Diagnostic Contact lens fitting in the young patient – #Tips4EyeDocs

Diagnostic contact lens fitting of the child patient from ten (10) through seventeen (17) years of age is probably one of the most rewarding in a clinician’s daily practice life. I have tried a few things over the years and I hope that these might help you.

Rarely do children have large palpebral aperture size nor are their lids loose. On the contrary, their apertures are small and the lids tight; these two make insertion of a diagnostic contact lens difficult at times.

When you do see a small aperture size, consider a 14.0 lens or smaller as a first fit trial lens. Because of the small apertures, success in inserting the lens the first time is essential to retain confidence in the process.  I have found that parents and patient alike will continue the lens fitting process if the doctor or the assistant can insert the lens on the first try.

Often the child will prefer not to wear glasses at all, even to the point of removing the glasses when they are out of sight of parents, family members or teachers.  Although this should be a strong motivation to try contact lenses, the fear factor is concomitantly high and the process of diagnostic contact lenses can quickly extinguish the drive for contacts. Of course, if the child wears eye makeup, the child may overcome this fear.

A good starting point is a lens of 14.0 mm in diameter. A larger lens, even 0.2mm larger, may be too large.  Although not ideal for an adult, a spherical lens that approximates the spherical equivalent may provide sufficient and satisfactory vision for a child. Such vision may be adequate and sufficient for average school activities. As facility with lens handling improves, then a larger toric lens may be contemplated.

For rigid lenses, the diagnostic fitting should be as comfortable as possible and I do apply a single drop of surface anesthesia to minimize lens sensation at the outset. There are quite a few of my peers who might find this unacceptable, but I have found that this dramatically improves rigid lens acceptance.  In addition, the lack of excessive tearing makes the lens movement that much better to assess and refract over.  Depending upon the goal of the rigid lens fit, I will start with an 8.6 diameter lens. Frequently this covers the cornea sufficiently while still providing satisfactory comfort, fit, movement and lens flexure.

Children who are short in stature may find difficulty in positioning themselves within a biomicroscope. The even when the chair is raised at its highest point, the child’s eyes might not be high enough.   In those cases, a bundled rubber block that is wrapped in plastic may give the additional one inch that elevates the eyes high enough for slit lamp use. Of course, a handheld slit lamp would be much preferred.

Dispensing the lens at the end of that first visit is key to continue the momentum and enthusiasm for lenses. If the patient cannot demonstrate facility with lens removal and insert, then a follow up will be needed.  I don’t usually see patients coming back more than twice for training in lens handling.

In summary, children make good contact lens patients. Frequently, just asking the patient what they know about contact lenses can spark an interest that is underlying but not mentioned. In general, parents support their children in wearing contact lenses. The doctor and staff can easily support that interest by introducing the topic and providing an immediate forum for beliefs and concerns that parent and child may have.  Don’t miss an opportunity by not talking about it.

About Richard Hom OD, MPA

Dr. Hom holds Doctor of Optometry and Masters in Public Administration degrees and practices family eye care and consults on public policy, health information technology and program evaluation.
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7 Responses to Diagnostic Contact lens fitting in the young patient – #Tips4EyeDocs

  1. Excellent point about the small diameter for initial pediatric fits. I personally also often choose a higher-modulus lens for the initial fit b/c they don’t easily invert on the patient’s finger. Many people say dailies are a good choice for pediatrics b/c there is little care involved. I agree with that philosophy, but find that very often a BRAND NEW WEARER has a very difficult time handling a super-floppy & fragile low modulus daily disposable. For the very first fit in a pediatric case I frequently choose Ciba’s Night & Day b/c it’s a small diameter (13.8) and higher modulus lens, which makes initial insertion training much easier IMO. It has the added benefit of being FDA approved for extended wear…you know, just in case!

    • Michael,

      Thanks for your thoughts and comments. I concur that a high modulus lens is much preferred and both the Ciba Night and Day and the B+L PureVision 2 HD can meet both requirements. I posted to try to leave out my own brand biases. Thanks again.

  2. Frank Won says:

    Here are a few tricks that I like to use with SCL fits on pediatric patients:
    1) Insert the lens like you’re parallel parking a car. Insert one edge under the upper lid (if possible, then drop the lower edge down. Have the patient look down and blink VERY slowly (if possible). This will remove any bubbles inserted during this process.
    2) Make sure the trial lens being inserted is highly lubricated. The capillary action of the solution on the lens will do half the work for you if you allow it to.
    3) Tell the patient exactly what you’re going to do before you do it and what to expect before it happens.
    4) As mentioned above, choose a lens with a slightly higher modulus. Though I generally prefer (almost exclusively daily lenses for pediatric patients), I periodically do start them off with a lens like an Air Optix (or Night and Day).

    Great article! I always enjoy reading your stuff

  3. Mary Lou says:

    I fit kids in this age group all the time. I much prefer a daily lens but to increase the success in handling I use an oasys as a “training lens” then order moist daily. Now that they are available in a toric lens with a wide amount of parameters I am excited to be able to fit even more kids with a daily lens. And I have great staff who actually do the initial lens insertion for the diagnostic visit. They are much better than I!

  4. Kids? Contact lenses? GP’s: lens of choice!!!

    • Thanks for your comment. I concur that RGPs are a lens of good choice, but unfortunately, the popularity of soft lenses make the alternative of a RGPs difficult.

      • Soft lenses are easy; they provide nearly immediate gratification. The selling points of firm lenses nearly always make sense…at least in our neighborhood they are the economic alternative as well. Your low spheres and the other cases that will do with a daily disposable; the really sports addicted young people will opt for the soft lenses, I agree…but I think that we will see a greater usage of GP scleral lenses in these kids as well.

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