Pediatric Contact Lens Fitting – A Tiny Bit Different!

Many ODs fit a variety of contact lenses. Many specialize in custom lenses for difficult to fit corneas and other conditions. Some ODs consider themselves to be pediatric ODs. But few find themselves dipping their toes into both areas. In some situations, there are benefits to fitting children and even infants in contact lenses. While it may seem contraindicated and even impossible, there are a variety of situations where the benefits often outweigh the risks. Keep in mind that every case and patient is different and parent and child motivation are a crucial element necessary for success!


Children born with congenital cataracts have one option for proper visual development – cataract removal. This is different than your typical cataract extraction in your elderly patients because typically no intraocular lens (IOL) will be inserted. The eye is still growing, so an IOL inserted will be too small in a few months or a year, and will require follow-up surgery if utilized. 
 This leaves the child as an aphake at an extremely young age. It also leaves them as a high hyperope, as the lens contributes between +14 to +20 diopters to the eye’s power. Typically after lensectomy to remove the cataract and allow light to reach the retina, we fit the child with high-powered plus contact lenses to ensure proper visual development.

One of the most common lenses fit for infants is the B&L Silsoft Lens (photo on right). Similar to the silicone hydrogel lenses we’re familiar with but with a lower water content, it decreases the bacteria that can penetrate the lens into the eye. This makes the lens safer for infants especially with sleep schedules that may be around the clock. Many practitioners will use a version of the extended-wear model, allowing parents to insert the lens(es) once every week-month and remove for cleaning. Replacement is often at the 3-6 month mark, as these lenses are thicker, high plus lenses and more costly than typical disposable lenses.


Often, kids with very high or very unequal prescriptions will be prescribed glasses as part of their therapy to correct their vision and stabilize binocularity. However, very young children often aren’t too keen on the idea of glasses on their faces, especially when one of their eyes sees much better than the other. Cosmetically, parents can also be concerned if one eye is plano and the other is a +8.00, as glasses can cause the eye to appear more enlarged. In this situation, contacts are also much more beneficial as there will be less or no aniseikonia (image size difference) with the contacts. The child won’t be able to pull the glasses off their face and this will maximize the therapeutic benefits of the lenses. In some scenarios, it may be beneficial to maximize amblyopic therapy with a contact lens in the amblyopic eye and atropine in the strong eye when the child is very resistant to things on their face (i.e. glasses/patching). Even some children with myopic errors and who wear glasses, but refuse patching. may be treated with a contact lens under the glasses in the form of a blacked out pupil lens. The lens does not obscure the iris color, but blocks light from entering the eye and serves as a patch without the look or feel of one.

Active Children with High Rx Errors 

Slightly older kids who are active in sports may find that they need sharp acuity to participate in these activities. Playing basketball or football may require a separate pair of sports goggles, which can be expensive. Responsible children who show strong motivation to wear lenses with parent cooperation can be successfully fitted with contacts for full or part time wear. The safest modality for this age bracket is daily disposable lenses, which eliminate the need for lens care and decrease the likelihood of infection. Ensuring that the child, not the parent, is the primary motivation behind the lens fitting process is crucial. Forcing a lens into an uncooperative child who doesn’t want them will only be traumatic and unsuccessful. Before letting anyone leave with lenses, making sure that the child, not the parent, can insert and remove lenses successfully is vital. Starting proper lens wear habits early can be beneficial for later success. Take more time to educate the child and schedule multiple visits as needed. Follow up care is more frequent in this patient base as well, especially to ensure proper health of the eyes as they grow.

Ortho-K and Presbyopic Lenses for Myopic Control

New research has shown that several unconventional contact lenses can be used in the pediatric population to help halt the growth of myopia. As parents of childhood myopes are well aware, they can get frustrated when their child needs a new pair of glasses every six months because they continue to get more myopic. Ortho-K lenses are one technology that has been shown to help halt this by reshaping the cornea while the wearer is sleeping.

Used in adults, the lenses are slept in and removed during the day, and the wearer has a flatter cornea with which they see clearly through (progression in photo on right). The lens works the same way for children, but has been shown to decrease myopic progression over time when compared to their glasses-wearing counterparts. Children may have some apprehension to this lens at first, as it is a rigid lens and requires some adaptation with more “lens awareness” than soft lenses. However, these lenses only worn overnight during sleep, so most of that lens awareness won’t be noticed by the child, and the lenses are removed while awake (when the child gets to be glasses free!).

There is also research on the effectiveness of multifocal silicone lenses for myopia control by using the peripheral add on the lens to focus the peripheral retina. One of the theories of myopic progression states that myopia increases based on “hyperopic defocus.”  In a nutshell, this means that even if the eye is focused at the fovea with the correct prescription, in a child’s eye, the peripheral retina is still blurry and actually HYPEROPIC. This will cause the retina to think that it needs to grow longer in axial length to meet the longer rays, worsening the condition. How do we correct the peripheral retina with plus while keeping the fovea clear with the current Rx? Presbyopic contact lenses in children! There is no alternative in spectacle lenses that can simulate this, and the results have been very promising so far. In trials, children have been able to tolerate add powers that most adults find disorienting, as children’s visual systems are much more malleable.

Prosthetic Lenses for Congenital Diseases

Children born with conditions such as aniridia may have potentially debilitating glare and halo due to the fact that they have no iris, and therefore no sphincter to decrease the amount of light that gets to the retina. Contacts with a solid painted iris not only give the cosmetic look of an iris, they also decrease the amount of glare and can increase acuity. Children with ocular albinism also will often have decreased or no iris pigment and will be extremely photosensitive and thus may benefit cosmetically and functionally from such a lens. Depending on the subtype of albinism, however, improvement of vision with the lenses may not be likely due to foveal hypoplasia. Fitting children with lenses such as the Alden or Orion lenses can allow them not only to walk around without debilitating photosensitvity, but deter potential teasing due to the apparent nature of the conditions. The contacts can also divert light to the macula to potentially improve vision.

Assessing pediatric contact lens wear is like every other contact lens fit – patient dependent. Just like you wouldn’t fit a 30-year-old noncompliant patient with GPC and corneal neovascularization with 1 year old lenses, you likely wouldn’t fit a 7 year old child who doesn’t want the lenses but whose mom wants them for him. Use your best judgment and gage your comfort level before you move ahead. If you don’t feel comfortable fitting a child with lenses, but feel the situation is appropriate, refer to another OD who can help. Keep in mind that in almost every case, a backup pair of glasses (and yearly exams and follow up care) is always a necessity!





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