Kids and contact lenses - benefits, safety and getting to 'yes'

There are numerous reasons why contact lenses are beneficial for children. Firstly, for myopic children, contact lenses represent the most effective and widely available myopia control strategy.¹ The last decade has seen enormous growth in the research publications on myopia control, especially in the soft contact lens (CL) domain. Recent randomized controlled trials on today's commercially available dual focus,² multifocal³ and 'extended depth of focus'⁴ soft CL designs have been published, along with meta-analyses on orthokeratology.⁵ On the spectacle front, novel designs seem to be surpassing the previous progressive addition^6,7 and bifocal⁸ spectacle lens myopia control outcomes, with one RCT⁹ having been published and two more clinical trials underway.

Despite the benefits of contact lenses, there are still barriers in the mind of the practitioner, parent and young patient to childhood CL wear. Here we address these often cited barriers, with the goal to support your clinical communication on the benefits and safety of contact lenses for kids, to get towards achieving a 'yes' from the parent and patient.

A survey of contact lens prescribing in patients up to 17 years of age examined demographics and trends over time. Comparison to non-myopia control fits in the same age group showed that myopia control (MC) fits were younger (13 vs 15 years), 52% were rigid lens fits, likely orthokeratology (12% in non-MC fits) and 84% wore their CLs for 7 days a week (56% in non-MC fits). MC fits increased enormously from only 0.2% of all CL fits to children in 2011 to 6.8% in 2018, but this still represents a small proportion of all childhood CL fits.¹⁰

Another recent survey of practitioner attitudes and practices in myopia control found that Australasian eye care practitioners prescribed myopia controlling CLs to around 40% of progressing / young myopes, but this reduced to 30% in Europe and North America, 15% in Asia and only 10% in South America.¹¹ This survey was a repeat of one conducted four years prior, showing only small percentage improvements from 2015 to 2019 in all world regions, despite the enormous growth in research outcomes and product availability.¹² In both surveys, single vision spectacles and contact lenses are prescribed to over 50% of myopic children across the world, although regional shifts away from this non-evidence based practice are occurring. Australasia leads the way with 50% of single vision prescribing in 2015 reducing to 28% in 2019, while other world regions are more slowly changing from 60-70% in 2015 to just over 50% in 2019.

The sum total is that we could all probably be fitting more myopia controlling CLs to kids, given the multiple benefits we provide our patients by doing so. We can do better!

Perhaps your young patient, and their parent, haven't considered contact lenses as an option. As eye care practitioners (ECPs), it's easy to understand the functional and psychological benefits a high ametrope gains from packing away their thick spectacles and switching to contact lens wear. We might think that teens would be similarly aware of their appearance but that aesthetics and function are less of an issue for children.

This is simply not true - children (8-12 years) get as much of a quality-of-life benefit from CL wear as do teens (13-17 years). Research has shown that both groups report similar improvements in vision related quality of life - being improved satisfaction with their vision correction, ability to participate in activities and their appearance.¹³ These benefits existed independent of age or level of refractive error, with both low and high ametropes achieving similar benefits.

Furthermore, fitting children (8-11 years) with contact lenses does not change their global self-worth, but it does improve their own perceptions of their physical appearance, competence in athletic activities and social acceptance.¹⁴ These psychological benefits of CL wear for children are a crucially important part of the clinical picture when considering the commitment and compliance that is required in childhood visual development.

The short term risk of complications is top of mind for ECPs, and parents may have a perception of CLs being unsafe. Hence it's important to have simple, evidence based phrases ready for these discussions.

Risk of microbial keratitis. Arguably the most concerning complication of CL wear, the risk of microbial keratitis (MK) is 1 in 5,000 patient-wearing years for daily disposable soft CLs, and approximately 1 in 1,000 for reusable soft CLs and orthokeratology. For a summary on the research on this, read our blog Contact Lens Safety in Kids.

This is a crucially important 'sound bite' to have to mind as parents can be particularly concerned about childhood CL wear in younger children.

Risk of any complication. A chart review of over 3,500 CL wearers covering 13,000 visits showed that there were 426 visits (3.3%) featuring an 'event' which interrupted CL wear. Of all patients, 88% had no clinical events and 1.2% had multiple events. When examined by type and age, serious complications (microbial keratitis) occurred similarly in children and teens, at 0.1% frequency (1 per 1,000). Significant complications, either infiltrative or mechanical, occurred in 0.9% of child wearers and 2.3% of teenage wearers.¹⁶ A summary of this analysis, when combined with categorization of adverse event types by Sankaridurg et al¹⁷ is shown in the Table below.

