Kids and Contacts
By Linda Conlin, ABOC, NCLEC
Release Date: February, 2013
Expiration Date: September 28, 2017
Upon completion of this course, the participant
should be able to:
- Identify common vision conditions in young children.
- Understand special considerations for fitting infants and children with contact lenses versus older patients.
- Understand evaluation techniques, instrumentation and the role of caregivers in pediatric contact lens fits.
With over 30 years of experience and licensed in Connecticut, Massachusetts and Rhode Island, Linda Conlin is a writer and lecturer for regional and national meetings. She is chair of the Connecticut Board of Examiners for Opticians and is a manager for OptiCare Eye Health and Vision Centers, a multidisciplinary ophthalmic practice in Connecticut.
This course is approved for one (1) hour of CE credit by the National Contact Lens Examiners (NCLE). Course CTWJM547-2.
The past two decades have seen a
marked increase in how often
eyecare professionals (ECPs) fit
children with contact lenses. ODs
and physicians prescribe contact lenses for
children more frequently partially because of
improvements and adaptations in the contact
lenses themselves. The other part is that kids need
them. Six to nine percent of children younger than 18 have some type of vision condition. Amblyopia
accounts for five percent of that number. The
statistics, however, represent only the tip of
the pediatric vision care problem, and as
ECPs we should be concerned with a few
more. For example, 25 percent of school-age
children have vision problems. More than 11
percent of teenagers have undetected or
untreated vision problems. Mentally and
physically handicapped children have twice the incidence of vision problems as children
These statistics do not just represent fitting opportunities. They represent roadblocks that these children will face
over their lifetimes if they do not receive vision correction at a young age. For example,
statistics show that children with visual conditions frequently face additional challenges.
- More than 70 percent of juvenile offenders have undiagnosed vision problems.
- More than 50 percent of children who have a vision screening and are recommended
to have an eye examination do not get one.
- Vision screenings detect only five percent of all vision problems.
- Twenty percent of school-age children
have a learning disability.
- Seventy percent of those children have
some form of visual impairment.
- In the youngest children, retinopathy of
prematurity occurs in more than 16 percent of premature births.
- Astigmatism is present in 30 to 70 percent of children up to 2 years of age.
- In preschoolers, the incidence of ambly-opia is three to five percent and two to
four percent for strabismus.
- Approximately one percent of 3-year-olds wear corrective lenses.
- Two percent of children entering first
grade are myopic. (Fig. 1)
IDENTIFYING THE PROBLEM
Infants, very young children and some
children with disabilities frequently do
not respond to questions or cooperate
well with the ECP during a typical eye
exam and contact lens evaluation. At the
same time, children usually become anx
ious about procedures, so an ECP must
be more flexible and creative when dealing with children.
Even though the child's parent will
have supplied the history and chief complaint, the ECP must establish a rapport
with the child. How? Reviewing the history and clarifying information with the
parent before taking a young child into
the exam room can help reduce stress.
After all, he/she will spend what they
may perceive to be a long time in a dark,
perhaps scary room. Begin the evaluation
while walking with the child to the exam
room. Talk to the child about herself in a
friendly manner and in a language she
will understand. Look for obvious
defects like nystagmus or strabismus and
unusual posture or head tilt that may
indicate vision problems.
Ask the parent to hold a small child on
his or her lap in the exam chair. Use
instruments such as a handheld autore-fractor and keratometer while a parent
holds the child. Make the process more
like playtime and less like a clinical proce
dure. For example, play "peekaboo"
when you cover each eye with the occluder. Animated cartoons or mechanical toys
with sound make excellent fixation targets
for distance, while handheld toys work
well for near. Play the "Match Game"
with children who do not speak. Ask the
child to match the Allen cards you or a
parent show him to the same pictures on
the distance screen (Fig. 2).
Children who are too young to match
pictures can reach for a small object held at
near and retrieve a toy they see across the
room. Observe the way the child
approaches the toy for more clues to vision
problems. Teller acuity cards are another
option. Because children prefer to look at
patterns rather than solid color fields, the
cards have a striped pattern on one half
and are blank on the other. The stripes
become progressively smaller, and the
child will stop responding to the cards
when he/she can no longer see the pattern.
