The safety of fitting children in contact lenses is well-established.1-3 Contact lenses can be beneficial to our young patients for a variety of reasons, including treating aniseikonia or high ametropia, myopia control, and providing freedom from glasses to play sports or manage sensory sensitivities; the list goes on.
Overall, most children do well with contact lenses after the initial fit. However, some require troubleshooting before being able to comfortably wear their lenses.
Addressing 5 common complaints from pediatric patients
1. “My eyes feel irritated.”
Persistent contact lens discomfort can be due to a variety of reasons and will often lead to dropout if not addressed in the very early stages of wear. However, to remedy the situation, one must first understand the underlying cause.
Consider the following questions to determine the root of the problem:
Does the lens fit appropriately?
Tighter fitting and steeper base curve contact lenses offer better comfort, whereas excessive movement and smaller diameter contact lenses tend to reduce comfort.4
Are there deposits on the lens?
The contact lens surface must be smooth and wettable with minimal deposits. Consider switching to a daily disposable contact lens modality. If a reusable lens is necessary (due to prescription, fit, cost, etc.), a hydrogen-peroxide-based cleanser can help reduce surface deposits and improve comfort.5
Is there mechanical irritation?
Contact lens thickness and edge shape can cause discomfort when rubbing against the eyelids. Toric and multifocal lenses tend to be thicker by design and are more susceptible to causing greater discomfort.4
Is there an allergy?
Patients can develop a reaction to the contact lens material. Giant papillary conjunctivitis (GPC) develops due to mechanical irritation and an immunologic response due to the lens edge design or surface deposits. It presents with itching, redness, large papillae, and mucoid discharge.
GPC typically resolves with cessation of contact lens use, however, more severe cases require steroids. Once resolved, patients can often successfully be fit into a daily disposable lens or different edge design.6-9
Environmental or seasonal allergies can also affect contact lens tolerance. Allergic conjunctivitis presents with red, itchy eyes and watery discharge. The standard treatment of over-the-counter antihistamine drops are often sufficient. Advise patients to instill the drops 5 minutes prior to contact lens insertion and after contact lens removal.
Does the patient have untreated meibomian gland dysfunction?
Meibomian gland disease and dysfunction (MGD) is becoming increasingly common in the pediatric populations. Studies have found that treating MGD improves contact lens comfort and tolerability.10 Prior to fitting a pediatric patient with contact lenses, it is important to treat any underlying lid disease and establish a nightly lid hygiene routine.
I recommend the following routine for maintenance care:
- Perform warm compresses with lid massage regularly. Advise parents to introduce a Bruder Mask as a spa treatment to make the experience exciting and enjoyable.
- Use a hypochlorous acid-based cleanser to gently cleanse the eyelids.
- Incorporate omega-3s naturally (if possible). Flaxseeds or chia seeds mixed into yogurt or a smoothie are often manageable for picky eaters.
Is the patient suffering from another form of dry eye?
Wearing contact lenses is a known risk factor for dry eye, with approximately 50% of wearers experiencing dry eye symptoms.11 As such, assessing the ocular surface is critical to successful contact lens wear.
Several risk factors for dry eye have been identified in the pediatric population, including:10-11
- Ocular allergy
- Inflammatory or autoimmune conditions
- Digital device use frequency and duration
- Less time outdoors
- Contact lens use (!)
Studies on the treatment of dry eye in the pediatric population are lacking. Current recommendations are limited to unpreserved lubricating drops and management of any potential underlying systemic condition.11
2. “It takes too long to put my contact lenses in.”
After completing in-office contact lens training, young patients must transfer what they’ve learned to the real world. They may have successfully handled their contact lenses in-office, but struggle to insert the lenses at home.
To minimize frustration at home, encourage parents to be involved in the training process so they can be a resource for their kids. In addition, have a frank discussion with patients after the training session—they may struggle at home and that’s okay.
The pressure of getting up and ready for school on time can be overwhelming. Encourage families to limit their contact lens process to 5 to 10 minutes on school days. Take advantage of weekend mornings to practice contact lens application and removal when there is less of a time restriction. This minimizes frustration and allows the patient to take breaks, regroup, and try again.
Setting up a “contact lens station” at home can also be helpful. This consists of a table, chair, magnifying mirror, contact lens solution, and an extra pair of contact lenses. Replicating the in-office set-up serves as a crutch to transition to successful contact lens wear. Most children will be able to easily insert and remove their lenses with a few days or weeks of practice.
