Clinical Update

PE DI AT R IC S

Contact Lenses in Children:

Getting It RightLens, Age and Need
by linda roach, contributing writer
interviewing david g. hunter, md, phd, amy k. hutchinson, md, and amir pirouzian, md

I
t might come as a surprise to
parents, but contact lenses are
C o n t a c t L e n s f o r an A p hak i c I n f an t
a mainstay of optical correc- 1 2
tion options for children with
special refractive needs. For
a myopic 10-year-old hockey player,
contact lenses can solve the problem of
eyeglasses that fog up during the game.
For a preschooler with anisometropia,
they can give the brain the two sharp
images it needs to develop stereoacu-
2012 Buddy M. Russell, FCLSA, COMT,
ity. And for tiny infants with aphakia Emory Eye Center
after congenital cataract removal, they
(1) Instillation of fluorescein to evaluate lens fit in a 2-month-old boy. (2) An
can bring the world into focus and
RGP contact lens is gently inserted into his aphakic eye.
encourage the visual system to mature
normally. and well tolerated, it comes in the high contact lenses usually are not used
Successful use of contact lenses in powers required for aphakia (from +7 D in young children because they are
children doesnt have to be difficult. to +32 D), and the material resists ab- harder to handle and less suitable for
A physicians recommendations about sorption of topical ophthalmic drugs. extended wear due to their lower oxy-
the lenses best suited to a childs age Rigid gas-permeable lenses. gen transmission than silicone or RPG
and needs, as well as the doctors skill Some clinicians prefer to put aphakic materials. If a child does start to wear
in training parents to insert and re- children of any age, even infants, in these lenses, close monitoring for hy-
move an infants or a toddlers lenses, contact lenses made from rigid gas- peremia or other signs of ocular stress
can go a long way toward helping chil- permeable (RGP) materials, both for is recommended.
dren benefit from contacts. their oxygen transmissibility and for Silicone hydrogel soft lenses are a
2 012 b u d d y m . r u s s e l l , f c l s a , c o m t, e m o r y e y e c e n t e r

The Lenses: Recommended Uses
Several types of lens are available for
pediatric patients. Each has its ben-
efits, and the choice will depend on the
individual childs needs.
Silsoft lens. For aphakic infants
who have not received an intraocular
lens (IOL), the most widely used con-
tact lens is Silsoft (Bausch + Lomb).
It is an extremely soft, extended wear
lens made from 100 percent silicone
polymer, which is generally acknowl-
edged to have the best oxygen perme-
ability of any contact lens. Easy to fit
the smaller steps in refractive power
that they offer. Silsoft lenses are easy
to fit, so a lot of people use them. But
currently they only come in 3-diopter
increments for patients with hyperopia
greater than 20 diopterswhereas
with an RGP lens, you can be more
precise in correcting the childs refrac-
tive error, said Amy K. Hutchinson,
MD, associate professor of ophthal-
mology at Emory University. She noted
that to prevent corneal erosions, RGP
lenses must be fitted carefully by a
well-experienced contact lens fitter.
Soft lenses. Conventional soft
newer form of soft lens with higher
oxygen transmission. If the child is
prescribed a silicone hydrogel lens,
care should be taken during the fit-
ting process to avoid corneal erosions
from a tight lens. A few studies have
implicated erosions as a cofactor in
microbial keratitis related to silicone
hydrogel lensesespecially those used
for extended wear.1
If the clinician has concerns about
parental adherence to lens care guide-
lines, daily disposable lenses offer a
possible solution independent of the
childs age. Daily disposables are nice

