Feature, Report

Telling it like it is: kids and contact lenses

A multitude of studies both on self-esteem and myopia control show kids as young as eight can manage contact lenses safely and competently. Insight speaks with eyecare practitioners and academics about treating this younger age group.

Sport has many benefits for children beyond their physical health, with studies showing it can have a bearing on their emotional and social development by teaching them important life skills.

For many children, their vision – or use of spectacles – can be a barrier to these vital interactions, hence why researchers and practitioners note that it is a common entry point into contact lens wear.

Contact lenses also give children new-found confidence. A randomised trial of the effect of contact lens wear on self-perception in children published more than a decade ago showed pre-teen children aged eight to 11 felt their physical appearance, athletic competence and social acceptance improved compared with spectacle wear.

The same study concluded that eyecare practitioners should consider the social and visual benefits of contact lenses when choosing the most appropriate vision correction modality for children as young as eight.

Today – with the alarming rise of myopia – there has never been greater demand for contact lenses among the paediatric population, which is fuelling rapid advances in lens design and technology.

But contact lenses generally come with greater safety risks through noncompliance. And perceived complexity of management, increased chair time and cost to parents can be key concerns for practitioners.

Customisation in growing market

Dr Philip Cheng is director of The Myopia Clinic, in the Melbourne suburb of Kew, offering a comprehensive myopia control and orthokeratology (orthoK) service.

Alarmingly, during the past six months, he has noticed a drastic rise in myopia.

“I’m seeing more children diagnosed with myopia for the first time, young kids with high myopia who have progressed rapidly, and at-risk children with axial length increase. I’ve seen a discernible change, which I think is environmental, as a result of the extended Stage 4 lockdowns in metropolitan Melbourne,” he says.

Dr Philip Cheng.

Cheng is noticing more awareness of orthoK among parents and is receiving more referrals from friends and families of existing patients.

“Myopia management is growing as an area of expertise – a service – but until recently the products and the concepts have essentially been the same,” he says.

“Now, we’re seeing manufacturers developing lenses specifically for myopia control. Soft multifocal contact lenses such as CooperVision’s MiSight 1day have gained traction. Once it got FDA approval in the US [in November 2019], it bought it into frame a bit more here, and now we’re seeing the real-life results.”

Cheng keeps abreast of developments in this segment and says research results can be sceptical but seeing soft multifocal contact lenses work in real-life quells any doubts.

“As the MiSight power range is limited to -6 dioptres, I also prescribe NaturalVue Multifocal 1 day contact lenses from Visioneering Technologies (VTI) in the US which goes up to -12.25 dioptres,” Cheng says.

“Spanish company mark’ennovy produce a monthly-replacement contact lens, Mylo, which has been on the market for about a year. They licensed the Brien Holden Vision Institute (BHVI)’s extended depth of focus (EDOF) technology to create their customised lens but it takes around three weeks to get trial lenses.”

With a greater body of evidence supporting the use of soft contact lenses for myopia control in children, more companies are investing to get a foothold in the market.

In July, Johnson & Johnson reportedly received FDA’s Breakthrough Device designation for its myopia control lens. Then, in October, Bausch + Lomb announced it had acquired an exclusive license for a myopia control contact lens design developed by BHVI.

Cheng says although contact lenses for kids are a great option, the safety aspect is paramount.

“Parents worry about how their child might cope with trying contact lenses for the first time. I saw a 10-year-old child recently who was scared about trying contacts. It helps to demonstrate that it’s a soft piece of plastic; let them touch it. Once the lens was on her eye she loved it, and amazed she could see clearly again,” Cheng says.

“I also discuss safety risks and hygiene. I find kids do well when it comes to compliance – better than teens, who can get complacent.”

Dr Philip Cheng, director of The Myopia Clinic, has found young children do better than teens when it comes to contact lens compliance.

To help demonstrate this, in 2017, Professor Mark Bullimore, a name synonymous with myopia management from the University of Houston, published a review on the safety of soft contact lenses in children, in response to increasing interest in the past decade in fitting children with contact lenses.

The overall picture showed that the incidence of corneal infiltrative events in children was no higher than in adults, and in the youngest age range of eight to 11 years, it may be markedly lower which he attributed to better compliance and closer parental supervision.

More recently, a study by Australian optometrist Dr Kate Gifford found the comparative lifetime risks of contact lens wear starting at age eight for myopia control are less than the lifetime risks of vision impairment with myopia more than 6 dioptres or axial length more than 26 mm.

In Gifford’s view, eyecare practitioners should be confident to proactively recommend myopia control contact lens wear to younger children, as both the safety profile and potential preventative ocular health benefits are evident.

Cheng says he also emphasises that myopia control contact lenses are a long-term treatment, not a quick fix. He cautions patients against only relying on treatment, highlighting environmental factors such as excessive screen time, reading and indoor time can have a detrimental effect on myopia.

