Children who become myopic typically do so around age eight years, requiring some form of vision correction.^1,2 However, for those children that are active, glasses are considered an impediment during recreational activities.^3,4 Contact lenses are an alternative vision correction option that can easily be updated as the prescription changes. Research shows children are capable of wearing both gas permeable and soft contact lenses, and thus far there have been no documented long-term consequences of fitting children with contact lenses.⁵ Interestingly, children who wear contact lenses exhibit a boost in self-perception of physical appearance, athletic competence and social acceptance, compared with spectacle wearers.⁴ Young contact lens wearers who did not like wearing their glasses even report feeling smarter than spectacle wearers.⁴ 

The purpose of this article is to illustrate differences between fitting children and adults with contact lenses to provide readers confidence when fitting children.

Physical Benefits
In addition to improving self-perception, contact lenses offer other benefits to children that adults may not recognize, such as myopia control. Controlled studies and randomized clinical trials show that corneal reshaping contact lenses can slow the progression of myopia in children.^6-11 Soft bifocal contact lenses have a similar effect.^12-15 Maintaining a lower level of myopia ultimately provides myopic patients with more options for vision correction and more predictable refractive surgery results, better quality of life, and possibly a lower risk of sight-threatening issues such as cataract, glaucoma, choroidal atrophy and retinal detachment.^16-28 Children are also less likely than college students to experience ocular health problems and corneal infiltrative events associated with contact lens wear.^29-31 

Despite the benefits of contact lens wear for children and the lower risks of contact lens complications, only approximately 10% of optometrists agree that eight to nine years is an appropriate age to introduce contact lenses, although approximately one-third of doctors said they now fit kids at a younger age than they did one year ago due to the availability of daily disposable lenses and improved lens materials, as well as specific requests from the parent or child.³²

First Time Correction
Many optometrists will not fit a child with contact lenses when they first become myopic, instead telling them that it is an option if the child proves capable of responsible spectacle wear for one year. However, there is very little about responsible spectacle care that prepares a child for independent contact lens wear (other than providing additional time to mature), effectively negating the intention to train the child. So, practitioners should provide children with the option of contact lens wear at myopia onset, and monitor their progress at follow-up appointments. Of course, contact lens wearers should still have a pair of spectacles to wear in case of issues.

	Fig. 1. Teaching children insertion, removal and care of contact lenses requires only a few additional minutes of training, compared with teenagers.

Anxiety
Compared with adults, children don't have as much experience seeing a practitioner, and often have an exaggerated response to pain and other negative physical stimuli. Thus, many believe that anything placed in the eye will feel like the standard dilating eye drop. There are two ways—opposite in nature, but equally successful—to confront this issue: either, when inserting contact lenses, explain every detail of what you are doing in a soothing, empathetic tone to help alleviate anxiety; or prepare the contact lens for insertion without allowing the child to notice, distract them and insert the lens before they realize what’s coming. Depending on your personality, the empathetic parent or the crazy uncle routine will help make the fitting process as easy as possible (Figure 1).

Motivation
Doctors often say that a child’s motivation is the most important key for success, but that is not entirely true. Many children believe that anything inserted into the eye will hurt, so they are initially unmotivated to even try contact lenses. In fact, more often than not, it may be the parent’s idea for their child to try contact lenses. Thus, it is important to assess motivation after you insert the lens—children will frequently change their minds once they realize contact lenses improve vision without causing pain, and will thus be more likely to continue wearing them. Conversely, adults simply won’t ask about contact lens wear unless they are motivated, so assess motivation during the initial conversation.

Fig. 2. Children are very capable of independent contact lens insertion, removal and care.

Insertion and Removal
Children require, on average, about 11 minutes more than teenagers to learn proper insertion and removal techniques for contact lenses. Most of this difference is due to outliers: twice as many teenagers require less than 20 minutes to learn insertion and removal compared with children, and some children require multiple visits to master contact lens insertion. The median difference between children and teenagers is in fact only five minutes.³³ Children typically remember contact lens care instructions as well as teenagers following initial instruction, but remember less than teenagers at longer intervals. Therefore, each time a child returns for a follow-up, ask them how they care for their lenses, and correct any misconceptions to ensure proper care (Figure 2).

