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Fun and Function Myopic Kids in ContactsWRITER Dr Celine Zhang Optometrist Celine Zhang sees plenty of children with onset myopia in her Sydney practice. Concerningly, she has noticed the average age of children at initial presentation is younger than it was prior to the COVID-19 pandemic, and over time, they’re experiencing faster rates of myopic progression than ever before.1There is no safe level of myopia progression, and children who develop myopia in early childhood have a greater risk of progression than those who develop it later in life.2With this in mind, Ms Zhang takes a proactive approach to every case, with clear myopia management advice provided to the child and their caregiver(s) from the very beginning. Children with myopia require some form of refractive correction to see clearly. This can take the form of glasses or contact lenses in all their variations, ranging from single-vision to peripheral myopic defocus spectacles, to dual-focus soft contact lenses and orthokeratology (OK) lenses. The average age of myopia onset is eightyears-old.3At eight, children are in primary school and leading action-packed lives, learning at school, playing with friends, and exploring the world around them. Spectacle wear can sometimes get in the way of such busy lifestyles. Contact lenses can be a great refractive solution and, when using targeted myopia contact lens solutions, can also become an effective therapy to help stem progression of myopia. It can be a rewarding endeavour to fit children in contact lenses, however, there are important considerations to keep in mind and teamwork – between the child, their parents, and the practitioner – is essential for a successful contact lens fit. CLINICAL INDICATIONS FOR MYOPIA CONTROL CONTACT LENS WEAR Myopia management takes many forms, ranging from pharmacological management with atropine and lifestyle advice, to targeted spectacle lens and contact lens solutions. They all come with their own pros and cons, which means your myopia management approach must be tailored to the individual child’s situation. Contact lenses are just one piece of the puzzle. Children and teenagers with no previous contact lens experience can be successfully fitted, with the mean training time for children between eight to 16 years being 30 minutes. A 2015 study by Paquette et al, found no significant differences in the instruction time by age group or gender.4Children and teenagers can safely wear and care for soft contact lenses, however, the child and their caregiver should always be made aware of the possible side effects and clinical safety profiles of contact lenses. With proper education on safe contact lens wear time, lens hygiene and the different modalities available, the practitioner can help reduce the risk of adverse events such as microbial keratitis (MK). A child has more risk of visual impairment from complications of high myopia than the comparative lifetime risk of MK in contact lens wear, especially in the case of daily disposable contact lens wear compared to other modalities.5CONTACT LENS OPTIONSThere are several contact lens options available on the market for myopia control. Lens selection will depend on a range of factors including: the patient’s refractive error (myopia and astigmatism), corneal topography, the condition of their ocular surface, the child’s and caregiver’s capabilities for handling the lenses, the practitioner’s experience and comfort in fitting the lens, cost, and the availability of lenses on the market to cater for all these factors. In general, current myopia-control soft lenses on the market cater for patients with a spherical prescription and less than 1.00D of astigmatism. Children with myopia and moderate astigmatism are more suited to OK lenses where mild-to-moderate levels of astigmatism can be corrected for. The following is not an exhaustive list of contact lenses available, but those I have used in practice. Daily Disposables Daily disposable contact lenses can be a suitable option for appropriate children. If the lenses are lost or dropped, they are easily replaced by opening a new blister pack. This eliminates the potential for solution-related complications and contact lens case contamination. An example of a daily disposable contact lens targeted to myopia control is CooperVision’s Misight 1-day lens, a dual-focus daily disposable soft contact lens option that is available in spherical range up to -10.00DS. Another daily disposable option available is the SEED 1dayPure EDOF lens, an extended depth of focus design".