Kids’ Kases
— Practical Solutions

By Katheryn Dabbs-Schramm, ABOC, FNAO

Providing eyewear for a child can be challenging, as there are many variable and fitting considerations. This course will teach the reader a logical and systematic approach that starts with identifying the greatest obstacles (fitting limitations) and developing a plan to overcome them. This clear and practical system will help develop techniques for fitting children with facial difference, photophobia and other anomalies. Although this course deals with pediatrics, the systematic approach discussed can be applied to any patient, regardless of age, medical condition and physical or mental challenge.

ASSESSMENT/PLAN

First, the optician should identify any fitting challenges or limitations.

It may be the size of a premature infant that presents the greatest fitting challenge. It may be the child's Rx itself that limits selection and drives decision. Or, for a premature infant prescribed +30 lenses, it can be a combination of two major factors, frame size and lens power.

MAKE A PLAN

Successfully fitting a child with eyeglasses begins with determining the primary fitting limitation and then addressing any secondary or crossover limitations. Then, formulate a fitting plan based on those limiting factors by asking the following questions.

1. What is the greatest challenge to fitting this child?
2. What is the next greatest challenge?
3. Based on the prescription presented and conversation with the parents, what is the most likely diagnosis?
4. How can the prescription be managed?
   1. Frame requirements
   2. Lens requirements
   3. Special product needs
5. What are the cosmetic considerations?
6. What are the obstacles to compliance?

COMPLIANCE

A three-year-old child enters the busy dispensary accompanied by his mother who holds in her hand a plastic bag containing a lens and several pieces of the child’s eyeglass frame. The child is not happy and neither is mom.

Mom loudly complains that the glasses are less than two days old, cost $300 and her son simply will not keep them on. She wants her money back immediately.

WHAT WENT WRONG?

As soon as a parent says, “My child will not keep his glasses on,” there is a problem. If the child required a tracheotomy tube to breath, mom would not allow the child to remove it, even if it meant staying with the child every moment of the day and night. Mom knows without the tube, the child would die. Yet, the same parent cannot keep the glasses on her three-year old child.

Sufficient importance was not placed on the glasses for the mother to insist they be worn. She does not understand the importance of the glasses and what is likely to occur if glasses are not worn.

There is no magic pill, no strap or other gimmick that will secure glasses on a child. Children wear glasses because their parents are motivated by knowledge. The parents understand the condition for which the glasses have been prescribed and the correlation between compliance and successful treatment. The glasses have become sufficiently important to give the parents the desire to comply.

KIDS’ KASES—WILLIAM, RALPH AND KATIE

Twelve-year-old William enters the dispensary wearing sunglasses and a baseball cap. Dad presents a prescription of -2.00 O.U. The father and son are looking for glasses that will allow William to see better at distance, while decreasing his light sensitivity and improving his visual comfort.

Nine-year-old Ralph also wears sunglasses and cap. Ralph is very light complexioned and of average build. He is outgoing and speaks rather loudly for himself. Presenting an Rx of -2.50 -1.00 X 90 and -2.50 -0.500 X 180, Ralph explains that he has worn glasses since he was six months of age. He doesn’t like glasses, hates the way he looks in them, but realizes that he needs something for classroom use.

Enter ten-year-old Katie with both her mother and father. Katie explains her parents are interested in finding a way to control her epileptic seizures, which seem to be triggered by a particular color. Katie has no refractive error, but presents a prescription written by a pediatric neurologist. The Rx indicates Katie’s seizures are linked to “blue” light.

The three children are very different. Yet each has the same primary fitting limitation. While conventional eyeglass frames will work Each child requires a specialized tint, so selecting the appropriate color for the lens is essential.

The BPI 500 Series of lens dyes have been very effective in reducing symptoms associated with many photophobic conditions like macular degeneration, retinitis pigmentosa, aniridia, glaucoma, and albinism. Special brown dyes or Coppertone lenses (Vision-Ease) are successful in blocking blue light. However, it is not enough just to compare color. In order to match patient needs with the lens properties and color effects, a transmission curve or spectrophotometer reading of the desired color must be obtained. In addition, some tints will be more effective indoors but inadequate in full sunlight. So, lighting conditions must be considered as well.

Another difficulty encountered when duplicating the effects of a particular color in polycarbonate is attaining the proper density. Because Trivex provides impact resistance and tints more readily, it also can be an efficient, effective lens choice.

Once the desired lens transmission curve is determined, all other fitting considerations revolve around that initial decision. The prescription and associated diagnosis, the frame and lens choices, cosmetic considerations, and ultimately, compliance, are based on the primary fitting limitation—the lens transmission curve needed.

