Good communication when working with younger patients comes from both a sound understanding of their eye health needs and an enthusiasm for the service you’re delivering. It’s about listening and learning from the patient, and having fun. Young people are sometimes challenging but can be very rewarding to work with – do it well and you could be their eye care practitioner for life.
Research suggests that children enjoy their experience of contact lenses too. Among those aged 10-17 years using contact lenses, almost all say they like wearing them (93 per cent) and feel better about their ability to participate in sport when wearing their contact lenses (88 per cent).1 A similar proportion say they feel more confident (86 per cent) when wearing contact lenses rather than glasses.1
Most practitioners say they prescribe contact lenses for children under the age of 18, but few offer them to younger children.2 For those aged under 10 years, practitioners are likely to recommend only spectacles. In fact parents are more likely than practitioners to initiate discussion of contact lenses in this age group.2
So how can we use our communication skills to create a positive experience for even more of our young patients?
Opportunities and patient benefits
It is now well documented that young people benefit greatly from wearing contact lenses, and researchers recommend their use become more routine in the pre-teen years.3,4
They may also gain improved quality of life from using contact lenses compared to spectacles, in particular due to increased confidence in sports and in social situations.5 For many sports, spectacles are either impractical or not permitted and it is considered much safer to wear lenses and ocular trauma is considered less likely with contact lenses.6
Consider the highly hyperopic 10-year-old who is keen on rugby but not allowed to play matches when using his correction, and the nine-year-old dance-mad myope unable to wear her spectacles while performing. These are just a couple of examples where contact lenses could transform the lives young patients lead.
Compliance and ease of use of contact lenses7,8 is much greater than perceived, with nine out of 10 young people able to successfully wear and care for their lenses.9 Even very young children stand to benefit hugely from early consideration of contact lens wear. In fact many young people with anisometropia or high ametropia gain better vision with contact lenses than spectacles.10
Various soft contact lens approaches to controlling myopic progression in children have been investigated.11 Orthokeratology is another option for slowing the progression of myopia and early efficacy studies are positive.12,13 In future, with the growing prevalence of myopia and interest in these approaches, practitioners can expect to fit increasing numbers of children with contact lenses, and also consider potentially managing them with future contact lenses for myopia control.
It can be a great asset to your practice to start fitting younger people with contact lenses, in particular if these provide a gain in vision over spectacles. You and your practice stand to enhance your reputation for ‘vision care’ as a whole, and such fitting is an excellent source of referrals for other patients who may have previously thought they were unsuitable for contact lenses.
Increasing the focus on young patients can improve creativity and morale among staff as patient satisfaction is very high with this group, and it’s generally fun and dynamic too!
What to look and listen for
Building a rapport with a child or young person, and getting to know them and how they enjoy their time outside of your consulting room is the best way to determine their interest and suitability for contact lenses. Think about children’s needs and interests, especially if you are not a parent yourself.
Ask young patients if they wear their glasses during sports or when performing, as their parents may not be aware that they take their glasses off. They might be afraid of breaking them, losing them, or causing an injury during a game. If this is the case, it’s useful to simulate for the parent the child’s vision without the use of glasses so that they understand the full picture.
Try to find out what they have a flare for inside and outside of school, what they enjoy and why. Crucially, the question to ask is, ‘Is there anything you’d really like to try if you didn’t have to wear your glasses?’ and then, ‘Is there anything you’re doing at the moment you think you’d do better if you didn’t have to wear your glasses?’
Asking the child, ‘How do you feel about contact lenses?’ is a great way to make them feel important, get them involved and gauge their response. If the child is positive, the parent can be brought in to the conversation from there. There is little point in pushing a child if they are not interested at this stage, and beware of pushy parents making the decision for them!
Establish trust
Because of many preconceptions, endorsement of contact lenses by the optometrist is paramount for building trust – don’t wait for parents to ask.
It’s important when fitting contact lenses that all parties believe the child is responsible enough to look after the lenses and their eyes. This can be difficult to establish in practice, but a good way might be to ask the child, ‘Do you need to be reminded to brush your teeth?’, and relate the responsibility to contact lens wear, explaining that it would not be up to the parents to look after the lenses! This may also help determine the most appropriate lens modality for the child.