Irresponsibility
Optometrists and parents often agree that children who frequently lose or break spectacles are poor candidates for contact lens wear. In fact, children who lose or break their spectacles may be the best candidates. Children rarely remove their glasses because they prefer blurry vision—instead, most cases of lost or broken spectacles happen when the child is not actively wearing them for appearance reasons or during recreational activities and the glasses are forgotten or crushed. Contact lenses provide clear vision without altering appearance, limiting peripheral vision, falling off or fogging up during sports.^34,35 Children also reported better quality of life scores while handling contact lenses than when handling spectacles.³ This is presumably because glasses are removed throughout the day for different reasons, but contact lenses are only handled in the morning and prior to bedtime. 

Less overall manipulation of lenses results in higher handling quality of life than spectacles, even though it is more difficult to insert and remove contact lenses than it is to put on and take off glasses.

Compliance
Children are often more compliant with contact lens care than older patients, possibly because they are more used to following instructions from teachers and adults. However, children are also more likely to forget these messages if they deviate from their routine—for example, if they spend the night at a friend’s house. If a child is sleeping elsewhere for the night, parents should instruct hosts to remind the child to remove their contact lenses before bedtime. 

One exception to this might be corneal reshaping contact lenses. Because children typically have lower prescriptions and corneal epithelium that responds more effectively to corneal reshaping lens wear than adults, they often experience uncorrected visual benefits of corneal reshaping lens wear for a longer period than adults.³⁶ This means they may be able to wear their lenses only every other night, instead of every night. So when they spend the night at a friend’s house, they don’t necessarily have to remember to insert their lenses. 

Swimming
Since children swim more frequently than adults, and contact lenses are known to harbor bacteria and other potential pathogens, it is important to educate children and their guardians about contact lens care while swimming.^37-42 Research shows use of swimming goggles can reduce the bacterial contamination of contact lenses, but no evidence-based recommendations exist regarding what to do with the lenses if goggles are not worn. Potential options include removing lenses during swimming or disposing of or disinfecting lenses immediately after swimming. Regardless of your recommendation, make sure your staff relays the same message to all patients.

Corneal Reshaping Contact Lenses
Children are excellent candidates for corneal reshaping contact lenses. These specialty lenses slow the progression of myopia, and are worn at home in a controlled environment. Typically, the corneas of children are easier to correct during the initial adaptation phase because glasses provide appropriate correction later in the day as the cornea begins to return to the baseline curvature. 

However, because myopia progresses until age 15 or 16 years, children are less likely than adults to gain full myopic correction from their spectacles.^43,44 As the child’s cornea returns to normal curvature during the initial adaptation, the glasses don’t over-correct the increasing myopia as much as they would in an adult with a stable, full myopic prescription in glasses. Children also adapt more easily to overcome the over-minused condition, so soft contact lenses with half of the baseline prescription are less necessary for children compared with adults. Children also do not drive, meaning they lodge far fewer complaints than adults of haloes around lights at night. However, children are just as at risk for microbial keratitis as adults, especially since the contact lenses are worn during sleep, so they should be educated about symptoms of corneal infections.^45-47 

Bifocal Contact Lenses
Children are increasingly being fit with soft bifocal contact lenses for myopia control. However, fitting a child with soft bifocal contact lenses is nothing like fitting a presbyopic adult; in fact, fitting a child with soft bifocal contact lenses for myopia control is more like fitting a child with single vision contact lenses, primarily because they accommodate even while wearing bifocal lenses. Even the highest add powers rarely result in complaints from children, presumably because they typically accommodate better than adults, even when wearing a soft bifocal lens. Young convergence excess patients may even benefit from soft bifocal lens wear, presumably because they accommodate less with soft bifocal lenses. This may be because human body is adept at adjusting to uncomfortable situations, and these children may learn to relax accommodation to alleviate symptoms caused by convergence excess.^48,49

Conclusion
Children experience a range of visual and non-visual benefits from contact lens wear beyond those experienced by adults, without increased risks due to adverse physiological effects or irresponsibility. With additional considerations towards alleviating a child’s anxiety and making the fitting process as fun as possible, children are as easy to fit with contact lenses as teenagers and adults. 

Many practitioners love the additional challenge and free advertising that children bring to the practice. Children are extremely social beings; they participate in sports and recreational activities and hang out with their friends. Because they are not yet completely independent, parents often congregate around them, opening up the possibility for a discussion between adults regarding a child’s sudden independence from glasses. In some cases, such a discussion may result in a referral, benefiting both the new patient and the practice. So, don’t be afraid to offer contact lenses to your young patients!   

Dr. Walline is an associate professor at the Ohio State University College of Optometry and the Study Chair of the Bifocal Lenses In Nearsighted Kids (BLINK) Study, a randomized clinical trial sponsored by the National Eye Institute.

