Cover Focus: Our Children's Vision Crisis
9 Indications for Kids and Contacts

A Continuum of Care

Here are some cases for which contact lenses may be the best option for your youngest patients.

by Regina S. Garriott, O.D., Fullerton, Calif.

Whenever I recommend putting a child in contact lenses, I almost always get the same reaction from the parents: "You can put contact lenses on a child this age?" Not only can you put a child in contact lenses; it's often necessary for pediatric patients.

Contact lenses provide children some of the same optical advantages as they do adults. These include better peripheral vision, less distortion and less troublesome image size differences. Contact lenses also eliminate the unwanted prismatic effects of spectacles. Also, the hyperopic patient will experience a decreased accommodative demand when using contact lenses.1

As optometrists, we need to know when our pediatric patients might benefit from contact lenses. We also must help parents understand the valuable non-cosmetic roles they play.

I don't make my decision to fit the patient based on the child's age.  Rather, I base my decision on how visually disabled the child is and whether the family is ready to comply with the treatment regimen. (For more about this, see "A Continuum of Care.")

Here are nine instances in which you should consider fitting your youngest patients in contact lenses.

1. Excessive Hyperopia, Myopia or Astigmatism
A highly hyperopic child often experiences considerable distortion and undesirable prismatic effects from high-plus spectacle lenses. This, in turn, leads to compromised visual acuity and binocularity.2

Further complicating the effects of spectacles is that the patient rarely looks through the optical center. The weight of the spectacle lenses often makes them slide down the small bridge of the nose, forcing the child to view through the upper portion of the lens. Also, active children often knock their frames out of adjustment, so these kids are even less likely to view through the center. Three things can greatly compromise cosmesis: magnification of the eyes, the need for lenticularized lenses and difficulty in maintaining a proper fit of the frame.

Contact lenses can help eliminate these problems. I'm not suggesting that we fit every hyperopic child with contact lenses, but we should at least consider this option if it means improved visual performance, comfort, cosmesis and self-esteem.

The highly myopic child also may have distortion, prismatic effects, heavy lenses, poor fit and diminished cosmesis from glasses. He or she experiences minification of images rather than magnification. This minification can complicate a child's ability to adapt to spectacles, especially when reading. Again, contact lenses can help eliminate these problems.

Children with high amounts of astigmatism experience similar advantages from contact lenses as hyperopes and myopes, perhaps more so because the distortion is worse for high astigmats who wear spectacles. Again, contact lenses cause less disparity between a patient's eyes, both in cosmetic appearance and the image size the child sees.

In some instances the child's refractive status does not mandate contact lens wear, but the lenses can dramatically improve his or her performance at frequent activities. For example, a young athlete may enjoy improved peripheral awareness while wearing contact lenses rather than spectacles.

Another example: A 9-year old girl recently presented for her annual exam. She had low myopia, for which she wore spectacles. She was a serious ballet student—she took nine classes a week with a well-known ballet company—and felt uncomfortable wearing glasses during the constant physical movement (jumping, spinning, bending and being lifted or inverted) associated with this activity. She asked us to fit her with contact lenses.

2. Anisometropia
This is a special refractive condition for which many children receive contact lenses. Again, specta- cles may cause distortion and prismatic effects for many young patients. The anisometropic patient may also face some unique problems with spectacles. Due to the dioptric difference between the two eyes, spectacle correction often results in differing image sizes. This, in turn, leads to spectacle-induced aniseikonia.

Ocular images that differ in size, clarity or luminance can compromise fusion.3 Discomfort, suppression or poor stereopsis may result. Once again, cosmesis is a factor because the patient's eyes appear to be different sizes.

Contact lenses help eliminate the differences between interocular image sizes. They allow the patient to enjoy improved fusion, visual development and stereopsis.4-9 This is especially significant for the anisometropic patients who are amblyopic.10 Contact lenses create better conditions for binocularity by reducing the need for suppression, thus favoring improvement of amblyopia.

3. Aphakia
Aphakia results when the crystalline lens is surgically removed due to infantile cataracts, or during vitrectomy or retinal repair in an infant with posterior segment disease. Depending upon the circumstances, either unilateral or bilateral aphakia can exist.

In either case, contact lenses are indicated (I usually use the Silsoft Super Plus lens). The resultant high hyperopia makes spectacles extremely impractical for the infant. Consider: Aphakic patients require a high prescription, and unless the child looks through the center of the lenses, he or she will experience extreme distortion.

