The Pediatric Dispensers Rulebook: Making Kids Glasses Childs Play

By Barry Santini, A.A.S., ABOM

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.

For pupillary distance, measure from outer canthus to inner canthus.

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?