Paediatric contact lenses

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Fitting children with contact lenses (CLs) provides a tremendous opportunity to develop a practice, in addition to giving a sense of satisfaction by making a difference to younger patients’ lives. However, there can be reticence from parents, patients and some practitioners in offering lenses to children as an option for vision correction. The first article will review whether children should be routinely fitted with CLs and the impact it has on them. The children referred to here are from around eight years to their early teens; younger children and babies are not considered here.

Children under 16 represent around one in five of the total UK population, which is similar to those of retirement age.1 Children are an important age group for the future growth of CLs. Interest in lenses starts at an early age and their use is widely suited to this age group, bearing in mind their lifestyle. However, only a small proportion of practitioners fit under 10-year-olds with CLs, and only a third consider fitting 10-12 year-olds; the average age practitioners start to prescribe at is 13 years.

Why fit children with lenses?

As with any patient, fitting CLs offers the convenience of spectacle-free wear in addition to the primary benefit of visual performance improvements. They provide consistent, natural vision with minimal peripheral distortion, increased field of view and remove the burden of spectacles. Lenses can improve vision for sport and leisure activities, where children often remove spectacles for fear of breaking them, and so also provide an additional element of safety.

There are a large number of clinical and visual indications to fit children with CLs. These are refractive, pathological and to improve binocularity (Table 1). There is also the potential for being free from CL wear during the day, and possibly myopia control, with orthokeratology, in addition to the protection from UV-radiation offered by some lenses.

An additional key benefit of CL wear for this age group is its effect on appearance, improving interactions with peers and building self-confidence, and helping teach responsibility. Quality of life benefits afforded by CLs for the young are often overlooked; in addition to improving confidence,2 fitting children can lead to psychological and emotional benefits.

There is a considerable personal reward gained from fitting children with lenses; seeing them smile and grow in confidence having discovered the benefits of CLs and mastered their handling gives a huge sense of achievement to practitioners. Children are enthusiastic, quick to learn, relatively easy to fit and represent a large untapped population of CL wearers. The cost of lenses is unlikely to be considered an issue compared with new spectacles and monthly payment options can make finances manageable. They are a useful way to help build a practice; this can continue for many years as children and their families are likely to be patients for life with improvements made to their appearance, visual performance, confidence and quality of life.

Are children compliant?

There are many barriers presented by parents when considering fitting children; one is their child’s potential level of compliance with lens wear and care. This is from the parents’ perception of their child’s behaviour, and could also be due to the link highlighted in the lay press between potentially sight threatening complications and non-compliant behaviour.5 These stories present how lessons are not being learnt with compliance and bemoan the potential downsides with CLs.

Good compliance is essential to maintain successful CL wear and minimise the risk of ocular complications, some of which can be serious.6,7 It is quite probable that children will be non-compliant in one way or other, whether deliberate or unintentional, as are other CL wearers. The proportion of non-compliant CL wearers is reported to range from 40 to 91 per cent8 and patients are often confused or ignorant about their behaviour. It has been demonstrated that 16-50 per cent of patients do not wash their hands prior to lens handling. Compliance is the responsibility of all involved: in this case, patient, parent and practitioner. However, studies have shown that compliance is no worse in young children than other wearers and they are quite capable of handling lenses and managing their wear and care.3,9 A survey of 11-13 year-olds wearing soft CLs over six months found a high level of compliance and ability to follow instructions. Ninety per cent knew daily cleaning was necessary, 96 per cent understood about lens disinfection and 99 per cent were able to express confidence in caring for their CLs.

Compliance is thought to be influenced by a patient’s beliefs. The Human Belief Model, introduced by Becker and Maiman, was developed to reveal reasons behind non-compliance in general healthcare.10 The model shows far more opportunities not to comply with a procedure than follow it, especially if a patient believes the consequences of non-compliance are unlikely to happen. It describes that people will be compliant if they follow certain beliefs, including being interested in health and motivated to follow health recommendations. Sokol11 found undesirable beliefs from all the HBM dimensions could be found among non-compliant lens wearers. To improve compliance, patients need to acquire knowledge and self-management abilities, and want to apply them throughout the time they wear their CLs. Children are quite impressionable at a young age, and so best practice for good habits about compliance could be learned and established by wearing lenses from an early age. External factors are also known to affect patient compliance (Figure 2).12

The important steps in lens wear, care and hygiene should be reiterated at all aftercare visits to improve compliance, in addition to careful explanation during the initial fitting. Reasons should be given why cleaning and disinfection are important for comfortable, trouble-free CL wear. By keeping the care regimen and wearing routine simple yet effective, compliance rates can be increased. Verbal and written instructions should be provided in addition to demonstrating the cleaning, disinfection and case care routine. There is a range of strategies that can be taken to improve compliance (Table 2).

What about the risks of fitting children with lenses?

Although there are benefits in fitting children with CLs, there could also be the possibility of trouble in the unlikely event of a significant issue with lens wear. This could be why practitioners are at times reluctant to fit younger patients. It is essential that children do not abuse the wear of CLs since, although very rare, microbial keratitis could be devastating. Practitioners should rely on feedback from parents who can more easily evaluate the child’s level of responsibility and who will ultimately have the final say. Lenses are a medical device and, as such, require a level of respect from the wearer. There is no evidence of differences in the levels of contact lens safety in children compared to adults and no increased risk of microbial keratitis.

How can children be motivated to wear CLs?