Allowing patients and parents time to think is also important. As a practitioner, we hope to see patients who are motivated and concordant with safe lens wear. A perceived poor value of the products and service from patients and families who didn’t actively choose contact lenses will not be a basis for a valued service, nor a stable income stream.
Moreover, rushing into lens wear and the commitments that it brings can leave parents feeling disgruntled and unhappy, even if this was what they ultimately would choose.
In addition, it’s important to communicate that contact lenses aren’t a total replacement for spectacles, and why this is, right from the outset. Explain the benefits of having a combination of vision correction options for different situations, including sunglasses, and that new glasses will still need to be purchased from time to time.
Remember the three Ms: Motivation, Maturity and the role of the Mother (or Father!). Interest and motivation, maturity and ability to care for contact lenses are seen as more important considerations when recommending contact lenses than age, and the parents’ role is also recognised especially if they have experience of wearing lenses themselves.1
Some practitioners recommend bringing parents in for a separate teaching session as well as attending the child’s teach. From time to time, children with special needs will come up as cases who could benefit hugely from contact lenses. It may then be more appropriate to teach the parents how to handle the lenses and look after eye health as well as the child.
Once fitted, it is the visual and social benefits of lens wear that motivate kids and teenagers to succeed with contact lenses. Ask what contact lens wear has helped with and how it’s made a difference. Look out for the achievements that result, such as, in the case of the rugby-playing 10-year old, being awarded ‘Most improved player of the season’. For performers it might be a successful audition, or for all children a new activity or achievement at school to listen for.
[CaptionComponent="556"]What to say and do
It’s essential to be confident when we communicate the safety of contact lenses for young eyes, firstly because it will be a new concept for many parents, and secondly because they may have been misinformed by what they have read online or been told by others.
Information on the benefits of contact lenses and the responsibilities of lens users should be unapologetic and freely available in the practice waiting areas. This will introduce families to the idea of contact lenses for young people and what this entails.
Mention contact lenses as an option at the time of the child’s first correction and when it becomes a full-time need. It’s a good idea at this point to provide an indication of cost. While contact lenses are considered essential for many users, they rarely are by the NHS unless for a medical indication such as keratoconus. It may be useful to use a cost analogy, with music and sports lessons, for example – most often parents want the best for their children and are more than happy to pay for it.
Remember to balance quality of life benefits with a realistic appraisal of relative risks in any discussion with parents. Don’t restrict your advice to a simple choice between contact lenses and spectacles; information should also be provided on the protective effect of outdoor activity on myopia progression14 and the benefits of UV protection for children.15
In addition to verbal instructions, it’s also important to have special leaflets for young people when it comes to practising handling, with diagrams, photographs or videos. Digital apps such as Acuvue LensPal can also be helpful. Pay special attention to hand hygiene too. As with adult patients, emergency eye care information for out-of-hours service should always be given in writing.
Although daily disposables are the most commonly prescribed modality for children,1 reusable lenses are also a popular choice with practitioners. Clear written instructions for the disinfection of reusable lenses should be prepared for reference by children and parents. We must remember that sometimes they come away with a bag of bottles; step-by-step regimes should be clearly written down and the bottles labelled 1, 2, 3 etc.
Phrases like, ‘You can’t clean a car without rubbing it’ and ‘Would you keep the same bath water for a week?’ are useful analogies for all patients when discussing the importance of cleaning lenses, and younger patients often relate better to a real-life situation.
Get support staff on board
Having reliable and enthusiastic support staff is vital to the success of fitting children with contact lenses because of the role that they play in the additional time to teach application of lenses, reassure parents and reorder lenses. Introducing another member of staff as a ‘contact lens buddy’ often breaks down any barriers for the family.
Educating your staff on why lenses benefit young people, how they can improve visual quality over spectacles, and what language you would like to use is a great first step. They can also help in alerting you to any potential issues, such as frequently lost lenses.
Make sure your staff, and your practice, are child friendly. Discuss the benefits of fitting young people with contact lenses at training sessions, and foster an interest among staff who enjoy working with this age group. Offering free WiFi in the waiting area and accommodating siblings while the child is being seen are just some of the ways that your team can help.
Address any concerns
Invite parental concerns, and address these appropriately based on current evidence. Prepare your explanations carefully using simple language (Table 1) and make sure the whole team is familiar with them.
