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Soft Contact Lens Wear in Children and Teenagers: A Healthy Vision Correction OptionTwo recent studies reviewing the long-term safety of soft contact lens (SCL) wear in children found low complication rates, similar to that of adults, with minimal impact on ocular physiology. 1,2This article summarises the key points within both papers and how they relate to fitting children with daily disposable contact lenses in clinical practice. WRITER Claire Mallon LEARNING OBJECTIVES On completion of this CPD activity, participants should be able to: 1. Realise the rising incidence of myopia and its risk to long-term ocular health, 2. Be aware of the functional and emotional benefits of fitting contact lenses to children, 3. Understand perceived barriers to children wearing contact lenses, and 4. Be prepared with evidence, to reassure young patients and their carers that soft contact lenses can be a safe myopia control option. It is predictedthat around 50% of the world’s population (almost five billion people) will be myopic by 2050 with many regions, including Western Europe, set to reach this level by 2040. 3Coupled with increasing prevalence, the onset of myopia is occurring at an earlier age and progressing at a faster rate than in previous generations, 4leading to increased risks of visual impairment from conditions such as retinal detachment, glaucoma and myopic maculopathy later in life, with significant direct and indirect public health costs. 5In response, the World Council of Optometry (March 2021) passed a resolution advising eye care professionals (ECPs) to incorporate a standard of care for myopia management into their practices.6This includes an emphasis on educating parents and young patients on lifestyle, dietary, and other factors to prevent or delay the onset of myopia, as well as providing evidence-based interventions (contact lenses, spectacles or pharmaceuticals) that slow its progression. Restricted access to atropine for some ECPs, and limited availability of spectacle lenses for myopia control across the world, means soft contact lenses (SCLs) are currently the most readily available choice with a strong evidence-base of proven efficacy.7CONTACT LENS FITTING PRACTICESThere are numerous functional and emotional benefits of fitting contact lenses to children, including improved visual performance, academic and athletic achievements as well as increased self-esteem and peer perception. A growing body of evidence supports this as the first choice in refractive error correction for all ametropes. 8-10Research has also shown that specifically designed myopia control SCLs, and some multifocal SCL designs (originally designed for presbyopia), have been successful in slowing the progression of myopia.7,11-17However, in a recent international survey of contact lens fitting for myopia control in children, myopia control fits represented only 2.3% of all contact lens fits to children.18PERCEIVED BARRIERS Healthy contact lens wear is and should be foremost for ECPs when fitting all patients. When fitting children or teenagers, it is also a primary concern for parents. Contact lenses help children feel more competent when taking part in sport and other activities. Two global surveys on ECP and parent perceptions, and attitudes regarding myopia and myopia management, suggest that ECPs face barriers from parents who believe that young children are not suitable for contact lenses.19,20This belief is in direct contrast to research indicating that children are easily fitted with contact lenses; they can wear contact lenses safely and are confident in handling them.21Parents also believe that contact lens wear is less safe in teenagers than the general population.22Research shows the incidence of serious contact lens-related adverse events, such as microbial keratitis (MK), is rare among adult contact lens wearers, particularly those who wear daily disposable lenses.23A systematic review of literature published in 2017, regarding the safety of SCLs in children, indicated that the incidence of corneal infiltrative events (CIEs) in children is similar to that in adults. In the younger age categories, it may be lower; however, children under the age of 13 years have been underrepresented in these studies. 24Young children quickly become competent at handling contact lenses. “ Research has also shown that specifically designed myopia control SCLs… have been successful in slowing the progression of myopia”REAL WORLD RESULTSTwo recent studies have specifically reviewed the long-term safety of SCL wear in children in this age group. 