“ In addition to the myopia control benefits of certain contact lens designs, contact lens wear can positively impact quality of life for children and teens”Monthly DisposablesMonthly disposable lenses available for myopia control include CooperVision’s Proclear and Biofinity centre-distance multifocal lenses, and mark’ennovy’s Mylo soft contact lens. The latter is a monthly-disposable extended depth of focus design, which is available in a spherical range up to -15.00DS. Orthokeratology Orthokeratology has been a mainstay for myopia control practitioners over many years. There are a range of OK lens designs available, with different myopia control efficacy profiles. This highly customisable rigid lens can correct moderate levels of myopia and astigmatism. One of the benefits of OK lens wear, apart from myopia control and glasses-free vision during the day, is that the lenses are always worn under parental supervision – they are worn overnight to gently reshape the corneal curvature and removed upon waking. Some parents and children may feel more comfortable with this modality of wear. OK lenses are rigid and smaller than soft lenses, which can make them somewhat easier to handle for children with smaller palpebral apertures. OTHER BENEFITS OF CONTACT LENS WEAR FOR CHILDREN In addition to the myopia control benefits of certain contact lens designs, contact lens wear can positively impact quality of life for children and teens. Wearing contact lenses can significantly improve how children feel about their appearance and social acceptance compared with those who wear glasses. They can be more practical for those who participate in sports and athletic activities, and children who are rough on glasses will benefit from not having to return to the practice for frequent glasses repairs, replacements, and adjustments. Contact lenses also have a distinct cosmetic and clinical advantage over glasses, especially for children with a highly myopic prescription or anisometropia. They provide a wider field of clear vision, remove the minification effect of spectacles lenses, and give the wearer freedom from the weight of spectacles. Anisometropic children may benefit from contact lens wear to reduce the aniseikonia that comes with glasses wear, which can in turn improve binocularity. READY OR NOT? Not all children will be ready to wear contact lenses. Good signs that a child is ready include: • They can follow direction and instructions in the consultation room, • They express interest in contact lenses or not wanting to wear glasses, • They have good hygiene, • The child is participating in a lot of sports, • They are a rough and tumble kid who is always in need of a glasses repair, replacement, or adjustment, and/or • Their caregivers are motivated for their child to wear contact lenses. To ascertain motivation levels, I try to spark a conversation that highlights the benefits of wearing contact lenses. This can be anything from asking, “Wouldn’t it be great to see the soccer ball without glasses on?” or, “Would you like to wake up every morning and not have to wear glasses to see well?”. ENCOURAGING RESISTANT PATIENTSSome children have no interest in contact lenses. Encouraging them to give them a try can be challenging for all concerned – the child, their parents and the optometrist – especially if they have already made up their mind. I find it helpful to drive home the benefits of wearing contact lenses, and not only in terms of lifestyle. I take time to explain how contact lens wear can improve the child’s eye health, and how it will help them in the classroom and home. Exploring reasons for reluctance is very important as it can provide further opportunities for reassurance. It may be that they fear wearing contact lenses will hurt, or that they will be difficult to insert and remove. It could be that they love their glasses. My rule of thumb is to address their concerns truthfully and keep an open door for any more questions they may have. Of course, it is normal for any child to feel a bit nervous about wearing contact lenses for the first time. One thing I’ve found helpful is to prepare them, even before a contact lens insertion and removal education session, by providing an information sheet and advising them to watch some YouTube videos about contact lens insertion and handling. If you’re going to recommend YouTube, I recommend you filter through some of the available content and only send links to your preferred videos. Better still, record a video for your practice. Watching videos of other kids handling their contact lenses, particularly if they are filmed with you or your colleagues in practice, can be comforting for the child and reassuring for their parents. Doing so will also open an avenue for the child to become curious about the process and ask questions.Tips From the Consult Room Here are some tips I’ve gathered in the consultation room while fitting paediatric contact lenses. I hope you may find some of them helpful. 1. School holidays can be a good time for children to begin contact lens wear. This will give them opportunities to try contact lenses in a range of situations and get used to them before handling their lenses during the school term. 2. School holidays are also easier for booking children into contact lens appointments and aftercares as they are not restricted to the busy after-school appointment slots. 