Stress the benefits of contact lenses and use the latest research findings to inform your discussions and motivate parents. For instance, more than eight in 10 parents of vision corrected children (82 per cent) say their child’s positive self-esteem is absolutely critical to them as a parent.2 Discussing quality of life benefits, as well as visual and practical advantages, may therefore help to allay parents’ concerns.
Adapt your schedule
It may be convenient for the initial fitting to occur in the school holidays – especially Easter, Christmas or summer – when there is more time for appointments. The child is not in a rush in the morning to put lenses on before school and can more easily remove the lenses during the day.
Unlike for adults, and dependent upon time restrictions, you may decide to break the contact lens fit into two appointments. Don’t aim for too much the first time. When working with young people, the purpose of this appointment is simply to elicit needs and investigate potential complications such as atopy (hay fever, asthma, eczema etc) that may affect lens wear and require appropriate management.
The first appointment is the time to establish the ‘ground rules’ for lens wear and agree on how the young person will fit lens care into their daily routine. Some practitioners ask their young patients to sign an ‘agreement’ in easy-to-understand language so that they undertake lens wear with careful consideration.
It’s a good idea at this first appointment to give the patient some lenses to play with – tear them apart to test the strength, and let them dry out and rehydrate them, to see how they work. An anterior eye assessment with fluorescein and lid eversion will test how well the patient is likely to react to lens application at the next visit.
Adapt your language
The language we use when speaking to younger children is also likely to be very different. When introducing the lenses, tell the young person that, ‘Today, we’ll just aim for one contact lens to pop on the eye’. If you get further than this, then great. Some children do well with a family member or friend who also wears lenses to give encouragement and reassurance.
With a younger child, it’s useful to demonstrate the application technique that you’re going to use firstly on a teddy bear or toy, or on a model eye so that the child can see how the lens sits. Always fully engage with and ask permission from the child before you do anything at all, such as ‘Can I put my thumb on your eyelid please?’ and ‘I’m going to hold your eyelid back a little now, is that OK?’ This helps them to feel in control. If they’re uncomfortable, stop straight away.
If they didn’t like the process but still want to wear contact lenses (which is often the case at first), ask them to come back in six weeks to try again, when their motivation and confidence is high again and they’ve had time to think.
Most children and teenagers are quick learners and the application and removal techniques are quickly mastered. Calm and gentle encouragement is always useful and the whole process, when successful, is hugely rewarding for all concerned.
If the child or teen is struggling and frustrated by lens handling it’s often worth rebooking for another day. For a sporty child you might suggest that everything gets better with practice or, for a despondent teen, ask if they would be so willing to give up on a level of their favourite computer game!
Try giving them some ‘homework’, which might be practising holding open the lids, looking at their eyes in the mirror and practising bringing their finger towards the eye (but not touching it). Tell them to read your written instructions carefully because you might ‘test’ them next time. Questions might include, ‘What’s the very first thing you do before touching your lenses or eyes?’
If you need to rebook a teach session, you might use phrases such as, ‘You’re doing really well but I think you need a bit of a rest now. Let’s do this again on another day’ or ‘Do you know some grown-ups take two or three lessons before getting it right? I’m sure it will seem much easier next time if you do your practice homework.’
Issue final advice
Give clear instructions about what to do if the lenses do fall out at school. In many cases it may be that the child functions well with one lens and can wait until home time to clean it properly before reinsertion under the parents’ guidance.
If young, ask children to complete a wearing chart so that they can write in the time of lens application and removal for each day the lens is worn, and mark their ‘days off’ on the chart too. They can write any handling problems or questions on the chart and these can be addressed at the aftercare visit if not before. Acuvue LensPal can also be useful for tracking progress.
Leave them with a final reminder: ‘If in doubt, take them out!’ and ‘Beware eyes that don’t look, see or feel right’ – if this persists, then they must feel welcome to come back to see you.
Aftercare appointments
Some practitioners use a simple contact lens compliance quiz to test children’s knowledge of care procedures at the teach session and aftercare appointments.19 Asking the child to demonstrate their lens care and handling is another approach. Again keep the messages simple, and at every aftercare address the three Ss: Don’t swim, shower or sleep in the lenses.