1,2The Adverse event rates in the retrospective cohort study of safety of paediatric soft contact lens wear: the ReCSS study, retrospectively and independently reviewed clinic records for 963 children who were first fitted aged eight to 12 years (average 10.5 years) and followed through to age 16 years. This sample included 782 children attending community optometry practices in seven different geographical regions of the United States, as well as 181 children from two randomised control trials (RCTs) investigating the efficacy of myopia control lenses. These RCTs were conducted in Canada, Portugal, Singapore, Spain and the United Kingdom. Children attending community practices were wearing all types of SCLs (materials, designs, and modalities) while children in the RCTs wore MiSight 1 day (CooperVision). The review equates to 2,713 years of wear and 4,611 contact lens visits. Investigators assessing the ocular health of children wearing daily disposable lenses as part of a myopia control study followed 144 children across four sites in four countries (Canada, Portugal, Singapore and the United Kingdom) over six years.2Children wore lenses full-time, for more than 10 hours/day and six days/week. These children were aged eight to 12 years (average 10.1 years) at first fitting, wearing either MiSight 1 day or Proclear 1 day (CooperVision) lenses. Both lenses were identical in material (omafilcon A), physical design and overall thickness. They differed only in optical design, single vision (Proclear 1 day) compared with dual focus (MiSight 1 day). Therefore, both lenses could be assumed to have similar mechanical and physiological interactions with the ocular surface.After three years, those children wearing Proclear 1 day lenses changed to MiSight 1 day lenses for the remaining three years. All participants were reviewed one week, one month and six months after fitting, and subsequently followed at six-monthly intervals for six years, equating to 653 subject wearing years. The combined scale of these studies ensured an ability to determine the rate of serious contact lens-related adverse events, such as MK in the eight to 12 years age group. ADVERSE EVENTS: SERIOUS, SIGNIFICANT AND NON-SIGNIFICANT Table 1 lists the classification of adverse events used in the six-year ocular health study. These classifications are similar to those considered in the ReCSS study, where they also defined MK as presumed or probable. For the ReCSS study, presumed MK was considered when there were one or more corneal stromal infiltrates (>1mm), with pain plus one or more of an anterior chamber reaction (more than minimal), mucopurulent discharge or positive corneal culture being present. The presence of a subsequent corneal scar was a requirement if follow-up data and medical records were available. In the absence of data regarding resolution with a scar, aggressive treatment consistent with the standard of care for MK in North America was considered indicative.1Probable MK was considered if all of the criteria above were not met. All adverse events were reviewed in both studies, regardless of their association with contact lens wear.Table 1. Adverse Event Categorisation Reference Table for Investigators (after Woods et al).2Table 2. Ocular Adverse Event Summary (adapted from Woods et al).2Table 3. A comparison of the methods and findings of two studies evaluating safety of wearing contact lenses in young children. Figure 1. Age at Presentation of Ocular Adverse Events in the ReCSS1 (n=963) and Ocular Health Studies (n=144).2“ Healthy contact lens wear is and should be foremost for ECPs when fitting all patients”LOW COMPLICATION RATESThere were no contact lens-related serious adverse events (SAE) reported in the six-year ocular health study. Herpes zoster uveitis was the only ocular SAE, with 93% of events considered non-significant AEs and 45% of the ocular event episodes were not lensrelated (Table 2). The ReCSS study reported two MK cases from community case records, one presumed and one probable. This equates to a rate of 7.4/10,000 years of wear. This is a very low and comparable rate to that found in adults wearing SCLs.23,24Presumed MK was considered in the case of a 14-year-old male who reported sleeping in his daily disposable lenses, and probable MK for a 13-year-old male who wore daily disposable lenses. Neither study reported any adverse events in children under the age of 10 years (Figure 1) and both studies found annualised rates of corneal infiltrative events (CIEs) of less than 1% per year of wear. NO PHYSIOLOGICAL RESPONSELimbal, bulbar, and tarsal hyperaemia, tarsal roughness, corneal and conjunctival staining and corneal vascularisation were assessed at initial fitting and each subsequent visit in the six-year ocular health study. 