Two recent studies have indicated the long term high safety profile of soft contact lens (SCL) wear in children. Firstly, Chalmers et al¹⁸ evaluated real-world safety through a retrospective chart review which included both charts from clinical practice and children involved in two international randomized clinical trials. The children were wearing a variety of SCL types and modalities with 60% first fit with daily disposable. They were 8-16 years old with a mean age at first fitting of 10.5 years and 2.8 ± 1.5 years of follow up. The annual rate of corneal inflammatory events (non-infectious, such as inflammatory keratitis, CLARE and CLPU) was 0.66% per year (0.66 per 100 or 1 per 151). Contact lens papillary conjunctivitis was 0.48% per year (0.48 per 100 or 1 per 208). The risk of microbial keratitis was 7.4 per 10,000 years - only two cases were found in 2713 years of contact lens wear, and neither resulted in vision loss.

Secondly, Woods et al¹⁹ investigated ocular health and safety of children fit with hydrogel daily disposable SCLs within a clinical trial setting, and found that across six years of wear in 144 children, only three discontinued due to an ocular adverse event, and none of these were serious. Ocular health findings by biomicroscopy were similar to pre-lens wear, with 99% being grade-1 or lower, indicating that six years of daily disposable hydrogel SCL wear had minimal impact on ocular physiology in children.

Yes, they can! A prospective study examining chair time within the first three months of CL fitting found that children (8-12 years) took 12 minutes longer to learn to handle their CLs, but the time taken for initial fitting and follow up appointments was similar between children and teens.²⁰

Specific to daily disposable SCLs, one 2019 AAO Abstract reported that in 8- to 12-year-old children new to CL wear, after 1 week 57% reported handling as 'kind of easy' or 'really easy'. This increased to 85% at one month and 97% from 6 months through to the end of the 36 month study. Comfort was also reported highly, with over 95% reporting they 'sometimes' or 'don't notice' the feeling of CLs on their eyes. With regards to visual performance, when children were asked 'how well do you see with your CLs for school', almost all gave a rating of 'really well' or 'kind of well'.

Prior studies confirm this recent abstract. When surveyed after three months of soft contact lens wear, both children and teens reported similar wearing times (around 85% often / always) and excellent comfort.²⁰ Children reported their vision was ‘perfect’ with CLs more often than teens. If they had stopped wearing CLs, the reasons were similar between children and teens – wanting to ‘give their eyes a break’ or not having ‘enough time to put them on’.²¹

All in all, children are likely to be highly satisfied wearers with excellent comfort, lens fit and eye health outcomes.

The functional benefits of contact lens wear are easily explained, as a typical part of primary eye care practice and especially for patients with higher myopia. When it comes to myopia control, if shifting to CL wear represents a change to a more effective myopia control strategy (for example, changing from progressive addition spectacle lenses to dual-focus myopia controlling CLs or orthokeratology)¹ then explaining this benefit is vital.

When discussing myopia control, the motivating factor for us as ECPs is likely the preventative eye health aspect - being able to reduce our patients' long term risk of ocular pathology and vision impairment through reducing the final amount of myopia.²² For parents and patients, though, this may be too distant a concept to grasp. Try this instead:

Once a parent understands the benefit of their child having clearer vision for longer between eye exams through less frequent prescription changes, then moving onto the long term benefits of reducing pathology risk reaffirms the short-term benefits with those possible over the long-term as well.

The psychological benefits of CL wear are important to explain to parents - the confidence and ability to participate in more activities of life made possible for their myopic children by wearing CLs. Both functional and psychological benefits can be especially difficult for a non-myopic parent to grasp.

The Managing Myopia Guidelines Infographics and Parent Brochure include a panel which is designed to support your clinical communication of the benefits, safety and handling of contact lenses for kids. There are three key points:

1. Wearing contact lenses improves children's self confidence in school and sport^13,14
2. Children aged 8-12 appear to have a lower risk of infection in soft contact lens wear than teens¹⁵
3. Children only take 15 minutes more to learn to handle contact lenses than teens.²⁰

The key numbers on safety are also articulated - the risk of serious contact lens infection (microbial keratitis) is 1 per 1,000 patient-wearing years in orthokeratology and reusable soft CL wear, and 1 per 5,000 in daily disposable wearers. These simple numbers are easy to remember, and the sum total of these key points help alleviate parental concerns on CL wear to allow you more ability to communicate the array of benefits. How should you explain safety?

Considering the benefits for myopia control, visual function and personal confidence, contact lenses should be recommended for our myopic children more often than the surveys indicate they are. The safety profile is high and easily explained using the clinical communication tips described above.

While the average age of a child fit with contact lenses for myopia control is currently 13,¹⁰ it really should be lower to indicate proactive myopia management. To have the greatest impact on an individual child’s myopia progression, commencing an optical intervention for myopia control before age 12 is ideal as this is when progression is usually fastest.²³

• Contact Lens Safety in Kids

• Case study: Which contact lens should we choose for sports?