Approved for Ohio Credit by the Ohio Optical Dispensers Board

Healthy Sight Counseling for Children

By Denis Fisk, Director of Global Clinical Education, Transitions Optical, Inc.

HEALTHY SIGHT DEFINED
Healthy Sight is defined as the enhancement of the everyday quality of vision and the preservation of long-term ocular health—simply put, seeing well now and into the future.

Increasing numbers of eyecare professionals are adopting an integrated approach to achieve healthy sight. Called Healthy Sight Counseling (HSC), it considers factors beyond visual acuity—such as quality of vision, visual comfort and convenience, and long-term ocular protection and eye health— when making eyewear recommendations.

While Healthy Sight Counseling is a concept for all ages, achieving healthy sight in children needs to go beyond simple vision correction. It becomes even more important for children than for adults. After all, vision care in childhood can affect healthy sight for a lifetime.

Therefore, when making product recommendations for children, eyecare professionals can do more than prescribe and dispense eyeglasses. These include visual acuity, quality of vision (particularly light sensitivity and glare), trauma and ultra-violet radiation (UVR) protection as well as self- and peer-acceptance of spectacle wear. By taking the time to educate everyone on what is required to provide healthy sight now we can protect and help preserve it for the future.

HSC provides the eyecare professional with a blueprint for promoting Healthy Sight in the practice through a customized eyeglass prescription, maintenance and preventive eye care, and raising awareness of Healthy Sight through education.

Healthy Sight Counseling is a patient-centered approach based on primary care-medical methodology. Crucial to the successful implementation of Healthy Sight Counseling is the integration of three key components: Vision Care, Vision Wear and Education. Healthy Sight Counseling addresses both quantity and quality of vision issues, leading to what is called the customized eyeglass prescription, where specific eyewear recommendations are made taking into account the individual patient’s specific visual needs, occupational and recreational requirements, ocular and systemic health issues, risk factors and lifestyle.

HSC FOR CHILDREN
HSC is arguably more important for children than adults because of its preventive aspects. In general, the earlier preventive measures are adopted, the more effective they become. Furthermore, a child’s eyes are more susceptible than an adult’s to certain risk factors that affect long-term ocular health. These include impact-related trauma and UVR exposure.

Early detection and treatment of serious ocular abnormalities in children (particularly high and/or asymmetrical refractive errors, vision-threatening diseases and strabismus, which can lead to amblyopia) and the prompt and accurate correction of ametropias are critical. The use of various eyeglass lens enhancements to maximize both the quantity and quality of vision can play an important role in the development of the child from an ophthalmic, educational, functional and social aspect.

THE CHILD AS A PATIENT
A child is not simply a miniature adult. Children’s eyes, as well as their visual needs, differ from those of adults in a number of important ways. They are more vulnerable to UVR-related ocular damage. Good vision is critical to a child’s early educational, functional and social development. For the most part, children have different lifestyles than adults. Children spend more time outside than adults, experiencing up to three times more sun exposure. Children are the most physically active of any age group with a higher risk for sports-related eye injuries. Computer and video game use create special demands on vision. These differences make the approach to vision and eyecare quite different in the child than in the older patient.

Children’s Quantity of Vision may be limited by ocular disease or refractive error Quantity of Vision is defined by how well a child sees using a standard visual acuity chart, usually the Snellen chart. Accurately assessing the Quantity of Vision becomes more difficult the younger the child, but even in pre-verbal children, the experienced examiner can get some idea of visual status. Measuring the quantity of vision is useful in detecting medical and refractive abnormalities that can limit visual function. With refractive errors, measuring vision quantity can be helpful in assessing the adequacy of vision correction with eyeglasses.

Children’s Quality of Vision is defined as visual comfort and convenience, light modulation and glare protection. Again, the younger the child the more difficult but here decisions can be made by a knowledgeable professional that are best practice.

Children’s Eye Health concerns involve impact protection, UVR protection and attention to the systemic diseases and medications that may affect vision.

Putting all the above into action with Healthy Sight Counseling for Children should result in a customized eyeglass prescription, education of the parents as well as the child (to the level that they understand) and the development of a collaborative approach with other professionals so that care is seamless.

The most important components of the vision examination in the child are the early detection of potentially vision-threatening ocular diseases and strabismus and the prompt and appropriate intervention to maximize vision and decrease the potential for the development of amblyopia. The recognition of significant refractive errors that can impair visual functioning, impede educational progress and hinder psychosocial development is also crucial, as is the identification of special risk factors requiring specific optical precautions.

While there are many components to a vision examination, the simplest and most basic is the assessment of visual acuity. Other basic components of the child’s exam are the evaluation of the alignment of the eyes and stereopsis testing.

The World Health Organization has estimated that 5 to 15 percent of children worldwide have significant refractive errors. The potential price of failing to address this quantity of vision issue is tremendous from the viewpoint of school performance, acquisition of hand-eye-mediated motor coordination skills and psychosocial development. Visual impairment in the child can have a profound life-long socioeconomic impact in developing nations where large numbers of refractive errors go uncorrected.

