14

Pediatric Contact Lenses

Cleusa Coral-Ghanem and
Jeffrey J. Walline

1. What are the indications for contact lens

fitting in the child?
Children may benefit from contact lens wear for a variety of reasons,
ranging from correction of refractive error to vision therapy. The most
frequent indication for fitting children with contact lenses is the cor-
rection of refractive error. Glasses worn to correct high refractive error
may result in image magnification or minification, peripheral distor-
tion, prismatic distortion, and a reduced field of view. The spectacles
worn to correct high refractive error may also be uncomfortable and
cosmetically unappealing, and children can easily remove spectacles
that are uncomfortable, unappealing, or provide poor vision. Contact
lenses may decrease many of the symptoms suffered by children who
wear spectacles for high refractive error, and they are more difficult for
young children to remove.
The purpose of contact lens wear in young children is generally to
optimize visual input so that the child does not develop amblyopia,
but contact lenses may also be fitted to improve the child’s appearance
or to enhance amblyopia therapy routines. Disfigured eyes or unap-
pealing spectacles may be very traumatic for a young child, so contact
lenses may be used to mask disfigured eyes.
Contact lenses may also be used to decrease the amount of light that
reaches the retina in photophobic children, to patch an eye for children
who do not like to wear adhesive patches for amblyopia therapy, or to
decrease the magnitude of nystagmus, thereby improving the vision
and the appearance of children who exhibit nystagmus.

2. Is there a difference between

the fitting of contact lenses in a
child compared to an adult?
A child’s eye is adult sized by 2 years of age. Few contact lenses are
manufactured to fit children’s eyes, specifically so much of the fitting
 14. Pediatric Contact Lenses 131

process is similar to adults. The primary challenge in fitting a child is

not due to physical differences. The most difficult aspects of fitting a
child are overcoming the child’s stress, communicating with the child,
and accommodating the rapid development of a young eye.
Despite many similarities between a child’s and an adult’s eye, a
child’s palpebral fissure is generally smaller, which makes it more dif-
ficult to insert and remove contact lenses. This difficulty is exacerbated
when the child is crying. The aqueous component of the tear film is
generally increased in children. Since the concentration of lipids and
proteins in the tears are reduced in children, they rarely have problems
with contact lens deposits, except with contact lenses made of silicone
elastomers, on which lipid deposits may accumulate quickly. The cur-
vature of the cornea decreases over the first 2 years of age from ap-
proximately 45 D to 43 D, and the corneal diameter increases from
approximately 10 mm at birth to 11.5 mm by 3 or 4 years of age.

3. What contact lenses are utilized in

children?
Children can wear rigid gas permeable contact lenses or soft contact
lenses. The indication for contact lens wear and the parents’ experience
with contact lenses should be considered when determining the most
appropriate type of contact lens.
Soft contact lenses are most commonly fitted in children. Parents are
more likely to have experience with soft contact lenses than with rigid
contact lenses, and soft contact lenses may be prescribed in a frequent
replacement program so that spare lenses are readily available. How-
ever, it is difficult to find soft contact lenses with pediatric parameters.
They require more dexterity in handling than rigid gas permeable con-
tact lenses, and they pose a greater risk of infection than rigid contact
lenses, especially with extended wear.
Rigid gas permeable contact lenses are frequently well tolerated by
children, and they are more practical in terms of maintenance and care.
These lenses have excellent oxygen permeability, they correct irregular
astigmatism, and they can be custom made to fit children’s eyes. How-
ever, rigid contact lenses may be less comfortable initially, they are
more likely to dislocate or be lost than soft contact lenses, and they are
not available in multipacks.

4. How does one fit the child?

Some professionals use general anesthesia to fit a contact lens in an
infant. This will certainly facilitate the measurement of the ocular pa-
rameters, refractive power, and evaluation of the contact lens on the
eye, but there are serious potential risks associated with general anes-
thesia. Contact lens fitting under general anesthesia should be re-
stricted to those children who are impossible to examine and fit appro-
priately in the office. When fitting the contact lenses in the operating
room, the main priority is to determine the appropriate power of the
132 C. Coral-Ghanem and J.J. Walline

contact lens. The best method to determine the power is to place a

contact lens on the eye that approximates the resulting refractive error
of the child (approximately Ⳮ35 D). Retinoscopy should be performed
over this contact lens using refractive trial lenses to determine the most
appropriate power. Placing a high plus contact lens on the eye reduces
the error potentially induced by the variable working distance of a high
plus refractive trial lens. It may be necessary to stand on a stool or a
short ladder in order to achieve the appropriate working distance for
a child lying on an operating room table.
A toddler fitted in the office may need to be restrained, which can
be accomplished by having the parent hold the child, by wrapping a
sheet around the child, or by straddling the child while he or she is
lying on the floor. At least one extra pair of hands is necessary to con-
duct the fitting.
An eye care practitioner may consider having an office assistant in-
sert the contact lens in the child’s eye. Children may not trust the person
who inserts the first contact lens for some time thereafter, so evaluation
of the contact lens prescription may become very difficult. Once the
child calms down, the eye care practitioner should evaluate the pre-
scription and fit of the contact lens.

