— Practical Solutions
|May 31, 2010
Upon completion of this program, the participant
should be able to:
- How systematically and logically to assess the prescription requirements of any patient.
- Determine a plan of action for fitting even the most challenging pediatric patient.
- Understand the obstacles to compliance and how they can be overcome.
- Develop techniques for fitting children with Facial Difference, Photophobia and other anomalies.
Katheryn Dabbs-Schramm is President and CEO of A Child’s View, Inc. in Mission Viejo,Calif., a four-location optical dispensary specializing inpediatrics. She is a California Registered Dispensing Optician, recognized authority on children’s eyewear and author of the book “Dispensing Pediatric Eyewear.”
She is an Ambassador for the National Academy of Opticianry and writes for ophthalmic trade publications.
This course is approved for one (1) hour of CE credit by the American Board of Opticianry (ABO).
Course # SWJMI087-2
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
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
+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.
- What is the greatest challenge to fitting this child?
- What is the next greatest challenge?
- Based on the prescription presented and conversation with the
parents, what is the most likely diagnosis?
- How can the prescription be managed?
- Frame requirements
- Lens requirements
- Special product needs
- What are the cosmetic considerations?
- What are the obstacles to 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.
Treacher Collins Syndrome is a genetic condition causing
underdevelopment of many parts of
the head and face. Children with
Treacher Collins syndrome typically
have depressed cheekbones, a small
jaw, abnormally shaped ears, hearing
loss, dental abnormalities, absence of
medial eyelashes, coloboma of the
lower lid and a cleft palate.
Facial Difference is a generic term for craniofacial anomalies. The term is used for a variety of conditions affecting
the child’s head and face. These differences can be present
at birth, develop shortly thereafter, or result from disease or
injury. The child’s entire face may be affected or only a part
of the face. The resulting physical appearance can range
from minor to severe. Most facial differences do not affect
the child’s intellectual ability or potential.
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.
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
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
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.
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
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
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
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
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.
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.