All about pediatric contact lens and its fitting process

1. Pediatric contact lens and
fitting
MODERATOR : PRESENTER:
NIRAJ DEV JOSHI BIPIN KOIRALA
ANITA POUDEL
IOM , MMC

3. Presentation layout
1. Introduction
2. Indications
3. Pre fitting evaluation
4. Aphakia and its fitting
5. Options of contact lens
6. After care visit
7. Insertion and removal methods
8. Summary
9. References

4. Introduction:
 Contact lenses have an important role to play in the visual correction
of children and infants.
 They can permit more normal development of VA, and motor and
perceptual skills compared with spectacles especially in cases of high
refractive errors.
Contact lenses offer a 15% wider field of view compared to spectacle
lenses.

5. Spectacle vs Contact lens
 Many infants or children, as well as some parents
react negatively to spectacles.
 Contact lenses are preferred over spectacles due to the
difficulty of keeping spectacles on a Child face.

6. Difficulties with spectacles
1. Absence of a prominent nose bridge.
2. Spectacles are easily removed, bent, scratched and
broken.
3. Potential for retinal image size disparity.
4. Alterations/distortions in the peripheral field of view.

7.  Contact lens fitting is a rewarding task but is challenging as well.
 Fitting contact lenses to pediatric patients is usually very time
consuming and may be costly in some cases.
 A key factor in successful pediatric contact lens fitting is
the level of motivation of the child as well as the
parents.

8. Pediatric contact lens fitting collaboration
Manpower
EYE MD
Optometrist
Contact lens
practitioner
Family
members
Community
nurses
Pediatrician

9. Conditions for fitting pediatric
contact lens
1. Refractive errors
- Aphakia,
- Myopia,
- Hyperopia
- Astigmatism,
- Anisometropia
2. Binocular vision anomalies
- Accommodative esotropia

10. 3. Therapeutic
- Patching for amblyopia, Bandage ,
Photophobia , Nystagmus , Albinism
4. Cosmetic ( Prosthetic CLs)
- Scarred cornea, Aniridia, Iris coloboma ,
Traumatic damage to anterior eye ,
Micropthalmos

11. 5. When spectacles are inappropriate/disliked
- Craniofacial abnormalities
( Down’s , Treacher Collin’s syndromes)
6. Myopia control strategies.

12. Anatomical challenges for fitting contact lens
1. Small palpebral aperture size (PAS)
2. Strong orbicularis oculi muscle tone
3. Reduced blink frequency
4. Tear volume
5. Changing corneal shape and refractive error
6. Development of tear reflex
7. Steep anterior corneal curvature
8. Pupil size and shape

13. Other challenges
1. Poor cooperation from parents.
2. Anxiety regarding the fitting procedure
3. Inability to understand the procedure.
4. Poor economic back ground of family.

14. What age is appropriate to fit
the contact lens??
 Contact lens can be fitted as per requirement in any age
group of pediatrics including infants.
 AAO (2004) suggested that by the age of 8 a child will be
able to handle contact lens by himself under proper
guidelines of parents.

15. Investigators have demonstrated that the incidence of
contact lens related complications is lowest in younger
wearers aged 8-12 years and highest amongst those
aged 18-25 years, by about 3.5 times

16. Pre fitting
Evaluations

17. History taking
1. Chief complaints ( Reason for primary need of contact lens)
2. Ocular health history
3. Systemic health history
4. Family history.
5. Hobbies of child ( Sports , Swimming etc..)

18. Assessment of visual acuity
Various methods based on age of child can be done :

19. Measurement of ocular
parameters
1. Assessment of Refractive error
a. Retinoscopy
b. Auto refraction
c. Photo refraction
d. Handheld keratometer

20. 2. Assessment of corneal curvature.
a. Keratoscopy
b. Videokeratoscopy
c. Keratometry
d. Auto refractometer
e. Based on child’s age

21. 3. Measuring corneal diameter( HVID)
a. Hand-held rule
b. Comparator scale
c. Photographic or video images
d. Garticule in eyepiece of slit lamp
e. Weesly keratometer

22. Other testing procedure:
1. Ocular motility testing
2. Fixation stability testing
a. Cover uncover test
b. Corneal reflex test
c. CSM method
d. I-ARM method
e. Bruckner reflex
3. Assessment of visual potential

23. Cataract formation in infants may be due to a wide
range of causes including:
• Trauma.
• Systemic disease
• Maternal illness: Rubella (German measles )
• Exposure to drugs.
• Exposure to radiation.
• Genetic (autosomal dominant).
• Down syndrome.