5. How does one examine the lens–cornea

relationship in a child?
Children 5 years and older can typically be examined using a slit-lamp
biomicroscope with fluorescein and a cobalt blue filter. Small children
may need to sit on their knees and hold the slit lamp ‘‘like a motorcycle’’
in order for them to reach the chin rest and for them to be interested
enough to sit still for 1 to 2 minutes. If a child cannot be examined with
a slit lamp in the office, then a hand-hold Burton lamp with fluorescein
can be used. Portable slit lamps and a direct ophthalmoscope/20 D lens
combination works when other methods are not available.
When evaluating a contact lens fit, the key fitting criteria are similar
to those looked for in the adult. One should check the movement, cen-
tration, and fluorescein pattern of a rigid contact lens, and the move-
ment and centration of a soft contact lens. Determination of whether
the power of the contact lens is appropriate is also necessary in all
contact lens fittings.

6. When should contact lenses be fitted in an

aphakic child, and what is the visual
prognosis?
The developing visual system of an infant requires clear vision in order
to achieve maximum visual potential. As little as 1 to 2 weeks of con-
stant visual deprivation can result in amblyopia. When possible, a con-
tact lens should be fitted immediately after surgery or within 1 week.
Fitting the child with a contact lens while he or she is still on the op-
erating table eliminates the potential need for a second dose of general
 14. Pediatric Contact Lenses 133

anesthesia, and it decreases the time until the dispensing of the contact
lens.
Contact lens correction is more important and urgent for a unilateral
aphakic child than a bilateral aphakic child. The aphakic eye requires
high plus correction, which results in image size magnification. The
images of the two eyes are not equal in size, so they cannot be fused.
This can lead to symptoms and poor binocular vision development.
Fitting the unilateral aphake with contact lenses minimizes the image
size difference and allows for proper visual input for both eyes.
With careful monitoring and diligent care, an aphakic child can
achieve excellent visual acuity. The parents must be educated about the
continued care and therapy that is necessary to avoid amblyopia, and the
child must be examined regularly. The longer a child has good vision be-
fore a cataract develops, the better the prognosis. The visual prognosis of
an aphakic child following congenital cataracts is worse than the visual
prognosis of an aphakic child following trauma. The child who experi-
enced ocular trauma is more likely to have had a period of normal visual
development than a child with congenital cataracts.

7. What is the best contact lens for

fitting the aphakic child?
Rigid gas permeable contact lenses for aphakia are available in nearly
any material because they are custom designed for individual patients.
Two soft contact lenses specifically designed for pediatric aphakia are
available (Table 14.1).

8. How should one follow up the

aphakic infant in a contact lens?
An aphakic infant should be examined every week for the first 2
months. If the lens fits well and the health of the eye is maintained,
visits may be reduced to every 2 to 4 weeks for several months. When
the refractive error begins to stabilize (at approximately 6 months of
age), the child may be examined every 3 months. This schedule should
continue until the child enters school. At each visit, the child’s vision
should be evaluated, the fit and power of the contact lens should be
evaluated, and the ocular health should be assessed.
Glaucoma may occur in about 10% of children following cataract
removal; therefore, follow-up examinations should consist of routine
glaucoma checks as well. The child should be dilated every 6 to 12
months to evaluate the eye’s posterior segment.

9. What are the complications encountered in

pediatric contact lenses?
The most commonly encountered ocular complications are deposits,
tight contact lenses, and signs of hypoxia. Children may also encounter
 134
C. Coral-Ghanem and J.J. Walline
Table 14.1. Soft contact lenses specifically indicated for pediatric aphakia.
Manufacturer Series Material Base curve Diameter Power
Flexlens Products Pediatric Hefilcon A 6.0 to 10.8 mm 10.0 to 16.0 mm ⴐ10.50 to ⴐ30.00 D
(0.3-mm steps) (0.5-mm steps) (0.50-D steps)
Bausch & Lomb Silsoft Super Plus Elastofilcon A 7.5, 7.7, 7.9 11.3 ⴐ23.00 to ⴐ32.00 D
(Pediatric) (3.00-D steps)
 14. Pediatric Contact Lenses 135

corneal abrasions and ulcers, but these are more rare. By far, the most
commonly encountered complication is contact lens loss or breakage.

10. What is the social responsibility

of the eye doctor?
In the case of a child with a congenital cataract, if surgery is indicated,
the eye care practitioner must be concerned that the family’s socioeco-
nomic and psychological condition can support the long treatment that
will be necessary. On the other hand, it is possible to create false ex-
pectations and anxiety in the family that has already been assaulted by
the child’s disease. It is necessary that the parents understand the pro-
posed objectives for treatment and the potential benefits and risks. They
must be aware of the duration of the treatment as well as the expenses
that will be incurred. On the other hand, they must also understand
that only their initiative will allow the child to develop better vision.

Selected References
Donzis PB, Weissman BA, Demer JL. Pediatric contact lens care. In: Bennett ES,
Weissman BA, eds. Clinical Contact Lens Practice, Philadelphia: JB Lippincott,
1994: Chapter 51, pp. 1–8.
Matsumoto ER, Murphree L. The use of silicone elastomer lenses in aphakic
pediatric patients. Int Eyecare. 1986; 2:214–217.
Moore B. Managing young children in contact lens. Contact Lens Spectrum. 1996;
34–38.
Pe’er J, Rose L, Cohen E, Benezra D. Hard and soft contact lens fitting in infants.
CLAO J. 1987; 13:46–49.
Stenson SM. Pediatric contact lens fitting. In: Kastl PR, ed. Contact Lenses—The
CLAO Guide to Basic Science and Clinical Practice, Vol 3. Iowa: Kendall/Hunt
Publishing, 1995:179–195.