e y e n e t 37
 Pediatr ics

because the parents can just put them When to Use Contacts for Aphakia Dr. Hunter said. In patients over age
on the childs eye once and then throw Children who are born with cataracts 6 months with unilateral cataracts, my
them away at the end of the day, Dr. or who develop them in infancy re- preference is to place an intraocular
Hutchinson said. She noted that dis- quire refractive correction after their lens at surgery. However, if a child
posables also simplify lens care for cloudy lens is removed. Which ap- is already aphakic, I will stay with
children who have become old enough proach to use as primary therapy de- contact lenses but move quickly to a
to insert and care for contact lenses pends on the nature of the aphakia. secondary IOL if there is contact lens
themselves. Bilateral aphakia. If IOLs are not intolerance.
Scleral lenses. Some of the most implanted, contact lenses are the first Ages 1 to 6 months. The ongo-
helpful new things for tough cases choice for visual rehabilitation. Eye- ing Infant Aphakia Treatment Study
are the latest scleral or hybrid contact glasses may be prescribed if lost lenses has not yet determined the preferred
lenses, said David G. Hunter, MD, or parental difficulty with inserting method of optical correction for these
PhD, ophthalmologist-in-chief at Chil- and removing the lenses prevents suc- infants, Dr. Hutchinson said. She is
drens Hospital Boston and professor cess with this modality. a coinvestigator in this multicenter
of ophthalmology at Harvard Uni- Unilateral aphakia. Recommended trial, which randomized 114 infants to
versity. These large-diameter contact therapy for unilateral aphakia depends IOLs or contact lenses after cataract
lenses, which do not touch the cornea, on whether the child is older or young- surgery. At age 1 year, the two groups
can help children with a broad range er than age 2. had statistically equivalent visual out-
of refractive and ocular surface disor- Older than 2 years. Today, most comes. However, the greater incidence
ders, including congenital corneal an- children who undergo cataract remov- of complications requiring additional
esthesia syndromes, Stevens-Johnson al after age 2 will emerge from surgery surgical interventions in the IOL group
syndrome and corneal scarring after with an IOL in place. argues for continued caution; follow-
trauma. (For more information about If an IOL is not implanted, contact up through age 5 is continuing.3
these lenses, see the January feature lenses are usually the first choice for Fine-tuning with spectacles. Chil-
story at www.eyenetmagazine.org.) visual rehabilitation. Drs. Hunter and dren who are aphakic or pseudophakic
Orthokeratology lenses. Parents Hutchinson agreed in principle that may also need to use spectacles, for ex-
and pediatricians sometimes ask about eyeg lasses are a less desirable option ample, to correct for astigmatism that
these overnight contact lenses for for these children because the magni- IOLs or contact lenses do not address.
flattening myopic corneas. Research fication effect from the spectacle lens It is essential that school-age children
shows that the effects are temporary, interferes with development of binocu- have a reading add to allow the child to
and additional study is needed to de- larity. focus at near.
termine whether there is an increased Ages 6 months to 2 years. Many In addition, some children with
risk of infection and other complica- surgeons prefer IOLs for children in IOLs wear eyeglasses with low-power
tions when orthokeratology lenses are this age group, but contact lenses re- distance correction because their
used at night.2 main an important therapeutic option, implants leave them with slight hyper
opia. Dr. Hutchinson said she does this
C o n t a c t L e n s e s in O l d e r Chil dr e n for two reasons. I like these children
to wear eyeglasses for safety, she said.
At around age 10, children with normal levels of refractive error and a distaste for Also, we know that the childs eye will
wearing eyeglasses become interested in contact lenses, said Dr. Hunter. This is naturally undergo a myopic shift as it
either because of appearance or because of sports. Ive had several 8- or 9-year-old grows, so I prefer to initially undercor-
hockey players, for instance, who came in asking for contact lenses because their rect them. Then the residual refractive
glasses fog up while theyre playing. error can move toward emmetropia.
Some clinicians set rigid age limits for contact lenses (usually about 10 or 11
years), and others prefer a case-by-case evaluation of the childs maturity and re- Anisometropia and Amblyopia
sponsibility. I insist on the child being a participant in putting the contact lenses in In phakic children with amblyopia
and taking care of them, Dr. Hunter said. If their room is always a mess, then that caused by severe anisometropia, stra-
is probably a sign that theyre not going to be fastidious about taking care of their bismus or accommodative esotropia,
contact lenses. But if they are responsible kids who take care of their own hygiene, eyeglasses are usually the first form of
then we say yes. Theres no reason that we shouldnt put them in contact lenses just refractive therapy offered along with
because of their age, he said. eye patching. However, contact lenses
Dr. Hutchinson agreed. I have one little girl with accommodative esotropia who can be helpful if spectacle therapy
began wearing contact lenses when she was 4 years old. Her mom is a contact lens proves problematic.
tech, so they were comfortable with the idea. The girl has been in contact lenses for I am reluctant to prescribe con-
six years now and is doing well. tact lenses due to the increased risk
of infection of the sound eye and the