24. Pediatric Aphakia
Congenital aphakiaSurgical aphakia
Traumatic aphakia
The removal of congenital cataracts should occur before the age
of 3 months, followed by immediate and ‘permanent’ optical
correction of the resulting aphakia.

25. When to fit CL after cataract surgery ?
ICCE/ECCE
Pars plana
lensectomy
Phaco surgery
5 weeks
3 weeks
3 weeks

26. Why CL in pediatric aphakia ??
1. Good optical correction
2. Significantly reduced distortion and aniseikonia
3. Less image magnification
4. Promotes binocular development
5. Easy to change as required
6. Better tolerated than spectacles
7. Only choice for unilateral cases

27. What are the CL choices?
1. Silicone elastomer
2. Rigid gas-permeable
3. Hydrogel

28. Range of Contact Lens Parameters for
Paediatric Aphakia
Selection of the initial contact lens in cases of
Paediatric aphakia is based on age.
This provides the practitioner with a useful starting
point from which the final lens can be determined
based on clinical assessment.

29. Suggested lens parameters for
Initial lens Selection
Age (months) BOZR (mm) BVP (D)
0 – 6 7.5 + 29.00 D
7- 17 7.7 / 7.9 + 26.00 D
18 - 28 7.9 + 23.00 D
29 - 34 7.9 / 8.1 + 18.00 D
The suggested contact lens power is for distance . An increase of
+1.00 to +3.00 D can be incorporated based on the practitioner’s
desire to establish a near vision environment for the child.

30. Determining the Contact Lens
Power
1. The optimum contact lens prescription is determined by
retinoscopy.
2. Care must be taken to keep the trial lenses close to the eye of
the infant to minimize the risk of prescribing an incorrect
contact lens BVP due the high prescription involved.
3. Compensation must be made for the vertex distance.
For example, a trial lens of +19.00 D held at a vertex distance of
10 mm is equivalent to an on-eye contact lens power of +23.50 D.

31. Typically the contact lens BVP for an aphakic infant
corrected for distance vision is between +20.00 D and
+35.00 D depending on the age of the child.
An infant’s visual world is at near and, therefore, to
provide optimum focus the contact lens should be over-
corrected by +2.00 D to +3.00 D

32. The lens power is changed to a distance prescription by
the time the child goes to school.
Bifocal spectacles are prescribed for reading, which may
also incorporate any astigmatic correction that improves
the visual performance.

33. As a general guideline, especially when
retinoscopy is difficult, a BVP of:
+34.00 D is suitable for a 6 week old infant.
+28.00 D for a 6 month old baby.
+24.00 D at 1 year old.
Unilateral aphakic require contact lens correction as well as
extensive patching of the good eye in cases of suspected
amblyopia.

34. Pediatric Contact lens
1) Silicone elastomer
2) Hydrogel
3) Prosthetic CL
4) Siloxane hydrogel
5) Rigid gas permeable (RGP)
6) Hybrid lens
7) Scleral lens

35. 1) Silicone elastomer
Silicone rubber , hydrophobic material that is coated to make it
hydrophilic
Provide high oxygen permeability
Available as Silsoft by B&L
option for pediatric aphakia – 30 days continuous wear

36. Advantages
 Comfort
 Very durable , can withstand most handling and cleaning
procedure
 Easier to insert in small PAS
 Stays in place ( low rate of loss)
 No dehydration of material during wear

37. Disadvantages
 Poor lens wettability
 Hydrophobic – rapid lipid deposition
 Limited parameter
power range 3D step
3 base curve
1 diameter
 No UV protection
 Lens removal can be difficult
 Very costly