Talking the talk

Like Cheng’s clinic in inner-Melbourne, optometrist Ms Jessica Chi at Eyetech Optometrists in Carlton is also noticing an increase in myopia progression in patients who have been otherwise stable.

“Generally speaking, we’re seeing more kids with myopia now than in the past – not just East Asian kids but now Caucasian kids too. And after seven months of lockdown in Melbourne, we’re seeing more myopia progression. Why? Kids are spending less time outdoors and more time on screens during home-schooling,” Chi says.

Jessica Chi.

In June this year, Chi was invited to give a lecture at Optometry Australia’s Optometry Virtually Connected conference where she spoke about contact lens options for children and teenagers, and the benefits and challenges in managing this younger age group.

Drawing on 13 years’ experience in prescribing paediatric contact lenses, first at Richard Lindsay & Associates in East Melbourne and now at Eyetech, Chi says introducing kids and parents to contact lenses and their capacity to significantly improve quality of life is extremely rewarding.

“Language is important when discussing contact lenses. I talk about the benefits of contact lenses, and discuss the times when glasses are annoying; slipping and fogging et cetera. I show kids what contact lenses look like and encourage kids to touch them, so they get a sense of their softness. Many kids think inserting contact lenses is going to hurt. I wear contact lenses so I give a self-demonstration to show it’s not painful,” Chi explains.

“Sometimes kids aren’t ready to wear contact lenses after an initial introduction but at least by discussing it and handling a lens, they’re familiarising themselves with it and that plants a seed. Sometimes they’ll think about it and want to try again later.”

Chi says it’s also important to talk about the “why” behind wearing contact lenses.

“I talk about myopia control, and the repercussions of not wearing prescribed contact lenses. But this is more relevant for teenagers. I also believe it’s important to speak directly to the child – not just the parent – as this gives them a sense of ownership,” she says.

In Chi’s experience, daily disposables are the best option for young children.

“The more disposable, the better. Parents worry about infections, and I explain kids are less likely to have infections with daily disposables, and kids thrive on routine.”

Children are generally more compliant than anticipated, Chi says, because they are accustomed to following instructions and attend followup appointments as they are supervised by their parents.

“It’s a satisfying aspect of clinical practice when you see a young patient develop more confidence as a result of wearing contact lenses. It can significantly improve their quality of life – their academic and sporting life, and their self-perception.”

Safety and consent

By her own admission, Dr Nicole Carnt, chair of the Australian Standards Committee on Contact Lenses, has become more vocal on contact lens safety during the past five years.

A turning point in her advocacy came during a stint at Moorfields Eye Hospital in London as part of her post-doctoral research on microbial keratitis.

There, she witnessed a 14-year-old boy who needed an eye removed due to a corneal infection from Acanthamoeba due to contact lens wear.

Dr Nicole Carnt.

“He was a -3 myope who wore contact lenses to play football and happened to live in a suburb with ‘hard water’ – water that has high mineral content; in this case, limescale – on which bacterial biofilm grow, forming a food source for Acanthamoeba,” Carnt recalls.

A recent study led by Carnt conducted across greater Sydney found 29% of domestic tap water supply samples collected during summer and winter were contaminated with free living Acanthamoeba.

Now a Scientia Senior Lecturer at UNSW, Carnt leads a program of research into behavioural and host immune susceptibility to eye infections at UNSW and Westmead Institute for Medical Research.

She says it’s important for practitioners and contact lens wearers to have conversations about contact lens wear safety with all patients.

“Practitioners should also consider providing a consent form for patients. Contact lenses are a medical device and like surgery – which requires a consent form – patients should know the risks.”

Crucially, she says patients should be aware that, contrary to popular marketing images, contact lenses and water don’t mix. Carnt was integral in getting ‘no water’ stickers for contact lens packaging endorsed by respective British, American and Australian contact lens associations.

Optometrists can get the stickers from the Cornea & Contact Lens Society of Australia (CCLSA), which have right and left markings on them, so they can be placed on contact lens packaging and any paraphernalia, such as storage cases.

“The ‘no water’ stickers are what’s known in the industry as a ‘nudge’ to remind people, a visual reminder for patients not to use water with contact lenses,” Carnt explains.

She notes other innovations have helped make it easier to practice healthy contact lens wear, such as Menicon’s Miru 1-day flat pack, which keeps the inner surface of the contact lens facing downward to hygienically remove a contact lens without touching its inner surface.

Passionate about safer contact lens wear and minimising risk of severe infection, Carnt points to the latest data from leading academic Professor Fiona Stapleton on contact lens‐related corneal infection in Australia.

In a paper published in Clinical and Experimental Optometry in May this year, Stapleton surmised that given the growing enthusiasm for contact lens modalities for myopia control, “it is timely to consider the rates and risks of microbial keratitis with both orthokeratology and soft multifocal contact lens use in a paediatric population”.