There will be a level of anxiety on all sides when fitting young children with CLs. This should be turned into enthusiasm – children are always eager to learn new things – and the rewards can be significant for all. Children need to be motivated, and this must be apparent before fitting them. The need to wear lenses must come from the patient and not just their parents. They need to be keen to proceed with the fitting, want to touch their eyes and understand the need to care for their lenses for healthy, successful lens wear. It may well be parents who first suggest CLs for their child; the child may not have considered the functional benefits but are likely to be nervous about the prospect of wearing lenses and, in particular, putting lenses in. They may imagine the lenses will hurt, sting or worse. Once it has been agreed that CLs are to be pursued as a vision correction option, lenses should be inserted to show the child they are comfortable; the benefits will then become obvious. Encouragement is needed for the children throughout the fitting process as although they may be motivated, they may not always be enthusiastic, in particular during teaching lens handling.

When should children be fitted with contact lenses?

Determining a patient’s suitability to wear lenses from a clinical perspective is a relatively easy task compared to deciding whether a child is ready to wear lenses. There are a range of attitudinal and behavioural markers to be considered, including the patient’s ability to demonstrate their maturity, motivation, approach to compliance and ability to handle lenses, in addition to the need for parental consent.

The average age children are fitted initially is around 13 years, although research has shown that reducing this to eight to nine years has no negative effects on success. Lens fitting may be left until patients are older if practitioners are less comfortable in discussing lenses with such a young audience. There is no specific age at which lenses can be considered; this will be on an individual basis depending on a number of factors including maturity and patient needs (visual and quality of life). Some seven-year-olds may be ideal, whereas some twice this age may not. Parents are often unsure at what age children can start wearing lenses and will often wait for practitioner recommendation. They also often mistakenly believe, in particular if they are not a lens wearer themselves, that CLs are hard to adapt to, may be uncomfortable and hard to care for, in addition to concerns about the cost. These myths can be easily dispelled by discussing lenses as an option for their children and this proactivity will be welcomed by parent and patient. The initial discussion about CLs should therefore begin at an early stage. Lenses can be mentioned as a refractive error correction option when a child first needs spectacles, even if initially for part-time wear. This plants the seed at an early stage, and as time progresses both child and parent will begin to consider the benefits that lenses could offer. Interest in CL wear tends to be around three years from when patients start wearing spectacles; this may well coincide with when the prescription has reached a level at which spectacles need to be worn full-time. It is likely that interest by girls will begin at a younger age than with boys; girls tend to be concerned with their appearance at an earlier age (12.8 years compared to 13.5 years).

What are the objections to children wearing lenses?

As with all CL wear, there are a wide range of potential barriers about children wearing lenses from patients, their parents and also practitioners. These objections are summarised in Table 3 along with details that dispel the myths. The barriers of poor compliance have been addressed, along with the potential increase in risks fitting children. One of the main barriers to children being fitted with CLs is their parents; many will not be convinced that lenses are an appropriate option for their children, and this is mainly due to health and compliance concerns. This is where the practitioner’s role is important as a mediator between the child and parent, in particular if the parent is not keen when the patient is.

Conclusions

Parents often report that practitioners do not offer children contact lenses as an option for refractive error correction, despite their impact on a child’s development and confidence, in addition to the visual benefits. Recent research has shown how young children benefit as much as teenagers from lens wear, with no additional chair time needed for their fitting. Lens wear in the young does not lead to a higher risk of adverse events and children are mature enough to manage lenses. Although challenging at times, fitting children can be rewarding in addition to generating patients for life and being an excellent source of referrals.

The second article will discuss strategies to fit children with lenses and how to determine the most appropriate modality and lens type. It will also review myopia progression and the potential benefits of orthokeratology for this age group. ?

References

1.  www.wikipedia.org
2. Walline J, Jones L, Sinnott L et al. Randomized Trial of the Effect of Contact Lens Wear on Self-Perception in Children. Optom Vis Sci, 2009 Feb (E Pub ahead of print).
3. Walline J, Lones L, Rah M et al. Contact Lenses in Paediatrics (CLIP) Study: Chair Time and Ocular Health. Optom Vis Sci, September 2007; 84 (9): 896–902.
4. Walline J, Gaume A, Jones L et al & CLIP Study Group. Benefits of CL Wear for Children & Teens. Eye & CL, 2007; 33(6): 317-321.
5. Sulley A. Have I Got News For You? BCLA Presidential Address, Royal Society Medicine, London, September 2004.
6. Sulley A. Compliance in contact lens wear, Part 1. Optician, 2005, 5995; 229: 24-30.
7. Sulley A. Compliance in contact lens wear. Part 2. Optician, 2005, 6000; 229: 42-49.
8. Claydon B & Efron N. Non-compliance in CL wear. Oph Physl Opt, 1994 Oct;14(4):356-64.
9. Soni P et al, Will young children comply and follow instructions to successfully wear soft contact lenses? CLAO J, 1995 Apr;21(2):86-92.
10. Becker M H. New Directions in Patient Compliance. In: Health, Lexington Books, Canada (ed S J Choen) 1989, Chapter 1.
11. Sokol JL et al. A study of patient compliance in a contact lens wearing population. CLAO J, 1990; 16(3): 209-213.
12. Ettinger E. Building patient compliance. In: Professional Communications in Eyecare. Butterworth-Heinemann, 1984, Chapter 7.

? Optometrist Anna Sulley is a clinical affairs consultant, works in independent practice and is past president and fellow of the British Contact Lens Association