3. It’s best not to have an audience for the contact lens insertion and removal teach sessions. Have siblings wait in the waiting area. 4. Ensure the child/caregiver(s) can clearly identify the child’s left and right eye. If you are giving them open trial lens boxes, label each contact lens blister pack with ‘L’ or ‘R’ to avoid confusion. 5. Advise they plug the sink before lens insertion and removal to avoid lens loss. 6. Suggest they make a contact lens station at home, where they can practice putting their lenses in over a clean dinner plate or towel, rather than over the sink or on the benchtop. 7. Swimming lessons are a common after-school activity. It is important to explain that contact lenses should not be worn during water sports to reduce the risk of serious corneal infection. Outline an alternative for these events. 8. A good contact lens routine can make life a lot easier and reduce the risk of undesirable contact lens habits forming. Discuss when they are going to insert and remove their lenses and use their eye drops – this should be as much of the child’s routine as brushing their teeth. Another helpful strategy is to allow the child and parent time to handle a soft contact lens. I make it a positive experience, guiding them through washing their hands, opening the package, and touching the lens. Call it ‘exposure therapy’ if you will. It allows them to establish a realistic understanding of the contact lenses they will be wearing. Talk them through how small and jelly-like it is, and how it feels just like a waterdrop. You may even want to show them your own lens on eye and talk about how wonderful it can be to live glasses free. With potential OK wearers, make their first experience with lenses a great one by demonstrating glasses-free vision with a soft lens on eye. Finally, before you equip your young patient with their new contact lens supply, send them home with artificial tears and ask them to practice drop insertion. This will get them thinking about how to keep their eyelids open when inserting and removing their contact lenses. Additionally, the sensation of an eye drop on the eye will prepare them for the feeling of a lens. The contact lens conversation does not have to be ‘one and done’. Although the child in front of you may not be an instant contact lens convert, conversations over time will remind them that this is an option and allow them to grow more comfortable with the idea. “ When it comes to contact lens care, a detailed information sheet with illustrations/ photos, along with names of solutions and when to use them is pertinent”I ask my young patients about their interest in contact lens wear at every consultation and find avenues to chat about the benefits. You never know, they may just say ‘yes’ one day. OFFERING CLEAR INFORMATIONWe are lucky to have a wealth of continually evolving knowledge about myopia control, which can be referenced when educating patients and their carers to ensure they are onboard with your treatment strategy. However, in studies of adult patients, it has been reported that patients forget as much as half of the information they receive during medical appointments.7This makes it important to tailor your conversations to the child and parent in your consulting room. It is easy to fall into the trap of giving them every ‘ATOM’ of detail we’ve attained over the years. I would say that most of my patients don’t want to know all the nitty gritty details of peripheral hyperopic defocus, proposed mechanisms of atropine, and all the emerging research available to us. But be prepared with a succinct printable or ready-to-email myopia control information sheet if the child and parents would like to know more about each option available to them. When it comes to contact lens care, a detailed information sheet with illustrations/photos, along with names of solutions and when to use them is pertinent. Children with myopia should be reviewed frequently, usually in three to six-month intervals. Each visit is a good opportunity to remind the child and their caregiver(s) about the importance of good contact lens practices. Living with Generational MyopiaWRITER Melanie Kell As a high myope, and with a husband who has worn glasses since childhood, Jodie Hope* had no doubt that her children would need vision correction. So, it came as no surprise when she took Elizabeth* and Adam* to the optometrist; and was advised that they both had myopia. Now 10 and eight-years-old respectively, Elizabeth and Adam were first prescribed glasses while in kindergarten and have been treated with orthokeratology (OK) lenses since the age of seven. “I had never heard about OK, but I was happy to take the optometrist’s advice, and so