38. Parameters Available range
Material Elastofilcon
Water content 0.2%
oxygen permeability Dk 340
Oxygen transmissibility Dk/t 71
Base curves 7.5 , 7.7 , 7.9
Diameter 11.30 mm
Power +23 to +32 D ( 3D step)
Optical zone 7mm
Center thickness 0.51 and 0.71 mm

39. Fitting the lenses
 Take K reading
 Initial trial lens : 0.4mm to 0.6mm flatter than average K
reading
 Assessment using fluorescein and cobalt blue light
 Remove the lens if it shows central pooling
 Should show minimal apical clearance and some degree of
peripheral clearance
 Recheck fitting pattern after 10 and 60 minutes later
 Over refraction using retinoscopy to establish optimum BVP
and then increase BVP by +2D to +3D to ensure optimal near
vision

40. Lens insertion and removal
o Insert as for soft lenses . Hold the lens and 'post' it under the upper
eyelid; alternatively, loosely attach the lens to the index finger using
rigid lens wetting solution. Hold the lids apart and place the lens
directly onto the cornea
o Remove by lifting the lens out as with rigid lenses.
o Occasionally, a rubber suction holder may be necessary
Lens cleaning
o Rub lens with surfactant cleaner for soft lenses.
o Rinse with unpreserved saline.
o Soak overnight in RGP soaking solution

41. 2) Hydrogel lenses
Most commonly used for pediatric CL fitting
Used in pt who are intolerant of initial discomfort of RGP lenses
Advantages
 Available in a wide range of parameters so can fit any size
 Available in different water contents.
 Can be biocompatible.
 Relatively cheap.
Incorporate UV blocker

42. Disadvantages
 Low Dk ( corneal edema)
 Poor handling
 Not durable
 Infection risk in EW
 Can't mask irregularities

43. Parameters
Lens total diameter : 12.5 or 13mm
BOZR : 7 to 8mm
Fitting the lenses
Take K reading if possible
Take HVID and add 2 to 3mm to HVID for TD of trial lens
Assess the fit for centration and movement after blink
Perform retinoscopy and add (+2 to +3)D to ensure optimal
near vision in aphakia

44. Lens insertion and removal
Insert lens by holding between finger and thumb and
posting it up underneath the top eyelid.
For removal : a slight squeeze between the thumb and
forefinger is required
Lens cleaning
Numerous contact lens solutions available to clean and
disinfect lenses
Surfactant cleaning as well as lens soaking using
multipurpose solutions

45. 3) Prosthetic lenses
To improve the appearance of disfigured eye: aniridia , iris coloboma,
injured cornea
To block light reaching back of eyes; for photophobia to reduce glare
and increase comfort: albinism
To eliminate diplopia for certain eye conditions.
Amblyopia therapy :
 Pt wears identical appearing colored contact lenes ,Good eye
wears the lens with opaque pupil to block light from entering the eye
More effective than applying eye patch

46. 4) Siloxane hydrogel
Provide high oxygen permeability , much greater than
hydrogel
Ease of handling
Ease of lens replacement
- compared to silicone elastomer
Parameter range are increasing
Good extended wear capability

47. 5) Rigid gas permeable lens
Most infants can do well with RGP lenses
Preference : Menicon Z , Dk – 163 , 30 days continuous wear
Advantages
 Provide better VA than hydrogel
 Better physiological performance
 Allow improved tear flow and oxygen under Cl – high Dk
 Easy to handle
 Capable of compensating irregular corneal astigmatism
 Reduced bacterial and protein adherence

48. Disadvantages
 Prolonged adaptation period
 Risk of dislodgement
 Need an optometrist who can fit RGP lenses
 Corneal abrasion from eye rubbing
 Less good for sensitive eyes
 More easily lost than soft lenses

49. Fitting the lenses
 Take K readings if possible. If not first lens can be fitted empirically
on known average K, i.e. 7.1 mm for a neonate
 Instill a local anaesthetic before inserting the first trial lens.
 TD : 8 to 10mm
 BOZR equal to the flattest K
 Assess the fit with fluorescein, cobalt blue filter and ensure optimal
fit
 Assessing the RGP fit in children upto 5 yrs is not applicable with slit
lamp so hand-UV lamp OR a white light lamp with blue and yellow
filters.
 Carry out an over-refraction