1. Goss DA, Cox VD. Trends in the change of clinical refractive error in myopes. J Am Optom Assoc 1985;56:608-13.
2.Rahi JS, Cumberland PM, Peckham CS. Myopia over the lifecourse: prevalence and early life influences in the 1958 British birth cohort. Ophthalmology 2011;118:797-804.
3.Rah MJ, Walline JJ, Jones-Jordan LA, et al. Vision specific quality of life of pediatric contact lens wearers. Optom Vis Sci 2010;87:560-6.
4.Walline JJ, Jones LA, Sinnott L, et al. Randomized trial of the effect of contact lens wear on self-perception in children. Optom Vis Sci 2009;86:222-32.
5.Walline JJ, Lorenz KO, Nichols JJ. Long-term contact lens wear of children and teens. Eye Contact Lens 2013;39:283-9.
6.Charm J, Cho P. High Myopia-Partial Reduction Ortho-k: A 2-Year Randomized Study. Optom Vis Sci 2013;90:530-9.
7.Chen C, Cheung SW, Cho P. Myopia control using toric orthokeratology (TO-SEE study). Invest Ophthalmol Vis Sci 2013;54:6510-7.
8.Cho P, Cheung SW. Retardation of Myopia in Orthokeratology (ROMIO) Study: A 2-Year Randomized Clinical Trial. Invest Ophthalmol Vis Sci 2012;53:7077-85.
9.Cho P, Cheung SW, Edwards M. The longitudinal orthokeratology research in children (LORIC) in Hong Kong: a pilot study on refractive changes and myopic control. Curr Eye Res 2005;30:71-80.
10.Santodomingo-Rubido J, Villa-Collar C, Gilmartin B, et al. Myopia Control with Orthokeratology Contact Lenses in Spain (MCOS): Refractive and Biometric Changes. Invest Ophthalmol Vis Sci 2012.
11.Walline JJ, Jones LA, Sinnott LT. Corneal reshaping and myopia progression. Br J Ophthalmol 2009;93:1181-5.
12.Anstice NS, Phillips JR. Effect of dual-focus soft contact lens wear on axial myopia progression in children. Ophthalmology 2011;118:1152-61.
13.Lam CS, Tang WC, Tse DY, et al. Defocus Incorporated Soft Contact (DISC) lens slows myopia progression in Hong Kong Chinese schoolchildren: a 2-year randomised clinical trial. Br J Ophthalmol 2014;98:40-5.
14.Sankaridurg P, Holden B, Smith E, 3rd, et al. Decrease in rate of myopia progression with a contact lens designed to reduce relative peripheral hyperopia: one-year results. Invest Ophthalmol Vis Sci 2011;52:9362-7.
15.Walline JJ, Greiner KL, McVey ME, et al. Multifocal contact lens myopia control. Optom Vis Sci 2013;90:1207-14.
16.Bailey MD, Mitchell GL, Dhaliwal DK, et al. Patient satisfaction and visual symptoms after laser in situ keratomileusis. Ophthalmology 2003;110:1371-8.
17.Reviglio VE, Luna JD, Rodriguez ML, et al. Laser in situ keratomileusis using the LaserSight 200 laser: results of 950 consecutive cases. J Cataract Refract Surg 1999;25:1062-8.
18.Rose K, Harper R, Tromans C, et al. Quality of life in myopia. Br J Ophthalmol 2000;84:1031-4.
19.Eye Disease Case-Control Study Group. Risk factors for idiopathic rhegmatogenous retinal detachment. Am J Epidemiol 1993;137:749-57.
20.Hyams SW, Neumann E. Peripheral retina in myopia. With particular reference to retinal breaks. Br J Ophthalmol 1969;53:300-6.
21.Saw SM, Gazzard G, Shih-Yen EC, et al. Myopia and associated pathological complications. Ophthalmic Physiol Opt 2005;25:381-91.
22.Casson RJ, Gupta A, Newland HS, et al. Risk factors for primary open-angle glaucoma in a Burmese population: the Meiktila Eye Study. Clin Experiment Ophthalmol 2007;35:739-44.
23.Lee YA, Shih YF, Lin LL, et al. Association Between High Myopia and Progression of Visual Field Loss in Primary Open-angle Glaucoma. J Formos Med Assoc 2008;107:952-7.
24.Omoti AE, Edema OT. A review of the risk factors in primary open angle glaucoma. Niger J Clin Pract 2007;10:79-82.