38 m a r c h 2 0 1 2

loss of the protective feature of the
spectacles, Dr. Hutchinson said.
However, in some cases if the child
is terribly bothered by the appearance
of the unbalanced spectacles, I will
consider correcting the highly ametro-
pic eye with a contact lens, and having
the patient wear a thin pair of shatter-
resistant spectacles just for protection.
Dr. Hunter said he rarely uses con-
tact lenses in anisometropic phakic
children in the amblyopic age group.
The only time well use a contact
lens for these amblyopia cases is when
theres a real problem with using glass-
es, he said. Theres a magnification
difference between the two eyes. Con-
tact lenses minimize this difference
and make the therapy more tolerable
for the child. But they are not neces-
sarily essential.
Occlusion therapy. Infrequently, if
occlusion therapy with eye patching
and atropine fail to reverse amblyopia,
an opaque contact lens can be used
instead to suppress images from the
dominant eye.
Last resort? A phakic IOL. Since
2008, a handful of research papers
have proposed rescuing the vision of
extremely treatment-resistant amblyo-
pic children by implanting an ante-
rior chamber iris-claw phakic IOL
(Verisyse, AMO). Because this puts
endothelial cells at risk, surgeons who
have used this approach warn that it
should be reserved for special-needs
cases in which there is severe vision
loss from intractable noncompliance
with spectacle, contact lens and occlu-
sion therapy.4-6
The ideal form of treatment for
high refractive errors should be medi-
cal contact lenses. But in stubbornly
noncompliant patients, a phakic IOL
is a welcome alternative to keep these
children from falling through the
cracks, said Amir Pirouzian, MD,
author of a report on phakic implants
in seven children.4 Dr. Pirouzian is a
cornea/external disease and refractive
fellow and clinical instructor at the
susan purcell
Gavin Herbert Eye Institute, Univer-
sity of California, Irvine, and has also
completed a fellowship in pediatric
ophthalmology at UCLA.
The children on whom Dr. Pirouz-
ian operated were 5 to 11 years of age
at the time of surgery, with preopera-
tive corrected distance visual acuity
(CDVA) in the affected eye of 20/200,
20/400, or 20/1000 or worse. Three
years after surgery, five of the eyes had
CDVA of 20/40 or better, and the other
two measured 20/50 and 20/60.
Parental Issues
At first, parents of young children who
require optical correction are amazed
that contact lenses are an optionand
then they become apprehensive about
the logistics. When you first intro- grows and refraction changes.
duce the idea, parents are surprised
that even infants wear contact lenses,
Dr. Hutchinson said. But a large
number of aphakic patients can be
successful with contact lens therapy if
youre careful about screening families
and if you instruct the parents well.
Wearing time. For aphakic infants
in Silsoft contact lenses, both Drs.
Hutchinson and Hunter recommend
that parents let the infants wear the
lenses for as long as a week, 24 hours a
day, before removing them for cleaning.
When possible, Dr. Hutchinson
prefers to put aphakic infants and chil-
dren into RGP lenses, which must be
taken out and cleaned nightly.
If an older child wears disposable
soft contact lenses, she recommends
against sleeping in the lenses, even if
they are labeled for extended wear. I
dont like them to leave contact lenses
in overnight. Im concerned about
oxygen deprivation to the cornea over
night through a closed eyelid, she said.
Infections. The risk of contact
lensrelated corneal infections can be
minimal if parents care for the lenses
properly. In the contact lens group of
the Infant Aphakia trial, 1 of 57 babies
(less than 2 percent) developed pre-
sumed bacterial keratitis.3
Cost. Some families find the on-
going costs of contact lenses to be a
barrier to treatment compliance. For
instance, special silicone contact lenses
for infant aphakia cost from $300 to
$700 per pair, depending on the refrac-
tive power and level of customization.
Lens loss is common, and lenses also
Pediatr ics
HOW TO. Dr. Hunter refers parents to a
YouTube demonstration of contact lens
insertion in both an infant and a small
child. View it at www.youtube.com/
watch?v=sxHnoJP4t7I.
must be replaced as the childs eye
Training. Even if a family can af-
ford the costs, this modality will fail if
a contact lens technician does not help
relieve parents anxiety by training
them to insert and remove the lenses,
Dr. Hunter said. His practice even has
a secret weapon: a six-minute YouTube
video, made by the mother of two of
his patients. The video, which has been
viewed more than 42,000 times, shows
the mother calmly popping contact
lenses in and out of her babys eyes.
She also urges parents in a web post to
hang in there. Be patient and be-
lieve that you can do it.
Said Dr. Hunter: While it can be
very stressful for the family at first,
most parents become quite skilled at
inserting and removing lensesit be-
comes a matter of routine. It becomes
more like changing a diaper than this
awful event that everyone dreads.
Dr. Hunter founded and owns stock in REBI-
Scan, which is developing a device for pediatric
vision screening. Drs. Hutchinson and Pirouz-
ian report no financial conflicts.
1 Willcox MD et al. Eye Contact Lens. 2010;
36(6):340-345.
2 Van Meter WS et al. Ophthalmology. 2008;
115(12):2301-2313.
3 The Infant Aphakia Treatment Study
Group. Arch Ophthalmol. 2010;128(7):810-818.
4 Pirouzian A, Ip KC. J Cataract Refract Surg.
2010;36(9):1486-1493.
5 Trivedi RH, Wilson ME. J Cataract Refract
Surg. 2010;36(8):1432-1434.
6 Tychsen L et al. J AAPOS. 2008;12(3):282-
289.
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