Some pediatric aphakes require a high plus in one lens but less plus power in the other. The two eyes see different image sizes, compromising visual development. Contact lenses can reduce that problem, just as they would with another highly hyperopic child.

Current literature suggests that intraocular lenses are more viable for children than in the past.11,12 However, contact lens wear often remains the treatment of choice after extraction of congenital cataract, as the parameters of an implanted intraocular lens may become inappropriate as the child grows.13

4. Nystagmus
When evaluating a nystagmoid patient, you need to determine type of nystagmus, direction, frequency and whether the nystagmus is dampened or eliminated in a particular gaze (null point).

Sometimes you'll find the null point, but the patient cannot take advantage of it. Specifically, the null point may be outside the optical center or perhaps the entire range of the spectacle lens. This is an indicator that spectacles won't work for that patient.

1,2. A patient with Goldenhar's syndrome displays associated features of torticollis and auricular malformation, and wears a hearing aid due to auditory loss. With spectacles, the patient experienced undesired prismatic and distortion effects, and one eye appeared to be "higher" than the other. Contact lens correction eliminated the distortion and prismatic effects, and improved cosmesis.

Alternatively, contact lenses allow the patient to view objects in the null point position and still benefit from refractive correction.

5. Cranial Dystosis
Occasionally, an asymmetric facial structure can make spectacle wear ineffective. For example, we saw an 11-year-old boy with Goldenhar's syndrome (figures 1 and 2). He was highly hyperopic and hearing impaired, for which he used a hearing aid. He also had a highly asymmetrical facial structure and congenital torticollis, due to malformation of the cervical vertebrae.

All these factors made spectacle wear very difficult for him. The glasses sat at an awkward angle on his face, causing him to view through the distorted periphery. Also, the prismatic effect made one eye appear much higher than the other. Correction with contact lenses improved both his vision and his cosmetic appearance.

6. Albinism and aniridia
Patients with albinism or aniridia may experience extreme glare, which results in reduced visual acuity. A contact lens with a central tint and an opaque peripheral zone would reduce glare and photophobia in these patients, thus improving visual acuity.7 The former acts as a light filter, while the latter creates an artificial pupil.

7. Corneal Injury
Ocular injury can leave the corneal surface with significant distortion, resulting in degraded retinal images. In such instances RGP lenses can reestablish regularity to the eye's front refracting surface.14

Children are just as vulnerable to corneal injury as adults. However, some doctors hesitate to discuss contact lens options for these children and simply prescribe glasses.

Take the case of a 4-year-old boy who injured his eye when playing with a steak knife. He underwent surgery, and then wore glasses for astigmatism. After surgery, his best corrected visual acuity with spectacles was 20/90 in the left eye.

Later, we fit him with an RGP lens, and he immediately read 20/25. The RGP lens masked his irregularity and improved his visual acuity.

3,4. An amblyopic patient wearing a "pirate patch" for occlusion therapy felt self-conscious about her appearance while patching. The same patient now uses an "occluder contact lens" in lieu of the patch. The occluder contact lens is less apparent to other individuals.

8. Amblyopia and Strabismus
Many amblyopic and strabismic patients have occlusion therapy to improve their visual acuity or binocularity. While patching can be effective, children aren't always eager to comply. Discomfort or diminished cosmesis are often the reasons. Even when a child wears a patch, we can't always tell whether the child is "peeking" around it, thus defeating the purpose of this occlusion therapy.

I have used occluder contact lenses, with opaque central regions of various sizes on such patients (figures 3 and 4). The results: enhanced cosmesis, less self-consciousness and increased compliance.

I determine the diameter of the opaque region with a trial fit, including the minimum size needed to effectively occlude the pupil. One caution: While wearing such a lens, the patient can often appreciate forms in the periphery. This is probably acceptable when treating amblyopia or central suppression. However, in certain instances when you want to remove all binocularly viewed stimuli, such as when treating anomalous correspondence, an occluder contact lens may not provide enough occlusion.

9. Elective Fits
Younger patients occasionally ask us to fit them with contact lenses purely for cosmetic reasons. My experience with such patients has been largely mixed. Some do extremely well because they're highly motivated. Others become quickly discouraged by both the fitting and adaptation processes.

Because the diagnosis in these patients does not strongly suggest a medical need for contact lenses, it's important to make the patient understand that contact lenses do involve some risks. Be sure to discuss these at length with the family before you fit these children.