“Previous studies of contact lens‐related microbial keratitis have almost exclusively focused on adults and there are limited data on children wearing standard contact lenses. Hospital audits of paediatric microbial keratitis have been published but there are no population‐based studies,” Stapleton noted.

“One approach may be to use registry, myopia control product registration or case‐control studies to explore the risks in this population and to ensure that overnight orthokeratology and soft contact lenses rates are disaggregated.”

Despite the work of researchers like Stapleton and Dr Robin Charmers in the US, who has also studied safety of paediatric soft contact lens wear, Carnt says there are other considerations which are not often spoken about, such as how the immune system differs for a child compared to an adult, and how immune system status can change with prolonged contact lens wear.

“We don’t know how that will play out. Does it make kids more or less prone to infection? We don’t know. There are many unanswered questions,” Carnt says.

She also notes that skepticism of research results may be warranted.

“A lot of information and results from industry-sponsored trials don’t necessarily translate into real-world experience. People behave differently in trials; they receive regular care and are closely looked after. Trials generally recruit healthy people, and don’t represent the diversity of patients coming in the door of a regular practice,” she says.

“For example, silicon hydrogel extended wear clinical trials indicated a lower risk of microbial keratitis than hydrogels but in the market, this has not been the case, due to different demographics and different conditions.

“If it weren’t for the myopia epidemic, we wouldn’t be in this situation of being so proactive in fitting contact lenses in kids.”

Managing motivation

Carnt’s UNSW colleague, Dr Pauline Kang, see’s several paediatric patients at the university’s Myopia Clinic, which opened in 2015.

“Our paediatric patients range from as young as five, to late teens. We get referrals locally, and we also offer an option to manage or co-manage patients, like a stepping-stone for optometrists gaining experience in myopia management,” Kang says.

A senior lecturer who coordinates the clinic, Kang’s own research focuses on better understanding how different contact lenses induce myopia control effects.

Dr Pauline Kang.

She’s seeing a shift in practitioner mindset from the well-established use of orthoK towards the use of multifocal soft contact lenses. When it comes to contact lens wear compliance among children, Kang finds the patients – and parents – at the UNSW Myopia Clinic are highly motivated.

“They’ve typically been referred to us, so they are motivated – they want treatment and results. But generally speaking, patients who are prescribed orthokeratology are particularly motivated. It’s a specialty technique, involves a significant financial investment, often paying up front, which motivates compliance,” Kang says.

“Multifocal soft contact lens compliance depends to some extent on how practices charge. It requires more chair time, so practices may charge extra, which in turn can motivate patients. We see our multifocal soft contact lens patients at least every six months.”

When it comes to safety, Kang says the clinic goes through a detailed safety discussion with patients and uses an informed consent form to make sure they’ve ticked all the boxes to protect both the patients and the clinic to mitigate risk.

“We educate parents and patients, including teaching them to recognise when there’s an issue, and what to do. I try to give the child a sense of responsibility; I give them homework for when they come to see me, which I find helps with compliance.

“I use multiple modes of instructions for contact lens wear. I provide instructions verbally and in writing, which all practitioners should do, and I also recommend websites and reputable online videos on how to insert and remove contact lenses. I also book patient’s after-care appointments in advance.”

She says practitioners shouldn’t be nervous or fearful to prescribe contact lenses to kids.

“I always find it’s the adults who complain – not the kids. Rigid lenses can be uncomfortable to wear but kids are adaptable. Practitioners should be open to trying contact lenses on kids – they handle lenses well and studies show contact lenses do improve quality of life.”

Only myopia control treatment with FDA approval

CooperVision professional services manager Mr Joe Tanner says the evidence supports the safety and efficacy of the company’s MiSight 1 day contact lenses.

Mr Joe Tanner.

“In terms of safety generally, we refer to Professor Mark Bullimore’s extensive 2017 review on the safety of soft contact lenses in children, and his finding that the incidence of corneal infiltrative events in children is no higher than in adults, and in eight- to 11-year olds, it may be markedly lower.”

Tanner says the ongoing multi-centre study CooperVision commissioned in 2012 has had excellent clinical results, with the first three years’ results published in Optometry and Vision Science in 2019.

“A large component was looking at the safety profile and the results echo those highlighted in the Bullimore review,” he says.

Tanner says the results of the first three years were integral to MiSight 1 day receiving US FDA approval.

“It [FDA] set a pretty tough standard because the MiSight 1 day lens is specifically intended for children,” Tanner says.

“We were able to meet the FDA’s stringent safety and efficacy requirements. So far, MiSight 1 day remains the only treatment of any kind with FDA approval for slowing the progression of myopia in children.”

He says CooperVision is investing heavily locally and globally to support practitioners and wearers including the development of child-friendly instructional materials.

“Our ongoing MiSight 1 day study shows how quickly kids become self-sufficient at applying and removing lenses with the right support within the first few weeks,” he says. “Importantly, the great majority of children express a preference for wearing contact lenses over spectacles.”