Up until recently, quality of vision issues in children has not received much attention. This is not because they do not exist; they’ve been largely overlooked. Two recent studies have demonstrated that eyeglass-wearing children are bothered by the same quality of vision issues (specifically light sensitivity and glare) as adults, and, of even greater interest, the vast majority of them (more than 90 percent), when given the choice, prefer using eyeglass lens enhancements to address these quality of vision problems.

In assessing patient satisfaction with eyeglasses prescribed/dispensed, Healthy Sight Counseling expands the optician’s checklist to include quality of vision issues—specifically visual comfort, visual convenience, glare and light modulation.

Children do have quality of vision issues, the same as adults. But unlike adults, children may not readily identify these issues. It is the role of the optician in Healthy Sight Counseling for the child to explore quality of vision issues in the eyeglass-wearing child and use the customized eyeglass prescription, as in the adult, to specifically address them.

The results of two studies, assessing children’s preferences between clear and photochromic lenses with regard to visual comfort, visual convenience and self/peer-acceptance of eyeglass wear, shows the possibilities.

Madeline Romeu, OD and Susan Stenson, MD performed the first study in the U.S. in 2003. Carole Lakkis, BScOptom PhD and Kate Weidemann, BOptom, at Clinical Vision Research Australia at the University of Melbourne in 2006, performed the second.

In both studies, after completing two 30-day trial periods wearing photochromic lenses and clear lenses sequentially, participating children completed specially formulated pediatric quality-of-vision surveys, with questionnaires designed to assess their experiences wearing their lenses in different situations such as outdoor use, indoor use or when watching television, using computers or adjusting to lighting changes. The children were also queried regarding personal and peer acceptance of their eyeglasses.

These studies were based on similar studies previously performed in the adult population. (Four out of five patients preferred the visual comfort of Transitions Lenses 1.50 over regular, clear lenses. Stenson SM, Baldy CJ, Scherick KJ: Evaluation of vision-related quality of life for patients wearing photochromic lenses. CLAO Journal 2002; 28:128-135.)

Both studies found children significantly preferred photochromic lenses over clear lenses. In the Australian study, 88 percent of children chose to continue wearing photochromic lenses at the conclusion of the study. In the U.S. study, nine out of 10 children similarly chose photochromic lenses over clear lenses.

In the U.S. study, significant factors influencing this preference for photochromic over clear lenses included improved visual comfort as well as higher peer acceptance. Children in the study experienced a significant improvement in their ability to see in bright sunlight outdoors with photochromics over clear lenses. Forty-seven percent said they had “no trouble at all” seeing in bright sun when wearing photochromic lenses compared with 27 percent of those wearing clear lenses. Sixty-one percent reported their friends liked them better wearing photochromic glasses as compared to 46 percent whose friends liked them better wearing clear lenses.

Results from a parent survey also indicated a clear preference for photochromic lenses, with 98 percent of the children’s parents saying they would be likely to select photochromic lenses over clear lenses for their child in the future.

Both the U.S. and the Australian study convincingly demonstrate that children can and do appreciate the benefits of quality-of-vision eyeglass lens enhancements like photochromic lenses and, when given the opportunity, they appear to overwhelmingly prefer photochromics over standard clear eyeglass lenses.

Impact protection — Children live and prosper in an active, rough-and-tumble world—much more so than adults. And, all too often, children—and specifically children’s eyes—pay the price for living in this kind of world.

Approximately 40,000 sports-related ocular injuries occur in the U.S. each year. Of these 43 percent occur in children under 15 years of age. It has been estimated that 90 percent of these ocular injuries could be avoided with the use of appropriate sports-protective eyewear, but only about 15 percent of children use eye protection for sports. For this reason, all children’s eyeglasses should be dispensed in impact-resistant materials such as polycarbonate or Trivex materials.

In addition, for spectacle-wearing and non-spectacle-wearing children engaged in contact sports or sports involving high velocity projectiles (e.g. tennis, etc.) protective wrap-around sports glasses or goggles with impact-resistant lenses should be routinely recommended.

Ultraviolet Radiation — Ultraviolet radiation protection for the skin and the eye is among the most important aspects of preventive medicine in this century. This is because of the increasing hazard of UVR exposure due to the ongoing— and seemingly accelerating—depletion of the protective ozone layer.

Ocular UVR protection is particularly important in the child for two reasons: first, because the bulk of the lifetime UVR exposure occurs prior to age 18; and second, because the clear lens of the young child transmits 7.5 times the amount of potentially harmful UVR as the yellowing lens in the adult. Damage caused by exposure to UVR is cumulative and therefore protection needs to begin as early as possible.

Both acute and chronic UVR exposure can be harmful for the eyes. Acute intense exposure leads to what is essentially sunburn of the eyelids and the eyes (conjunctiva, cornea or retina). Chronic UVR exposure is more insidious and probably more important from the viewpoint of potential visual disability. While these conditions may not present in children, long-term cumulative UVR exposure has been identified as a risk factor in such diseases of later life as skin cancer of the eyelids, the development of cataract, age-related macular degeneration and pterygium.