51. Lens insertion and removal
For lens insertion: the child can be sitting or lying down.
loosely attach the lens to the index finger using lens wetting
solution, hold the lids apart and place the lens directly onto the
cornea.
For lens removal : manipulate the child's eyelid to break the
suction and then lifting the lens out with the aid of lid
Lens cleaning
Practitioner's system of choice

52. 6) Hybrid lenses
Combination of RGP and soft lens
Available : +6 D to – 13D
Indication
Astigmatism irregualar cornea , and keratoconus
Intolerance of RGPs
High ametropias

53. Disadvantages
 Narrow range of parameters
 Tendency to adhere to cornea
 May tear in the transition zone between soft skirt and
center RGP
 Low oxygen transmissibility
 Handling difficulties
 High replacement cost

54. 7) Scleral lenses
Rarely used for pediatric patient
More difficult to insert and remove
Very little chance of lens loss
High oxygen transmissibilty

56. Follow up & After care
Lens care procedure
 Same as for adults
 Care regime must be suited to the type of lens worn by the child
 Parents must be educated fully regarding the need for lens care,
including frequent lens replacement , solution and lens cases
Lens wearing schedule
 Lens type prescribed
 Ability to insert and remove lenses
 Level of assistance from parents
 Oxygen transmissibilty

57. Frequent follow up is needed in all cases of pediatric CL
fitting
The first after care is one week after CL dispensing
Second after care is usually scheduled 2 weeks later
After that every 6 month is recommended
Parental involvement is very crucial for successful of
pediatric lens wear

58. Contact Lenses In Pediatrics
(CLIP) Study

59. STUDY PROTOCOL
169 subjects
• 84 children (ages 8-12)
• 85 teenagers (ages 13-17)
• No CL wear in past
• Refractive error only; good ocular health
• Three clinical testing sites
The Ohio State University College of Optometry
New England College of Optometry
University of Houston College of Optometry

60. FITTING TIME:
Essentially the same for children and teens

61. Contact Lenses In Pediatrics
(CLIP) Study
Patient Outcomes: Quality of Life

62. Pediatric Refractive Error Profile
(PREP)
Pediatric quality of life scale for children and teens affected
only by refractive error
• Scored from 1 (negative) to 5 (positive)
• Scaled from 0 (poor) to 100 (good)
• 26 statements; 10 sub-scales (Overall PREP = mean of all
items)

63. PREP Score:
Switch to contact lenses improves quality of life

64. Post-CLIP Study
Lifestyle Questionnaire
Children and teens report success in key areas

65. Parents’ Perspectives on
Success:

66. The Safety of Soft Contact
Lenses in Children
Purpose
To estimate the incidence of complications, specifically corneal
infiltrative events and microbial keratitis, in patients under the age
of 18 years
Methods
Peer-review papers were identified using PubMed and the Web
of Science. Abroad range of studies are summarized including
large-scale epidemiological studies of contact lens related
complications, hospital-based case series, long- and short-term
prospective studies, and multicenter retrospective studies
1040-5488/17/9406-0638/0 VOL. 94, NO. 6, PP. 638Y646 OPTOMETRY AND VISION SCIENCE
Copyright * 2017 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Optometry

67. Results.
Nine prospective studies representing 1800 patient years of wear
in 7- to 19-year-olds include safety outcomes One retrospective
study found no cases of microbial keratitis occurred in 8- to 12-
year-olds (411 patient years) and an incidence of 15 per 10,000
patient years in 13- to 17-year-olds (1372 patient years)no higher
than the incidence of microbial keratitis in adults wearing soft
contact lenses on an overnight basis
Conclusions.
The overall picture is that the incidence of corneal
infiltrative events in children is no higher than in adults, and
in the youngest age range of 8 to 11 years, it may be
markedly lower

69. References
IACLE contact lens course module 5
INTERNET
Male
36%
Female
64%
Patient distrubition based on Gender
Male Female