far, it has been working pretty well, although I’m not completely convinced yet. Their prescriptions have been reasonably stable although Elizabeth’s recently increased quite a bit,” Ms Hope told mivision. Having grown up wearing glasses, Ms Hope says she appreciates the convenience OK provides her children, which only requires they wear their lenses at night, enabling them to participate in sports and other activities glasses-free. “I felt very inconvenienced by the need to wear glasses as a child, so I was looking for a technology that would provide control and convenience.” With her children commencing OK treatment from a young age, she said parental involvement has been essential. “While my daughter is now able to take her lenses out on her own, she still needs help with putting them in. Adam needs help for both insertion and removal – at $1,000 per pair of lenses, we don’t want to drop or lose them.” Although Ms Hope has been advised to encourage her children to spend more time outdoors, she said this has been “impossible” to achieve. “The kids have screen time, they do their schoolwork on laptops, and tests on the computer, so it’s hard to avoid, although we do try to do more outdoor activities on weekends. “I feel genetics has a lot to do with their eyesight. It’s my view that regardless of what we do, we are not going to have any great influence.” Ms Hope, whose myopia stabilised in high school, sees an optometrist every few years to have her own eye health checked. “Because I have a high degree of prescription, I know I am at greater risk of eye disease than most. I’ve known this since I was young, and I’ve known that there is nothing I can do about it, so it’s just about having regular examinations.” *Patients’ names changed for anonymity. CO-MANAGEMENT WITH COLLEAGUESMyopia presents a fantastic opportunity to co-manage patients with ophthalmologists and/or other optometrists. As optometrists, we are often the first point of contact with an emerging myope. If you aren’t confident in myopia management or do not have access to specific tools to evaluate these patients, don’t hesitate to co-manage with an ophthalmologist or optometrist colleague. There is increasing evidence that axial length measurement is an important piece of the puzzle for myopia management. Devices to measure axial length are common among ophthalmologists and starting to enter more optometry practices. If you don’t have one, find a colleague who does. Similarly, if you can’t access a corneal topographer, OK, myopia control spectacle lenses or soft lenses, contact a colleague who can. If you believe your patient needs low-dose atropine but you don’t have therapeutic prescribing qualifications, contact an appropriately qualified colleague in optometry or ophthalmology. Remember to write back to your colleagues to ensure the patient you referred experiences good continuity of care. With co-management, there is much we can do to reduce the long-term risks of myopia progression. “ Remember to write back to your colleagues to ensure the patient you referred experiences good continuity of care. With co-management, there is much we can do to reduce the longterm risks of myopia progression”Celine Zhang graduated from the UNSW Bachelor Optometry/Science course with First Class Honours. She has also completed the Specialist Certificate in Management of Paediatric Patients (Optometry) from the University of Melbourne. She has a special interest in paediatric optometry, vision therapy, myopia control, dry eye and therapeutic management of ocular disease. Celine Zhang practises at Eyecare Plus Kareela and Bankstown in Sydney. References1. Rosenfield, M. (2022), COVID-19 and myopia. Ophthalmic Physiol Opt, 42: 255-257., 2. Flitcroft, D. I. (2012). The complex interactions of retinal, optical and environmental factors in myopia aetiology. Progress in retinal and eye research, 31(6), 622-660. 3. Lin, L. L., Shih, Y. F., Hsiao, C. K., & Chen, C. J. (2004). Prevalence of myopia in Taiwanese schoolchildren: 1983 to 2000. Annals of the Academy of Medicine, Singapore, 33(1), 27–33. 4. Paquette, L., Jones, D. A., Sears, M., Nandakumar, K., & Woods, C. A. (2015). Contact lens fitting and training in a child and youth population. Contact Lens & Anterior Eye : the journal of the British Contact Lens Association, 38(6), 419–423. https://doi.org/10.1016/j. clae.2015.05.002 5. Gifford K. L. (2020). Childhood and lifetime risk comparison of myopia control with contact lenses. Contact Lens & Anterior Eye: The Journal of the British Contact Lens Association, 43(1), 26–32. https://doi. org/10.1016/j.clae.2019.11.007 6. Walline, J. J., Gaume, A., Jones, L. A., et al. (2007). Benefits of contact lens wear for children and teens. Eye & contact lens, 33(6 Pt 1), 317–321. https://doi. org/10.1097/ICL.0b013e31804f80fb 7. Kessels, R., 2003. Patients' memory for medical information. JRSM, 96(5), pp.219-222.