KIDS’ KASES—CHRISTOPHER

Christopher is a 12-year-old epileptic myope who has worn glasses since age three. With an Rx of -5.00 DS OU, Christopher needs to wear corrective lenses. His parents are concerned because he will not wear the sport frames prescribed for full-time use, when he was first diagnosed with epilepsy. Christopher’s seizures are almost completely controlled with medication so the parents now want dress eyewear. However, they want to be certain the glasses will not cause further injury if the child were to suffer another seizure. Christopher refuses contact lenses.

Primary Fitting Limitation —Fitting Christopher with dress eye-wear requires selecting a frame that will pose the least safety hazard. He has sport frames, which he refuses to wear. When selecting a frame concentrate on frames that will be as safe as possible and still attractive enough to be worn by a discerning 12 year old.

The first logical choice of frame material is plastic. While plastic frames still can cause impact-injury, they are less likely to cut as severely if Christopher were to fall during a seizure. Contrary to logic, a plastic frame selected for this child should not have spring hinges. Although spring hinges on children’s frames usually are recommended, frames with spring hinges should be discouraged for Christopher. When the temporal portion of the child’s frame is hit with sufficient force, the spring allows the temple pieces to open out. The spring structure and even the temple butt can be forced into the fleshy area at the child’s temple. A severe puncture wound can result. Remember, Christopher’s primary fitting limitation is safety.

Secondary or Crossover Limitations — The Rx of -5.00 O.U. presents a “crossover” (related) concern. The frame must also be suitable for high minus lenses that are as safe as possible. All fitting decisions, from the frame to lens material and even edging methods will be based on the primary fitting limitation—safety.

Considerations at a glance:

• The frame must maintain proper vertex (usually 13.5mm) without the frame resting on the cheeks or the eyelashes touching the finished lenses.
• Aspheric polycarbonate lenses with no less than a 1.2mm center thickness reduce edge thickness, improve visual performance, and enhance appearance.
• Instead of a standard hide-a-bevel, the edges should be rolled and a wider than normal safety bevel applied to further reduce risk of injury. Splitting of the bevelis helpful in preventing or reducing injury sustained during a seizure.

Seth Temple— Because the ears may not be functional and the transmitters require repositioning, a specially modified temple is used. The Seth temple is a skull temple modified to attach to the headband-using lightweight elastic. The flexibility of the elastic used allows unrestricted movement of the transmitters found at the end(s) of the headband.

Probable Diagnosis — Christopher is a myope, past the age of visual maturity.

Rx Management — Lenses with antireflection coating or additional scratch coating could be included here.

Compliance — Christopher’s visual system has fully matured so wearing corrective lenses has no lasting therapeutic effect. However, glasses will improve the quality of his life. Without them, Christopher cannot go to movies, attend sporting events, watch TV or play video games. With younger children, the parents are vital to obtaining compliance. Far less parental involvement is required with a 12-year-old high-myope. If Christopher is actively involved in selecting a frame that is as safe as possible and cosmetically pleasing, and because Christopher will also see better with corrective lenses, he will wear the glasses. The parents must be warned that no glasses are completely safe and no glasses prevent (all) injury.

A few words about Christopher’s sport glasses: Purchasing new dress eyewear does not negate the need for sport glasses. Wearing sport glasses while participating in active play must remain non-negotiable. Either Christopher wears protective eyewear or he should not be allowed to participate.

KIDS’ KASES—MICHAEL

Michael is a precocious six-year-old of average height and weight. He is intelligent and out-going. Michael has Treacher Collins Syndrome, a type of facial difference (see sidebar), and has been prescribed his first pair of prescription eyeglasses. The parents appear distraught and mom angrily thrusts forward a written prescription of -3.00 +1.00 X 180 and -2.75 +1.00 X 90.

Primary Fitting Limitation — Because Michael does not have fully developed ears and uses a bone conducting hearing aid, fitting him with eyeglasses can be quite challenging. However, once the glasses are in place, Michael’s appearance will improve as the frame adds symmetry to his misaligned features.

Frames selected for this child should be limited to metal of superior quality that will withstand the severe manipulation required to adjust the frame correctly. Most children with mild to moderate facial difference can be fitted without customizing the front. Children who do not have sufficient ear structure to support the glasses, or those with bone-conducting hearing aids require modification of the temple pieces.

Secondary or Crossover Limitations — The parent’s emotions may present a far greater obstacle than frame selection. Parents of children with facial difference have been through a great deal. It would seem the initial diagnosis and multiple surgical procedures would better prepare them for something as non-invasive as putting glasses on their child. Usually this is not so.

The parents may feel overly protective or they may be frustrated because no one seems willing or capable of helping them get glasses on their child. As they find themselves in public places, they may also become increasing uncomfortable with society’s reaction to their child. Many times these feelings are expressed as anger. Michael’s mother is angry and if her anxiety is not reduced, the family may leave the office before being helped.

