Contact Lenses

Eight Ways to Protect Your Practice When Prescribing CLs for Children

By Pamela Miller, OD, FAAO, JD, FNAP


Jan. 27, 2016

SYNOPSIS

Fitting young children with contact lenses offers the patient clear benefits–but there are steps to take to both ensure success and protect your practice from liability.

ACTION POINTS

BALANCE NEED & RISK. Only prescribe contacts for babies and toddlers when it makes a developmental difference.

GAUGE MATURITY & CLEANLINESS. Observe how well the child listens, how well they are able to follow your directions in the office, and how clean their hands and nails are.

INSTRUCT & DOCUMENT. Instruct both parent and child in proper wear and care regimen, and document that you did so.

Contact lenses can benefit  young children greatly–if the doctor takes proper precautions and care when prescribing. Before prescribing contact lenses for a young child, under the age of 10, you need to consider the safety of your patient, and how you can best instruct the child and the parent in caring for their eyes.

Does the Benefit Outweigh the Risk?

Contact lenses have no minimum age guideline in prescribing–you could prescribe them for an infant. As a general rule, the younger the patient, the more the contacts need to be balanced for a greater good. Said another way: the younger the patient, the greater the need should be for the contacts. For example, you would only prescribe contacts for infants or toddlers when it makes a developmental difference, allowing, for instance, a very myopic infant to see and explore their environment.

There are many kinds of glasses available for infants and toddlers, but sometimes contact lenses are a better option for babies with a very high prescription, or when there is a special vision or eye health consideration, such an anatomical difference between the two eyes, or if one eye is damaged.

If the patient is an eight-year-old who wants to wear contact lenses to help them play sports, and the doctor judges that they would be safer with contact lenses than with the sports glasses they have been prescribed, and that the contacts would boost their self-confidence and enjoyment of the sport, then the doctor would prescribe the contacts–as long as the child demonstrates the ability to properly insert and remove and follow the proper wear and care regimen.

On the other hand, if another eight-year-old wants the contacts exclusively for cosmetic reasons, has acceptable visual acuity in their glasses, and doesn’t need the contacts for safety or developmental reasons, and has shown that they are not able to properly insert and remove the lenses, the doctor would suggest the child wait a year and then try again.

Gauge Maturity Level of Child

It’s important to have a parent who will supervise the child in their contact lens wear, but, unless it’s an extreme situation, such as the infant or toddler who needs the contacts to stay on track developmentally, the child you prescribe the contacts for should demonstrate adequate maturity. They need to be mature enough to understand what contact lenses are, and that what they’re doing could potentially harm their eyes if not done properly.

I note how attentive the child is when I’m speaking to them, and how well they are able to follow my initial directions about inserting and removing the contact lens. I also look for more subtle signs that the child may not be ready for contacts, such as dirty hands and fingernails, and lack of manual dexterity.

Know When to Send Patient Out for Fitting

If you don’t have experience fitting infants and toddlers in contact lenses, it is best to send the patient to another optometrist to do the fitting. It’s very tricky fitting infants, and even toddlers, with contact lenses. In my practice, I send all patients younger than age 4, who need contact lenses, to another optometrist who has expertise in this area. I think of age 4 as a good rule-of-thumb for contact lens fittings in my office because by that age the child usually has manual dexterity and can express desire and challenges about working with the lenses.

Have a Script to Tell Parents Why You Want to Wait

If you judge that the child doesn’t yet have the coordination in their hands, or the ability to follow the proper wear and care regimen, you need to be ready to calmly explain to the parent that you think it would be best to try again the following year. This can be hard because some parents–frequently those who wear contact lenses themselves–are eager for their young child to be given contacts. They’ve seen what a difference contacts have made in their own lives, so now they want to spare their child what they perceive as the discomfort or stigma of glasses. This kind of parent, who insists that their child is ready for contacts, often has a high prescription, and may have flashbacks to their childhood of having to wear unattractive, thick glasses. They may not realize that glasses have come a long way since then.

I might say to a parent, “I agree that contact lenses might work well for Sarah, but I want to hold off for another year. I see that, even here in the office, she’s having trouble working with the contacts. I don’t want to prescribe them for her until I’m sure she can easily insert and remove the contacts, so that I won’t worry about her being able to follow the wear and care regimen she needs to follow to keep her eyes safe. In the meantime, we have a lot of really attractive glasses for Sarah to wear. Our optician will show you and Sarah different styles, and what we think she might like.”

The Younger the Child, The More Frequent the Follow-Up

If it’s a young child between the ages of about 4 and 8, I like to see the parent and child back in the office about every three months to make sure the child is able to follow the proper wear and care regimen, and that the child’s eyes are still healthy. I pre-appoint the child for the needed follow-up exams before they leave the office.

I sometimes will only prescribe contact lenses in three-month increments for young children because I want to make it more likely they will keep their three-month appointments for follow-up exams, and so I can assess whether they are successfully wearing the lenses or require any changes.

Consider Child’s Home Life

The parent who takes the child to their eye doctor appointments sometimes shares parenting responsibilities with a spouse they are divorced from. You want to feel confident that the child will have adequate supervision in the wearing of their contacts, regardless of whose home the child is in. You may want to ask the parent who accompanies the child to their appointment to be sure to instruct the other parent in the child’s contact lens regimen. You may elect to require that they also come into the office with the child. Even if you have confidence that the child understands the importance of following the proper regimen, and that they have the ability to do so, you want both parents to also understand.

In situations where the child is bouncing between their mother’s and father’s homes, it is best to supply them with a contact lens kit, a place where they can keep their contact lenses, including a couple extra pairs and solution all in one place, making it easy to transport from house to house.

Emphasize Importance of Not Over-Wearing or Wearing Damaged

Children often lose or damage their contact lenses. Both parents and children need to understand that it’s never OK to extend wear past the recommended wear and care cycle, and that it’s never OK for a child to wear a damaged contact lens.

Complicating matters is that children frequently won’t tell the parent that they have been over-wearing the same lens because they lost their contacts, or because they may fear their parent will get mad at them. They also may not want to tell because they know their parent will then ask them to wear their glasses until new contacts can be purchased. Children have been known to wear torn contact lenses, rather than tell the parent they damaged the lens and have no other lenses to change into. For those reasons, it might be best for parents to keep the supply of contacts for the child, and give them the contacts as needed.

I also emphasize the importance of purchasing the brand-name solution I have prescribed, rather than looking for cheaper, generic options, which often are not as high-quality as the brand-name solutions, or differ in ingredients from the specific solution I have prescribed.

Document That You Have Trained Both Child & Parent

Document in the child’s health record that you have instructed both the parent and the child in the proper insertion and removal of the contact lenses, and the proper wear and care regimen.

In my practice, we like to verify that the child can insert and remove the lenses three times while still in the office. If it’s an infant, you would watch the parent insert and remove the contacts more than once before leaving the office. I also document in the patient’s record that my staff and I witnessed them properly working with the contact lens before sending them home with the contacts.

I also document the dates when the patient has been pre-appointed to return for follow-up visits, and review the care, wearing time, etc., at the subsequent visits.

Pamela Miller, OD, FAAO, JD, FNAP, has a solo optometric practice in Highland, Calif. She has a law degree, holds a therapeutic license, is California State Board-certified and glaucoma-certified to prescribe eye medications, and offers comprehensive vision care, contact lenses, visual therapy and low vision services. To contact her: drpam@omnivision.com.

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