Further fitting appointments follow much like adult ones, although you may sometimes want to see children more frequently than older patients, in particular in the first few months. Try using a Burton lamp rather than a slit lamp and hold a mirror up to let them see their green eyes! Putting plenty of fluorescein in so that it drains down their nose is a great idea – ‘radioactive snot’ goes down really well with young patients and their accompanying brothers and sisters!
With teenagers who manage their own lens wear, it’s good to discuss the concept of a contact lens hours credits-based system with their eyes. Let them know that you will be able to see any signs of significant over-wear, including sleeping or napping in their lenses, at their aftercare appointments – manage these expectations and ground rules from the start.
Conclusion
Good communication comes from confidence in knowing that you’re doing the best for each individual. With children and teenagers, that may not always mean contact lenses but young patients can successfully wear and care for lenses, and gain visual, practical and social benefits. Asking, listening and learning will help us find out if they could be your next contact lens success story. Preparation, patience and a sense of fun will help everyone make sure that contact lenses are a great experience for the child or young person.
Extra tips for communicating with children and parents
- Use an iPad as a fixation target held over the child’s head (ask the child to hold it to keep their hands out of the way). Let them choose a YouTube clip
- Ensure the child’s head is upright and have them looking upwards for the parents to see what’s going on during fitting
- Demonstrate to the parent and child how to check the lens is on the eye
- Encourage good compliance by having everyone in the room wash their hands together at the start of every appointment
References
1 McParland M and Esterow G. Parent and child attitudes to vision correction. Poster presentation at British Contact Lens Association Clinical Conference, 2014.
2 A survey of UK contact lens practice for children and young people. College of Optometrists, 2014.
3 Walline JJ, Gaume A and Jones LA et al. Benefits of contact lens wear for children and teens. Eye & Contact Lens, 2007;33: 317-321.
4 Rah MJ, Walline JJ, Jones-Jordan LA et al. Vision specific quality of life of pediatric contact lens wearers. Optom Vis Sci, 2010;87 560-566.
5 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.
6 Ong HS, Barsam A, Morris OC et al. A survey of ocular sports trauma and the role of eye protection. Cont Lens Anterior Eye, 2012;35:285-7.
7 Chia, A, Johnson K and Martin F. Use of contact lenses to correct aphakia in children. Clin Experiment Ophthalmol, 2002;30 252-255.
8 Walline, JJ, Long S and Zadnik K. Daily disposable contact lens wear in myopic children. Optom Vis Sci, 2004;81:255-259.
9 Li L, Moody K, Tan DT et al. Contact Lenses in Pediatrics Study in Singapore. Eye & Contact Lens, 2009;35:188-195.
10 Evans B. Orthoptic indications for contact lens wear. Cont Lens Ant Eye, 2006;29:4 175-81.
11 Walline JJ, Linsley K, Vedula SS et al. Interventions to slow progression of myopia in children. Cochrane Database Syst Rev, 2011:12 CD004916.
12 Kakita T, Hiraoka T and Oshika T. Influence of overnight orthokeratology on axial elongation in childhood myopia. Invest Ophthalmol Vis Sci, 2011;6:52 2170-4.
13 Cho P and Cheung SW. Retardation of Myopia in Orthokeratology (ROMIO) study: a 2-year randomized clinical trial. Invest Ophthalmol Vis Sci, 2012;53:11 7077-85.
14 Sherwin JC, Reacher MH, Keogh RH et al. The association between time spent outdoors and myopia in children and adolescents: a systematic review and meta-analysis. Ophthalmology, 2012;119:10 2141-51.
15 Wolffsohn JS. The benefits of UV-blocking contact lenses. Optometry in Practice, 2013;14:2 61-72.
16 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, 2011:88:8 973-80.
17 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;52:9 6690-6.
18 Walline JJ, Jones LA, Rah MG et al. Contact lenses in pediatrics (CLIP) study: chair time and ocular health. Optom Vis Sci, 2007;84:896-902.
19 Evans B. Contact lens quiz for kids. Lecture handouts. www.bruce-evans.co.uk.
Acknowledgement
Images courtesy of The Vision Care Institute.
Optometrist Stephanie Campbell is a PhD student at the School of Optometry & Vision Sciences, Cardiff University. Optometrist Amanda Davidson is in independent practice in Lewes, East Sussex. Both are Faculty members at The Vision Care Institute