25.Giuffre G, Dardanoni G, Lodato G. A case-control study on risk factors for nuclear, cortical and posterior subcapsular cataract: The Casteldaccia Eye Study. Acta Ophthalmol Scand 2005;83:567-73.
26.Lim R, Mitchell P, Cumming RG. Refractive associations with cataract: the Blue Mountains Eye Study. Invest Ophthalmol Vis Sci 1999;40:3021-6.
27.McCarty CA. Cataract in the 21st Century: lessons from previous epidemiological research. Clin Exp Optom 2002;85:91-6.
28.Mukesh BN, Le A, Dimitrov PN, et al. Development of cataract and associated risk factors: the Visual Impairment Project. Arch Ophthalmol 2006;124:79-85.
29.Chalmers RL, Wagner H, Mitchell GL, et al. Age and other risk factors for corneal infiltrative and inflammatory events in young soft contact lens wearers from the Contact Lens Assessment in Youth (CLAY) study. Invest Ophthalmol Vis Sci 2011;52:6690-6.
30.Wagner H, Chalmers RL, Mitchell GL, et al. Risk Factors for Interruption to Soft Contact Lens Wear in Children and Young Adults. Optom Vis Sci 2011;88:973-80.
31.Wagner H, Richdale K, Mitchell GL, et al. Age, behavior, environment, and health factors in the soft contact lens risk survey. Optom Vis Sci 2014;91:252-61.
32.Sindt CW, Riley CM. Practitioner attitudes on children and contact lenses. Optometry 2011;82:44-5.
33.Walline JJ, Jones LA, Rah MJ, et al. Contact Lenses in Pediatrics (CLIP) Study: chair time and ocular health. Optom Vis Sci 2007;84:896-902.
34.Walline JJ, Bailey MD, Zadnik K. Vision-specific quality of life and modes of refractive error correction. Optom Vis Sci 2000;77:648-52.
35.Walline JJ, Gaume A, Jones LA, et al. Benefits of Contact Lens Wear for Children and Teens. Eye Contact Lens 2007;33:317-21.
36.Kang P, Swarbrick H. Time course of the effects of orthokeratology on peripheral refraction and corneal topography. Ophthalmic Physiol Opt 2013.
37.Choo J, Vuu K, Bergenske P, et al. Bacterial populations on silicone hydrogel and hydrogel contact lenses after swimming in a chlorinated pool. Optom Vis Sci 2005;82:134-7.
38.Kaji Y, Hu B, Kawana K, et al. Swimming with soft contact lenses: danger of acanthamoeba keratitis. Lancet Infect Dis 2005;5:392.
39.Lam J, Tan G, Tan DT, et al. Demographics and behaviour of patients with contact lens-related infectious keratitis in singapore. Ann Acad Med Singapore 2013;42:499-506.
40.Rabinovitch J, Cohen EJ, Genvert GI, et al. Seasonal variation in contact lens-associated corneal ulcers. Can J Ophthalmol 1987;22:155-6.
41.Vesaluoma M, Kalso S, Jokipii L, et al. Microbiological quality in Finnish public swimming pools and whirlpools with special reference to free living amoebae: a risk factor for contact lens wearers? Br J Ophthalmol 1995;79:178-81.
42.Wu YT, Tran J, Truong M, et al. Do swimming goggles limit microbial contamination of contact lenses? Optom Vis Sci 2011;88:456-60.
43.Goss DA. Cessation age of childhood myopia progression. Ophthalmic Physiol Opt 1987;7:195-7.
44.Thorn F, Gwiazda J, Held R. Myopia progression is specified by a double exponential growth function. Optom Vis Sci 2005;82:286-97.
45.Bullimore MA, Sinnott LT, Jones-Jordan LA. The risk of microbial keratitis with overnight corneal reshaping lenses. Optom Vis Sci 2013;90:937-44.
46.Watt K, Swarbrick HA. Microbial keratitis in overnight orthokeratology: review of the first 50 cases. Eye Contact Lens 2005;31:201-8.
47.Watt KG, Swarbrick HA. Trends in microbial keratitis associated with orthokeratology. Eye Contact Lens 2007;33:373-7; discussion 82.
48.Libassi DP, Barron CL, London R. Soft bifocal contact lenses for patients with nearpoint asthenopia. J Am Optom Assoc 1985;56:866-70.
49.Shainberg MJ. Nonsurgical treatment of teenagers with high AC/A ratio esotropia. Am Orthopt J 2014;64:32-6.