2A0–4 grading scale was applied where 0 = none, 1 = trace, 2 = mild, 3 = moderate and 4 = severe. Of the 26,137 findings across all visits over the six years, 99% of findings were less than Grade 1. The most common findings with a grade more than 0 included tarsal hyperaemia, tarsal roughness and bulbar hyperaemia, although each of these findings improved over time. However, this does highlight the importance of eyelid eversion in paediatric, as well as all other contact lens assessments. Reassuringly, overall ocular health was similar at final visit compared to baseline recordings at initial fitting. A comparison of the methods and findings of both studies is detailed in Table 3. PRACTITIONER, PATIENT AND PARENT CONFIDENCE – THE BENEFIT RISK APPROACH Previous myopia control studies have understandably focussed on the efficacy of the intervention with myopia progression and refractive outcomes rather than lens wear safety as the primary consideration. These studies described herein represent both the largest-ever review of the safety of contact lens wear in children, and the longest to specifically focus on ocular physiological responses to daily disposable SCL wear in children and teenagers. Practitioners will appreciate the fact that the ReCSS study included a range of eye care practice types and locations, and a variety of soft contact lens brands, modalities and designs complementing the study results from clinical trials. The inclusion of various practice settings, locations, size and geographical areas provides a realistic reflection of community patient bases, enabling ECPs to apply this knowledge to their young patients. The underlying aim of any myopia control strategy is to reduce the risk of sight-threatening complications associated with high myopia later in life.25Slowing myopia progression by one dioptre should reduce the likelihood of a patient developing maculopathy by 40% 26and to this end, early intervention is recommended. 13“ The combined scale of these studies ensured an ability to determine the rate of serious contact lens-related adverse events, such as MK in the eight to 12 years age group”These studies indicate that children as young as eight years of age can safely wear SCLs for several years. Closer monitoring of compliance in younger patients by their parents or carers may explain the absence of adverse events in children under 10 years. However, this evidence will help encourage more ECPs to fit children at a younger age and for those who already do, in myopia management or otherwise, it provides further reassurance to parents and will support them in continuing to encourage compliance. Considering the likelihood of children fitted with myopia control lenses to thereafter become lifelong contact lens wearers, encouraging compliance at every appointment from a young age is important to help minimise the potential risks associated with contact lens wear. CHANGE CHILDREN’S LIVES FOR THE BETTERThe results of the ReCSS and six-year Ocular Health studies will be welcomed by ECPs in improving their, and parents, understanding of the safety of SCLs in children and teenagers, particularly those fitted before the age of 13 years. In practice, ECPs fitting daily disposable SCLs and reinforcing and re-educating patients regarding compliance at each review appointment will be able to provide additional reassurance that this is a healthy option for refractive error correction and in the management of myopia progression. Key Points • Children are successful long-term contact lens wearers, • Safety of soft contact lens wear in children is equal to that in adults, • Risk of serious contact lens-related adverse events in children is low with compliant behaviour, • Children as young as eight years of age can wear daily disposable, daily wear lenses full time, with minimal impact on ocular health, and • ECPs have the evidence to reassure young patients and their carers that soft contact lenses and, in particular, daily disposables, are a healthy option for the correction of their refractive error – and management of myopia progression. ECPs are uniquely placed to impact significantly on the quality of life of their young patients, now and into the future. This article was contributed by CooperVision and has been concurrently published in Optician, December 2022. Publication was supported by CooperVision through an educational grant. To earn your CPD hours from this article visit mieducation.com/soft-contact-lens-wear-in-childrenand-teenagers-a-healthy-vision-correction-optionReferences“ We don’t know everything about myopia, but we know too much to do nothing.”Professor Brien Holden, BCLA 2015 1. Chalmers R, McNally J, Chamberlain P, Keay L. Adverse event rates in the retrospective cohort study of safety of paediatric soft contact lens wear: the ReCSS study. Ophthalmic & Physiological Optics 41(2021) 84-92. 