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.
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.|
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).
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).
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.
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.
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
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.
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