The optician must deal with all aspects of the glasses concisely and directly, treating the entire dispensing process as commonplace. The optician must be thorough and realistic. And, must do so in a caring, concerned, helpful manner that shows respect for the parents and above all, the child.

Probable Diagnosis — Since his parents deny exotropic strabismus (suspected by the minus correction) Michael is assumed only to be myopic with a slight astigmatism.
Rx Management — Since polycarbonate or Trivex lenses are standard for use on all children and a sturdy metal frame will be used, the only other management issues are related to compliance.
Cosmetic Considerations — There are four main areas of concern: color, shape, length of nose, and distance between the eyes. Each of these areas takes on far greater significance when fitting a child with facial difference.

1. Color—The eye will naturally travel to the brightest or most colorful area of the face. The frame color will help direct attention away from the Facial Difference. Colors natural to the child always are considered first with black and solid colored frames good alternatives. If the child has irregularly shaped or no eyebrows, the upper eyewire should be darker than the rest of the frame, when possible.

2. Shape—The shape of the frame should add symmetry and balance while making the facial contour appear as close to oval as possible. The shape of the temporal eyewire affects the overall contour of the face. The shape of the nasal eyewire creates facial symmetry. The depth of the frame gives the face balance.

3. Length of nose—The higher the bridge, the longer the nose appears. The lower the bridge the shorter it appears. This can be used to great advantage when working with little noses.

4. Distance between eyes—Frames that have a strong color or are wider at the nasal eyewires will make the nose appear wider and the eyes closer together. Solid color frame with thinner eyewires have the opposite effect. The greater the frontal angle, the wider the nose will appear within the nasal eyewires. When the nose is asymmetric, maintaining equal distance between the nasal eyewires will help create a symmetrical appearance. If this is not possible, the eyewires should be dark in color to add definition and create the illusion of symmetry.

When making the final selection, it is helpful to check the frame from a few feet away. The frame may not look as good up close, but have the desired effect from a short distance away.
Compliance — For the child with facial difference, the cosmetic appeal of the glasses plays a significant role in gaining compliance. Once the parents understand the importance of the prescription and see the symmetry and improved cosmetic appearance, compliance almost is assured. Even in cases of severe facial difference where extreme frame modification is required, usually there is cosmetic improvement.

KID’S KASES—MELANIE

Melanie is a very active five-year-old who loves to play soccer. She gaily skips into the dispensary proudly showing off her bright red Wildcats jersey. Mom is carrying Melanie’s glasses, which were purchased a few weeks prior. The on-file Rx is: +1.50 DS OU. Dad complains that Melanie’s glasses simply will not stay on while she is on the soccer field. The front was replaced last week when the glasses flew off and were broken during a game. Now, the parents want cable temples.

Primary Fitting Limitation — While there are no specific fitting limitations associated with the Rx, there is a liability issue that cannot be overlooked. Accommodating the parents and attempting to satisfy them may consider the well-meaning optician duplicitous. Melanie’s parents need to be warned of the dangers posed by wearing dress eyewear while participating in an organized sport.
Secondary or Crossover Limitations — There are no secondary or crossover limitations
Probable Diagnosis — The Rx suggests hyperopia. However, discussion with the parents reveals a controlled esotropic strabismus.
Rx Management — The child’s current glasses need cables added so they stay in place while Melanie is at school. In addition and most importantly, Melanie needs sport specific eyewear. This not only opens the door to a second-pair sale, it protects the office and best serves the needs of the child.
Cosmetic Considerations — Many children object to wearing sport glasses because of the appearance. Fortunately, now there are more styles available, which children actually like. While the frame must offer protection, it can still be relatively attractive. Using photosensitive lenses also aids acceptance and practicality.
Compliance — Although Melanie is wearing dress eyewear successfully; compliance can still be an issue for sport eyewear. The primary objections to sport glasses are appearance, comfort and peer pressure. While finding an attractive sport frame is easier, comfort remains a deterrent to compliance. Comfort has greatly improved over the past few years, but sport glasses are by design, not as comfortable as street-wear. Sport glasses must fit snuggly on the nose and this can be hot and feel restrictive. The use of attractive frames with photosensitive lenses has helped limit negative peer-pressure.

CONCLUSION

To serve the needs of all children, the optician must be familiar with most fitting limitations and be innovative when working with the unfamiliar. The optician must possess technical skill and be respectful, empathetic, and above all, professional. By using a systematic approach and looking at each child’s situation individually, any child, regardless of physical challenge, prescription requirement, or fitting limitation can wear attractive and comfortable eyewear.