. However, if their child complains of a problem with a defect
in their line of vision, by all means contact the manufacturer to have
replacement lenses prepared.
More than any other type of
dispensing, I think it is best to include all the care items required as
standard in the price of the eyewear. In addition, if siblings are present, you
may sense they are feeling left out or becoming jealous. Try giving them one of
the current novelty cases as a thank you for accompanying their brother or
sister. These are inexpensive ways of promoting your practice to the entire
family.
THE GOODBYE
When saying goodbye, try to avoid
using the old saw if you have any problems. I was taught the following
phrase from a former employee: Thank you for coming in to see us. If your
glasses need any attention, do not hesitate to come in again. I like that word
attention so much better than problems.
Follow up the delivery with a
personally signed thank you note. It is really the best way to emphasize your
professionalism, especially with the parents.
WHEN TO BREAK THE RULES
How does one know when to
improvise from the guidelines stated above? In a word, experience. Be patient.
Try different approaches and be prepared to learn from the kids, their parents
and each new dispensing situation. Besides keeping you on your toes,
attentiveness to the pediatric section of your practice will deliver manifold
benefits. Families like to shop where there kids are happy. And, arent you
happy when you see a happy kid?
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