For infants, observe their interest in
looking at objects around them. Watch
how they react to light, movement and
color. The Bruckner test is another indicator of refractive error. Use a direct oph-thalmoscope to illuminate both pupils
and observe the red reflex when light reflects from the retina. Inferior crescents
indicate myopia and superior crescents
The next step is to determine the prescription for corrective lenses. Streak retinoscopy
works well for children who cannot respond
to subjective tests. The practitioner flashes a
light beam horizontally across the retina and
observes the red reflex. The reflex moves
either with or against the horizontal motion.
Movement in the same direction as the light
indicates the need for plus power, while
movement in the opposite direction indicates minus power.
Instead of a phoroptor, use progressively
stronger, handheld trial lenses of the indicated plus or minus power in front of the
eye and repeat the test until the movement
is neutralized. When corrected for working
distance, the power that neutralized the
movement becomes the prescription.
INFANTS IN CONTACT LENSES
Once you have a prescription, you can
begin fitting the lenses. Let's start with a
look at contact lenses for infants. Congenital cataracts occur in 1.7 of 10,000 births
and can be bilateral or unilateral. Causes
include genetics, metabolic disorders, birth
trauma and maternal infection during
pregnancy. Unlike their use in adults, intra-ocular lens implants in infants to replace
the crystalline lens is controversial.
Eyeglasses on infants are impractical,
which makes contact lenses the most
common correction for pediatric aphakia.
Because the first year of life is critical to
visual development, ECPs usually fit contact lenses seven to 10 days after surgery,
with soft lenses as the most common solution to restore phakic vision. Keeping in
mind that a new baby's world is close; add
2D to 3D to the final prescription to
enhance near vision. Avoid tight-fitting
lenses because the child will spend a great
deal of time sleeping with them.
Fitting infants with contact lenses for
any vision problem presents some logisti
cal challenges. Infants cannot be told to
sit still or look at a target. They do, however, respond to voice recognition, touch
and smell. Try to spend some time holding and speaking softly to the baby before
beginning the fitting procedures. Instead
of a slit lamp, use a penlight and magnifier
or a lighted magnifier to evaluate the lens.
Work quickly when inserting and removing the lens to help keep the child calm.
Remember that this is an emotional time
for parents who may react poorly to the
Make sure the parents understand the
importance of follow-up exams. Generally, a follow-up visit is scheduled for 24
hours after the initial lens insertion, then
every one to two weeks afterward for lens
removal, cleaning and disinfection. Parents must know how to apply lens lubricant every morning and night.
After about four to six weeks, instruct
the parents in lens care, insertion and
removal. Advise parents to look for redness, discharge and the infant rubbing or
reaching for his eyes. Show parents how
to identify a decentered lens and the
methods to recenter it. Provide them with
written information on key points and a
24-hour phone number for assistance.
Whenever possible, provide a spare pair
of lenses. Subsequent follow-up visits
depend on specific medical issues, but
keep in mind that the corneal curvature
quickly becomes flatter during the first
year and may require one or more base
curve changes from the original fit.
CONTACT LENS PROCEDURES
FOR YOUNG CHILDREN
Contact lenses frequently are a good
choice for correcting vision in young children. In correction following surgery for
congenital cataracts and in aniseikonia,
contact lenses reduce differences in image
size between eyes and improve peripheral
vision. In amblyopia, an occluder or
opaque contact lens is preferable to a
patch because it's easier to keep in place.
In fact, contact lenses solve the problem
for parents who have to keep glasses
clean, comfortable and in place for many
children who need vision correction.
As with the eye exam, be flexible and
creative with fitting procedures. Handheld keratometers reduce the difficulty in
obtaining corneal curvature readings.
When children are too young even for a
handheld keratometer, the Bascom Palmer averages of corneal curvature provide a
good starting point. The averages are
based on age, ranging from birth to 9
years (Fig. 3).