Finally, there are cases in which a child may lack the dexterity to insert the lens on their own. Parents can take responsibility for inserting the lenses in this situation. However, continued practice should be encouraged.
3. “I’m having a hard time taking my contact lenses out.”
It is important for contact lens wearers to be able to remove their lenses independently. While parents can help with removal at home, situations may come up where they may not be available, and the child needs to remove their contact lenses on their own.
A child may get dirt or glitter in their eye while at school. They may get splashed with rainwater (or worse). Their contact lenses may start feeling uncomfortable for an unknown reason. Accidents happen. An irritant stuck under the lens can result in a corneal abrasion, which can lead to an infection if left untreated. Prompt removal of the lens minimizes that risk.
In addition, seasoned parents understand that sleep schedules don’t always go as planned. Parents may occasionally have nights out, necessitating a babysitter to help with lens removal. Children may go for a sleepover or overnight camp.
Young contact lens wearers should understand the risks of sleeping in contact lenses. Contact lens overwear can result in corneal de-epithelialization, sterile infiltrates, neovascularization, and microbial keratitis.4 Providing children with the tools and expectation to remove their lenses at night is critical to minimize the risk of complications.
Most of our pediatric patients leave our office comfortable removing their lenses after one training session. Others require an additional session or two. Staff should be trained in teaching contact lens removal in different ways. Provide patients with reliable YouTube videos for demonstration.
Three common contact lens removal methods are as follows:
- Standard Method: Loosen the lens by moving it with your index finger, then pinch with the thumb and index finger to remove.
- Sliding Method: Hold the upper lid open at the base of the lashes with the non-dominant hand. Hold the lower lid with the middle or ring finger of the dominant hand. Use the index finger of the dominant hand to slide the lens to the inner corner.
- Blinking Method: Instill a few lubricating drops and make the lids taut by pulling on the outer corner of the lid. Blink several times using the eyelids to remove the lens
4. “My contact lens keeps falling out.”
When soft contact lenses are falling out, I immediately consider a couple of possible factors:
- Does the contact lens fit properly?
- Is the contact lens drying out?
- Is the child rubbing their eyes?
A poor-fitting lens can result in contact lens discomfort. A flat lens will be loose and move around too freely. A steep lens may fit too tightly and “pop” off. Both can result in contact lens discomfort causing the patient to rub their eyes. Consider adjusting the lens or adding a lubricating drop to improve comfort. However, even with a perfect fit, some children take a couple of weeks to adapt to the lens before they’re comfortable.
If all looks well, encourage these patients to slowly build up to a full-time wear schedule, starting with 2 to 3 hours on the first day. Though studies suggest that a gradual wear schedule has no effect on contact lens comfort for adults, I have found that some children benefit.12
Minimize contact lens dropout by scheduling a 2-week contact lens follow-up. It serves as an opportunity to catch any issues with contact lens fit, comfort, and safety. It also provides an opportunity for patients and parents to discuss any of their concerns, ultimately resulting in less contact lens dropout.
5. “I see better with my glasses.”
This is the least common complaint, but will occasionally occur. While the majority of patients will see just as well—or better—with their contact lenses, some may notice a decrease in the quality of vision compared to their glasses. Again, this emphasizes the importance of the contact lens follow up appointment.
Soft contact lens technology continues to advance. Several contact lens designs correct high amounts of astigmatism and ametropia, including some daily disposable options, such as MyDay Toric (CooperVision) and Infuse ONEday for Astigmatism (Bausch and Lomb). For exceptionally high levels of irregular astigmatism, Biofinity XR Toric (CooperVision) provides astigmatism correction up to 5.75D with 5° steps.
The vast majority of patients can successfully fit in commercially available lenses. For those with irregular corneas or refractive errors, custom contact lenses can be prescribed. Intelliwave PRO (Art Optical) and Flexlens (X-Cel) offer wide parameters that support full customization of the lens size and power. Both lenses can be ordered with a warranty to allow for any necessary adjustments.
Final thoughts
Contact lenses provide numerous benefits to patients of ALL ages, including optical, sporting, cosmetic, and medical benefits. These benefits outweigh the risks in the vast majority of cases.
Troubleshooting minor complications can prevent contact lens wear dropout and allow patients to enjoy the freedom of contact lens wear.