2. Woods J, et al Ocular health of children wearing daily disposable contact lenses over a 6-year period. Contact Lens and Anterior Eye 44(2021) https://doi.org/10.1016/j. clae.2020.11.011. 3. Holden BA, et al Global Prevalence of Myopia and High Myopia and Temporal Trends from 2000through 2050. Ophthalmology 2016; 123: 1036-42 4. McCullough SJ, O’Donoghue L, Saunders KJ. Six-year refractive change among white children and young adults: evidence for significant increase in myopia among white UK children. PLoS ONE 2016 11(1): https://doi. org/10.1371/journal.pone.0146332. 5. Fricke TR, et al. Global prevalence of visual impairment associated with myopic macular degeneration and temporal trends from 2000 through 2050: Systematic review, meta-analysis and modelling Br J Ophthalmol. 2018; 102(7): 855-862. 6. The standard of care for myopia management by optometrists. World Council of Optometry Resolution https://worldcouncilofoptometry.info/resolution-thestandard-of-care-for-myopia-management-byoptometrists/ accessed 14/04/2021. 7. Chamberlain P, et al. A 3-year randomized clinical trial of MiSight lenses for myopia control, Optom Vis Sci. 2019:96(8): 556-567. 8. Walline JJ, et al. Benefits of contact lens wear in for children and teens. Eye & Contact Lens. 2007; 33(6 Pt 1):317-21. 9. Plowright AL, et al. Daily disposable lenses versus spectacles in teenagers. Optom Vis Sci. 2015; 92(1): 44-52. 10. Walline JJ, et al ACHIEVE Study Group. Randomized trial of the effect of contact lens wear on self-perception in children. Optom Vis Sci. 2009 Mar:86(3): 222-32. 11. Wolffsohn J, et al. Global trends in myopia management attitudes and strategies in clinical practice – 2019 Update. Contact Lens & Anterior Eye 2020; (43): 9-17. 12. Bullimore MA, Richdale K. Myopia control 2020: Where are we and where are we heading? Ophthalmic & Physiological Optics 40(2020) 254-270. 13. Walline JJ, et al. Interventions to slow progression of myopia in children. Cochrane Database of Systematic Reviews 2020, Issue 1. Art. No.: CD004916. DOI: 10.1002/14651858.CD004916.pub4. Accessed 5 March 2021. 14. Brennan NA, Toubouti YM, Cheng X, Bullimore MA, Efficacy in myopia control. Progress in Retinal and Eye Research 2020, 100923, ISSN 1350-9462. 15. Gifford KL, et al. IMI – Clinical management guidelines report. Invest. Ophthalmol. Vis. Sci. 2019:60(3):M184-M203. 16. Walline JJ, et al. Effect of high add power, medium add power, or single-vision contact lenses on myopia progression in children: The BLINK Randomized Clinical Trial. JAMA. 2020:324(6):571–580. 17. Jost B. Jonas, et al, IMI prevention of myopia and its progression. Invest. Ophthalmol. Vis. Sci. 2021;62(5):6. doi: https://doi.org/10.1167/iovs.62.5.6. 18. Efron N, et al. International Contact Lens Prescribing Survey, International survey of contact lens fitting for myopia control in children. Contact Lens & Anterior Eye 2020: 43(1) 4-8. 19. Sulley A, et al. Global survey on eye care professional perceptions and attitudes regarding myopia and its management. Contact Lens & Anterior Eye 2021: 44(1) Supplement 1. 20. Lumb E, et al. Global survey on parent perceptions and attitudes regarding myopia and myopia options. Contact Lens & Anterior Eye 2021: 44(1) Supplement 1. 21. Walline JJ, et al. Contact Lenses in Paediatrics (CLIP) Study: Chair time and ocular health. Optom Vis Sci. 2007:84(9): 896-902. 22. Zeri F, Durban JJ, Hidalgo F, Gispets J. Contact Lens Evolution Study. Attitudes towards contact lenses: a comparative study of teenagers and their parents. Contact Lens & Anterior Eye 2010 33(3): 119-123. 23. Stapleton F, et al. The epidemiology of microbial keratitis with silicone hydrogel contact lenses. Eye & Contact Lens. 2013; 39(1): 79-85. 24. Bullimore MA. The safety of soft contact lenses in children. Optom Vis Sci. 2017:94(6): 638-46. 25. Gifford KL. Childhood and lifetime risk comparison of myopia control with contact lenses. Contact Lens & Anterior Eye 2020: 43(1) 26-32. 26. Bullimore MA, Brennan NA. Myopia control: why each dioptre matters. Optom Vis Sci. 2019;96(6): 463-465. 27. Dumbleton KA, et al., The relationship between compliance with lens replacement and contact lens-related problems in silicone hydrogel wearers. Contact Lens & Anterior Eye, 2011 34(5): 216–22. 28. Rueff EM, Wolfe J, Bailey MD. A study of contact lens compliance in a non-clinical setting. Contact Lens & Anterior Eye, 2019 42(5): 557-561. 29. Chalmers RL, et al. Age and other risk factors for corneal infiltrative and inflammatory events in young soft contact lens wearers from the Contact Lens Assessment in Youth (CLAY) Study. Invest Ophthalmol Vis Sci 2011;52:6690-6.Claire Mallon BSc(Hons) MCOptom DipTp(IP) Prof Cert Glauc FHEA FBCLA is a Lecturer in Optometry and Clinic Lead for Contact Lenses at the University of Manchester.