Eyecare practitioners (ECPs) are often hesitant to fit pediatric patients with contact lenses. The reluctance may be due to several factors, including concerns about responsibility, longer appointment times, and risk of infection.
This article aims to mitigate provider concerns and encourage improving the standard of care for our young patients.
Studies on contact lens safety in children
Several studies have shown that the incidence of microbial keratitis and corneal infiltrative events (CIEs) occur at a similar or lower rate in children compared to adults.1-5 One study found that the incidence of corneal infiltrative events in children was no higher than in adults, with the youngest range (8 to 11 years old) having markedly lower rates.1 Another found that age was significantly associated with CIEs, with the lowest incidence among patients between 8 and 15 years old.3
A 2023 study reviewed seven prospective studies on safety among patients fit with contact lenses at age 12 years or younger. Collectively, they reported one case of microbial keratitis and 53 CIEs. The incidence of microbial keratitis was 2.7 per 10,000 patient-years, and the incidence of symptomatic CIEs was 42 per 10,000 patient-years.
The authors concluded that the incidence of microbial keratitis in children wearing soft lenses is no higher than in adults, and the incidence of CIEs seems to be markedly lower.2 The lower incidence of adverse events should not be surprising. Young patients often require parental involvement in their contact lens care.
Many ECPs consciously require parents to participate in contact lens training. Consequently, parents’ engagement and understanding of the risks and proper techniques for contact lens care contribute to the lower rate of contact lens complications among children.
The long-term effect of contact lens wear on children
Patients who start wearing lenses in childhood have more years of exposure to potential adverse events related to contact lens wear. Researchers conducted a survey of patients who had worn lenses for at least 10 years. Of the 175 participants, 49.2% were fit into contact lenses as children and 50.8% were fit as teenagers.
Of note, 20% fit as children and 19% fit as teenagers reported ever having had a painful, red eye that required a doctor visit. There were no differences in ocular health between the groups.6 Ultimately, the group that started wearing contact lenses in childhood did not have a higher incidence of complications.
Selecting the right lenses for pediatric patients
It is prudent to prescribe daily disposable contact lenses whenever possible due to the lower risk of infection.7-9 However, patients with high refractive errors or irregular astigmatism may require a biweekly or monthly modality.
For patients prescribed reusable lenses, hydrogen peroxide cleansers offer a simple, effective one-step system to lessen the risk of infection or intolerance.10 It’s important to spend time explaining the neutralization process to prevent the patient from following up with a chemical burn.
Debunking the chair time misconception
A common misconception is that fitting pediatric patients with contact lenses requires extra chair time. The CLIP (Contact Lenses in Pediatrics) study was designed to understand the additional time required to fit a pediatric patient (8 to 12 years old) with contact lenses as compared to a teenager (13 to 17 years old).
They found that, on average, the fitting process took an additional 15 minutes. Most of the time difference, however, was attributed to the insertion and removal training, which lasted about 40 minutes for children and about 30 minutes for teens.10
While it’s true the patient spends more time in the office, it is not in the provider’s chair. The additional time was used for contact lens training in its entirety. This process is often delegated to a staff member, leaving the provider’s chair time unaffected. The time and effort invested in this patient can result in additional years of contact lens revenue and word-of-mouth referrals.
How to asses contact lens readiness in children
Patient selection is important and can be a time saver. The child—not just the parent—must be motivated to wear the contact lenses. If the child is not on board, the fitting and training process can take a toll and may result in the patient leaving without any contact lenses. If you know that a patient is interested in contact lenses but is a little hesitant, encourage them to start preparing for contact lens training at home.
There are four steps that can help set pediatric contact lens wearers up for success:
- Emphasize the importance of clean fingers and clipped nails.
- Find a kid-friendly YouTube video of a child inserting and removing a soft contact lens.
- Encourage them to practice with lubricating gel drops. Have the patient place a gel drop on their finger and transfer it to the eye.
- Set up a “contact lens station” at home organized for comfort and convenience.
Let’s talk about contact lens tolerability in children
As with fitting a contact lens in any age group, it’s important to assess centration and movement. Most patients do well with commercially available contact lenses due to the range of base curve and diameter options. Poor tolerability of one contact lens does not translate into the child not being ready for any contact lens. Rather, assess the fit, adjust the parameters, or consider another brand.
Giant papillary conjunctivitis (GPC), with large papillae occurring on the superior tarsal conjunctiva, can occur with contact lens wear. It is attributed to the combination of mechanical trauma to the superior tarsal conjunctiva and an immunologic response to deposits on the anterior surface of the contact lens.
GPC typically resolves with a contact lens holiday. More severe cases may require a topical antihistamine; rarely, a steroid is required. Patients can often return to contact lens wear, with re-education about contact lens care or by switching to a daily disposable contact lens.10-12
The preservatives in multipurpose solutions can also cause irritation, with a lower incidence in those that use hydrogen peroxide-based solutions.13
Moving to an updated standard of care
There are times when fitting a young patient with a contact lens is a professional obligation as an ECP. Prescribing contact lenses for children isn’t always for cosmesis or convenience for things like sports. Contact lenses play a role in managing ocular disease and preventing ocular health problems as children grow. For example, young patients with significant anisometropia, corneal irregularities, or progressive myopia would benefit from contact lens wear.
Recent years have seen a rise in the incidence of myopia, with onset occurring at a younger age.14 Fortunately, ECPs have tools to help provide preventative care for children. Studies have shown that each additional 1 diopter of myopia is associated with an increased risk of myopic maculopathy, open-angle glaucoma, posterior subcapsular cataract, and retinal detachment.15
Peripheral defocus contact lenses and orthokeratology can slow the axial elongation of the eye, and reduce the risk of these visually threatening complications later in life. For those new to myopia control, Johnson & Johnson and CooperVision offer online certification courses for their myopia control programs.
For patients with ocular pathology, anisometropia, or high refractive errors, contact lenses are a medical necessity.16 This includes patients with corneal ectasia, corneal scars, and aphakia, among others. There is an opportunity and a need for optometrists to provide specialty contact lens fittings for pediatric patients.
For a deep dive into how to bill for medically necessary contact lenses, check out A Guide to Billing for Medically Necessary Contact Lenses.
Final thoughts
Pediatric contact lens fittings are accessible for most ECPs. With proper training and education, contacts can be a safe supplement to glasses.
