Being an Optometrist whose practice has an accent upon contact
lenses brings special experiences and responsibilities. I have
seen quite a few young children in the past three years, referred
to me by a pediatric ophthalmologist. These children include
many high myopes, some high astigmats and hyperopic convergent
squints. A very different form of contact lens practice.
Just a few years ago it was difficult for parents to contemplate
contact lenses for children. Apart from cost, there was the barrier
of lack of support and reassurance that contact lenses were a
workable option. I find that even with referral from an ophthalmologist
to reassure parents, hard work is still needed to gain the confidence
of parents and a child's trust.
Gaining a child's confidence, making the experience fun, allowing
them to feel special, are all essential components of fitting
contact lenses to children. It's the same story when you think
about it with adults, but kids are more open and honest in their
responses. Once a child's confidence is gained, they will even
be willing to stand up in class to share their story and special
feelings about their experiences with you. It's a great way to
build a rewarding practice!
A case study
There is one case of mine which came out of the blue. I had
expected to be seeing the mother, or perhaps an older child,
but within the pusher was concealed young Andrew, the patient.
Andrew was a 15 months old Downs baby with a hyperopic convergent
squint. Andrew's real name has not been provided for privacy
considerations.
Contact lenses were the only option because Andrew was intolerant
of his spectacles. The range of alternatives available sent me
straight to the Silicone Hydrogel Diagnostic set. I began prescribing
silicone hydrogels in 1999 when they were first launched in Australia.
My experience with these lenses has matched the reports published
in the professional literature and within the international contact
lens community in that they provide advanced corneal physiology
compared to other lens types. I was confident that these lenses
would perform well for Andrew but as with any new contact lens
wearer, it was essential to carefully monitor his progress particularly
in the early stages of adaptation.
Lens insertion between those narrow and squeezy lid apertures
using adult sized lens diameters, in conjunction with Andrew's
reflex closure, meant I had to wear him down to allow fatigue
to reduce his resistance. Despite this, about one hour later
Andrew had two plus fives on his eyes. It was the most difficult
lens insertion I have experienced, but also the most rewarding.
What a disarming smile.
After confirming his initial response to lens wear, the family
went home with some trepidation at the prospect of a very different
world. Because the family lived some distance away, the early
feedback was by way of phone followed up by visits to the office.
I involved Andrew's mother in assessment of his external eye
appearance, and emphasized her reporting responsibilities, in
particular with relevant risk factors and symptoms. My concerns
were based principally upon the possibilities of post lens tear
film debris not being sufficiently flushed overnight by eye movements.
Therefore I strongly recommended lubrication upon awakening.
Contact lens aftercare, as well as initial assessment for Andrew
took me back to the early seventies, when I did not possess a
slit lamp and clinical flexibility was called upon a great deal
more than it is now. Andrew seemed incapable of providing the
steadiness required with a slit lamp, so it was back to retinoscopy
and direct ophthalmoscopy, supported by fixation targets to attract
attention (be prepared, they go direct to the mouth!). I wasn't
able to do endothelial cell density counts, but then silicone
hydrogels have sufficient research track record for me to feel
confident in those respects.
At follow-up visits I found Andrew's corneal oedema to be insignificant
and limbal injection to be remarkably absent. At this age one
might expect children as young as Andrew to experience some difficulties
with contact lens wear considering what he and other infants
put into their mouths, let alone where their fingers might have
been before touching their eyes. However Andrew has had no adverse
responses and his tear film is remarkably clean.
The trauma involved in inserting his lenses has meant that Andrew's
mother now inserts them when he is on the verge of sleep. Although
the ophthalmologist involved had previously expressed a preference
for daily wear for very young patients, extended wear turned
out to be the most practical option in Andrew's case. During
the early stages, Andrew regularly managed to rub out his lenses,
but now he can almost achieve a full month of wear.
Final comments
There will be young patients and some parents, who show an initial
reluctance to embrace contact lenses because of the trauma associated
with lens insertion, daily maintenance is seen as inconvenient,
self image without spectacles is a difficult transition, or because
costs become a burden. Occasionally the whole concept of contact
lenses for their children seems too extreme. However in my experience,
many of these patients will volunteer to reassess contact lenses
when they are ready.
Silicone hydrogels are an ideal option for children because
they provide maximum physiological benefits and offer the greatest
flexibility in wear schedule. Even for high myopia with moderate
astigmatism, my preference is to use silicone hydrogels in spherical
correction, rather than settle for the optical and physiological
compromises inherent in using a conventional hydrophilic toric.
In my experience, the benefits of superior corneal physiology
with silicone hydrogels far outweigh the consequences of not
correcting astigmatism. |
Tell
a friend
In
The Practice | 
Ian G. Sim (B.Optom) UNSW