Most of us are well aware of the many benefits that contact lenses can offer to adult patients. These advantages can also apply to the younger population.

However, we often overlook them because we simply assume that it is not possible for children to wear contact lenses. Not only is this possible, but contact lenses are often the best treatment for our younger patients.

Dr. Garriott is an assistant professor at Southern California College of Optometry, where she also did a residency in pediatric optometry and vision therapy. She is a fellow in the American Academy of Optometry and a diplomate in its Binocular Vision and Perception Section.

1. Sampson WG. Correction of refractive errors: Effect on accommodation and convergence. Trans Am Acad Ophthalmol Otolaryngol 1971;75:124-32.
2. Polasky M. Clinical refraction. In Alexander KA, ed. The Lippincott Manual of Primary Eye Care. Philadelphia: J.B. Lippincott, 1995;7:186-211.
3. Lovasik JV, Szymkiw M. Effects of aniseikonia, anisometropia, accommodation, retinal illuminance and pupil size on stereopsis. Invest Ophthalmol Vis Sci 1985;26(5): 741-50.
4. Bartlett JD. Anisometropia and aniseikonia. In: Amos JA, ed. Diagnosis and Management in Vision Care. Stoneham, Mass.: Butterworth, 1987;7:173-202.
5. DeDonato LM, Rouse MW. Refractive Anisometropia. J Am Optom Assoc 1982;53:489-90.
6. Steiner AA. Corneal contact lenses. Their value in severe anisometropia in children. Eye Ear Nose Throat Month 1961;400:778-80.
7. Donzis PB, et al. Pediatric contact lens care. In: Clinical Contact Lens Practice. Philadelphia: Lippincott-Raven Publishers, 1997;51:1-8.
8. McLaughlin R. Reducing anisometropia and amblyopia in an infant. Contact Lens Spect 1994;9:9.
9. Abdulla N., O'Malley D, Bowell R, OKeefe M. Childhood anisometropia and contact lens. Contact Lens Month 1988;215:36-7.
10. Mets M, Price RL. Contact lens is the management of myopic anisometropic amblyopia. Am J Ophthalmol 1981;91:484-9.
11. BenEzra D, Cohen E, Rose L. Traumatic cataract in children: correction of aphakia by contact lens or intraocular lens. Am J Ophthalmol 1997 123(6):773-82.
12. Khater TT, Koch DD. Pediatric cataracts. Curr Opin Ophthalmol 1998;9(1):26-32.
13. Gordon RA, Donzis PB. Refractive development of the human eye. Arch Ophthalmol 1985;103:785.
14. McMahan T. Ocular trauma. In: Bennett ES, Weissman BA, eds. Clinical Contact Lens Practice. Philadelphia: Lippincott-Raven Publishers, 1997;47A:1-10.

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A Continuum of Care

Of course, the relative value of contact lens correction will not be the same for every patient. We must consider several factors in deciding which pediatric patients to fit, or what I call a "continuum of care." These include:

• Reason for fit. Are the lenses medically necessary or cosmetic? While you may fit many contact lenses for cosmetic reasons, the lenses are medically indicated in other patients, such as the unilateral infantile aphake.

Other diagnoses are not as extreme. For example, a low anisometropic patient may be able to perform adequately with spectacles, but can achieve optical advantages of contact lenses.

• Parents' perceptions. Even when contact lenses are medically indicated, you must consider the parents' perceptions. Some parents are contact lens wearers themselves, and appreciate the benefits they offer. Others think of them only as a cosmetic device, and an unnecessary one at that, or they're somewhat anxious about their children wearing them.

Parents who are negative or apprehensive about their children wearing contact lenses and the care regimen involved require much education and handholding. Whenever I fit a child in contact lenses, I discuss the diagnosis and the child's need for contact lenses in-depth with the parents. The better the parents understand their child's condition, the more favorable the outcome.

• Difficulty of fit. You may not be able to assess how well the lens performs until the patient has worn the lenses for a while. The lens you fit on an infant may look good in the office, but the child may repeatedly lose contact lenses.

Another consideration: Factors such as extreme parameters (toricity, corneal curvature), dermoids, postsurgical scarring or extremely small palpebral fissures can complicate the fit. Custom contact lens designs are often necessary to meet the special needs of children. The sizes and powers needed may be outside the normal lens parameters.

You should not decide whether to fit a patient with contact lenses based on the difficulty of fit. However, this factor is still an important initial consideration, given that it can affect patient education, chair time, material availability and fees.

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