If a child is too young to be held in a
parent's lap for slit lamp evaluation, use a
portable slit lamp. In the absence of corneal issues, a penlight and handheld
magnifier or a lighted magnifier may also
suffice for precorneal and lens evaluation.
Usually, the practitioner will need to hold
the child's eyelids open. If necessary, use
a Burton lamp with the cobalt filter for
Older children present different challenges. They may have anxiety about the
procedures and can be quite good at
resisting them. A sympathetic, reassuring
approach will help, but avoid being condescending. Explain what will happen in
simple terms. Don't fudge or fib.
Remove the mystery surrounding a contact lens by letting the child hold and
touch a disposable trial lens. It may be
helpful to demonstrate some procedures,
such as lens insertion or instrumentation,
on a doll or teddy bear. Praise the child
every time she cooperates. Avoid disapproval when she doesn't. Find another
approach and ask the child for help by
asking her how she wants to accomplish
the task. This may provide an idea for a
different task and reassures the child by
involving her. You might have to ask the
parent to swaddle a child who is completely uncooperative. But remember this
is a step of last resort. You may be able to
keep the child from moving, but you can
bet she will scream and cry.
HANDLE WITH CARE
As with adult contact lens fits, pediatric
contact lens fitting has risks. A study
reported in Pediatrics magazine reviewed
hospital emergency department visits
(ED) associated with medical device-associated adverse events (MDAE). In 2004
and 2005, ophthalmology visits were the
largest group of MDAEs for pediatric
patients. Of those visits, contact lenses
accounted for 23 percent of the MDAE
cases, the largest group. Forty percent of
all MDAEs for children 11 years of age
and older were related to ophthalmic
devices, and a majority of those cases
involved contact lenses. Contact lens-related MDAEs included corneal abrasion, ulceration and conjunctivitis (Fig. 4).
ECPs must build a rapport with parents
and their children regarding contact lens
wear and to adequately educate everyone
involved. Both children and parents must
be motivated and have realistic expectations about wear, care and cost. Keep in
mind that children may not complain
about contact lens problems or may
attempt to hide them because they are
afraid they have done something wrong or
that the lenses will be taken from them.
Stressing the importance of follow-up visits with both parents and children, and
scheduling the appointments in advance
can minimize the risk of contact lens-related complications.
Fitting an older child of parents who
wear contact lenses usually has the bonus
of a positive attitude toward contact lens
wear, eliminating the hurdle of explaining
the benefits of contact lens wear versus
the cost in time and money. But there can
be a downside. The reality is that if Mom
or Dad is noncompliant with contact lens
wear and care, little Johnny will be too.
Don't take foreknowledge of contact
lens wear for granted. Inform the parents
and child about the treatment, risks, care
and alternatives in the same way that you
would for a patient entirely new to contact lenses. This is an opportunity to
remind parents about the care they should
be taking of their own lenses. It is possible
that parents will recognize and correct
their own noncompliant behaviors when
they view them in light of the outcomes
they want for their child.
THE FUTURE IS IN THEIR EYES
Technological advances in lens materials
and easier care systems allow children to
begin wearing contact lenses at younger
ages. According to the American Opto-metric Association, studies have shown
that contact lens wear improves the quality of life for many children not only by
correcting vision, but also by improving
self-confidence. According to the 576
optometrists who participated in the
American Optometric Association (AOA)
Research and Information Center Children & Contact Lenses study, 71 percent
already prescribe lenses to children 10 to
12 years old, usually daily disposable lenses. Twenty-one percent said they are more
likely to fit children 10 to 12 years old
than they were a year ago. This means that
ECPs must be ready for a larger, younger
pediatric patient population. With parental support, new materials and easier care,
the minimum age for fitting children with
contact lenses is virtually nonexistent.
For all of its unique challenges, pediatric
contact lens fitting comes with unique
rewards. Eighty percent of early learning
is visual, and as statistics show, uncorrected and undetected vision problems can
have a long-term impact on a child's life.
The most important investment we can
make in our future is providing the best
care and education for our children.
Vision care is a critical part of that plan.