Therefore, it is important for all lenses to have 100 percent UVA and UVB absorption. Besides protecting the eyes from UVR, photochromic lenses have the ability to modulate light and, with AR-coatings, to decrease distracting, discomforting and disabling glare, thus acting to improve the quality of vision.

Next, take into consideration systemic diseases and the medications used to treat them and how these might impact on children’s vision and long-term eye health. Certain childhood diseases may impact on vision and long-term ocular health and these should be identified in the young patient. Of special relevance are childhood diabetes, asthma, cancer and attention deficit hyperactivity disorder (ADHD).

In addition to childhood diseases, a number of commonly prescribed medications used to treat these diseases in children can impact negatively on Healthy Sight. These include steroids (including inhalers), ADHD drugs, antihistamines, chemotherapeutic agents, insulin and oral diabetes medications. According to a Center for Disease Control survey, approximately 13 percent of children in the United States had a problem for which prescription medication had been taken regularly for at least three months [Summary Health Statistics for U.S. Children: National Health Interview Survey, 2004].

The Customized Eyeglass Prescription generated enables the optician to promote healthy sight. Modern eyeglasses can do more than simply correct vision. Lenses and lens enhancements actually do enhance vision, providing quality of vision and helping to protect the eyes and prevent vision-threatening ocular disease in later life.

Ocular protection from ultraviolet radiation and impact injuries, glare reduction and light modulation can all be effectively addressed with the right choice of lens materials and lens enhancements.

Spectacle lens materials and enhancements to be considered include impact-resistant lens materials such as polycarbonate or Trivex, high-index materials where appropriate, anti-reflection (AR) coatings, fixed tint lenses, photochromic lenses and polarized lenses. If the child is engaged in sports—especially high-velocity impact sports—protective sports goggles may also be required.

PRACTICAL TIPS
Use the variety of spectacle lens materials and lens enhancements to accomplish your goals. All spectacle lenses prescribed for children must be impact-resistant and 100 percent UVA- and UVB-absorbing. Anti-reflective coatings and fixed tint, photochromic or polarizing lenses provide improved quality of vision and should be considered in children’s eyewear the same as in eyewear for adults.

Don’t forget the importance of the frame. During frame selection, advise parents what constitutes not only a good frame but also one that fits well. Don’t let them—or their child—fall in love with a frame that simply doesn’t work. When deciding on a frame for the child, keep in mind that it is the child who will be wearing it. Children are unlikely to wear those eyeglasses if they don’t think they look good in them. Eyeglass frames are a fashion statement and should be treated as such. Also remember the parents who will be paying for them, so recommend frames that are durable and as “child-proof” as possible. Additionally, consider recommending special sports goggles if the child plays sports or is involved in active pursuits.

Bring out the best. Never withhold offering premium products for children. Parents want the best in everything for their children—why not in their eyewear?

Hands-on attention. Get the child physically engaged with eyewear selection. Utilize in-office educational tools to introduce parents to the importance of everyday eye health and available lens options.

Speak the right language. Talk to the CHILD about how good they look and how well they will see in their eyeglasses; talk to the PARENTS about specific lens benefits for their child. Stress the worry-free convenience of photochromics to parents; they want a simple optical solution that protects their kids’ eyes and makes them see well and comfortably under any and all light conditions. Basically parents want eyeglasses for their children that their children will wear.

Create healthy habits early. Remember, you want to instill healthy eye habits at a young age so children will be on their way to a lifetime of healthy sight.

Healthy Sight Counseling. While adult patients are expected to partner with their eyecare professionals and members of their medical team to work to achieve Healthy Sight, the situation becomes more complicated in children who are dependent on the many adults in their lives who look out for their well-being.

A team approach to children’s HSC is an important concept for the eyecare professional who is attempting to integrate HSC into the practice. As opposed to the situation in the adult, where HSC is typically a one-on-one interaction between the patient and the practitioner, when dealing with the child multiple patients are involved (i.e. the child, the parents, pediatricians, siblings, teachers, coaches, counselors, etc.).

Transitions research has revealed some startling gaps in education and awareness when it comes to Healthy Sight. Kids are twice as likely to wear sunscreen, as they are sunglasses. A recent survey (March 9 to 13, 2006 by ICR, Media, Pa.) found that one third of parents were “very unlikely” to get UVR blocking lenses for their children. This same survey found that parents were twice as likely to choose UVR blocking lenses for themselves, than they were for their children.

Transitions also offer a series of brochures to let patients know “What to Expect” from their eyes based on their age. The kids’ brochure provides information for parents on what’s happening to their child’s eyes and lists steps for preserving healthy sight.

Use this review checklist with each patient:

1) Check for visual satisfaction with eyeglasses prescribed.
2) Be sure all eyeglass lens designs and lens enhancements that will serve to improve the quantity and the quality of the child’s vision, protect the eyes and promote long-term ocular health have been offered.
3) Assist with appropriate eyeglass frame selection.
4) Discuss the importance of screening and regular follow-up eye exams in the child and adolescent.
5) Emphasize the need for ocular UVR and impact protection.
6) Let the parents know that Healthy Sight Counseling can work for them as well as for their child.

In this way—through Healthy Sight Counseling—we can help to promote a lifetime of healthy sight for children. ■