troubleshooting tips
Kids & Multifocals
by Karlen McLean, ABOC, NCLC
Fitting kids in bifocals, trifocals, or PALs may not include a large percentage of your patient population, but it demands deep knowledge and expertise to meet beginning-to-end dispensing challenges.
Kids' multifocal fittings are as individual as each patient, and fitting and dispensing details should be considered on a case-by-case basis. But knowing the basics will help you be a hit with kids—and their parents—and reduce your redo-remake rates.
CORRECT CORRECTIONS
Doctors who prescribe for kids can request a gamut of lens solutions for young patients who require distance and near correction in the same pair of eyewear. This can include flattop bifocals, usually FT28 or FT35, round or blended segs, occasionally trifocals, and also PALs. Multifocals for youngsters are typically prescribed as a form of visual therapy to help in cases of strabismus or amblyopia.
"Typically the doctor wants a defined reading area, so we normally utilize a FT28 or FT35 bifocal" says Bob Pino, optician and co-owner of An Optical Galleria in Centreville, Md.
PALs for very young patients and first-time eyewear consumers aren't impossible, but should be addressed with caution to patient lifestyle, eye health, and refractive error.
Diane Charles, LDO, manager of the optical dispensary for Children's Eye Doctors in Redmond, Wash., points out that: "With PALs, wandering eyes and small reading areas can combine to make it hard for a child to use PALs effectively. Our doctors usually insist on kids wearing regular bifocals for the first year. We usually don't consider PALS until eight or nine years old at the earliest."
| PAL Psychology |
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| When kids are young, they're adaptable, and most don't seem to mind a line versus no-line bifocal. However, it's important to keep cosmetics in mind because if the line does matter, kids may not wear their eyewear. This is where PALs come into play. "It's important that young patients wear their frames," says Amy Endo, ABOM, CPOT, of the office of Edwin Y. Endo, OD. "In addition to a preferred frame, a PAL can help keep the glasses on their face. The cosmetic appeal can be a factor, especially with teens." Parents also play a part in PAL determination, and may end up being the driving force for PALs. "My experience has been that young children aren't bothered by bifocal lines as much as their parents are," notes Diane Charles, LDO, of Children's Eye Doctors. "The parents are the ones asking about PALs. By the time the child is asking, they're into their teens and our doctors don't have problems fitting them in PALs because they've worn multifocals for so long." |
Another challenge when fitting PALs for kids is being able to find a frame large enough to get a usable distance and reading area that's small enough to properly fit young faces.
Finding a frame with a deep enough B-measurement can be difficult with today's popular narrow-B frame styles. Short-corridor PALs help fill this fitting gap, but very small frames won't work for PALs. If a smaller frame is required for fit, a flattop bifocal may be the best option.
Another option is using round or blended bifocals, which offer improved cosmetics but a more defined reading area.
When measuring round/blended bifocal heights for kids, it's recommended that the blend touch the inferior side of the pupil. Keep in mind when measuring seg height that there are typically 2mm to 3mm of blend, so heights must be set to accommodate the blend and give the patient a usable reading area.
Frames must be deep enough to fit seg heights. Image courtesy of Essilor
Seg height can be marked on the demo lens using tape, so the ECP and child can observe how it will work before the Rx lenses are made and height adjustment can be accommodated prior to ordering the lenses.
| Fitting Tips |
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| Finding a frame with the right fit and a deep enough B-measurement to handle a multifocal lens for kids can be challenging for ECPs, since small faces need small frames and multifocals need some room for a correct therapeutic fit. BRIDGE Fit an adjustable bridge with comfort pads so that multifocals can be raised and lowered slightly to hone distant/near viewing. Since many kids have unformed bridges that are flat, adjustable pads can help bridge the gap for a better fit. TEMPLES If necessary, customize the temple length. This may call for ordering a specialized length or manually shortening temples. Cable temples may help keep eyewear from sliding down or off and also keep multifocals in place for the child's best viewing. SIZE Select a frame size that fits now, not one that the child will grow into. Above all, take precise multifocal height measurements to ensure that there's enough room for a clear view of distance and near while keeping therapeutic use foremost. If the fit does not allow for proper multifocal usage, ask the child to select another frame. |
No matter the multifocal, kids grow and PDs and visual acuity can change with growth, so six-month check-ups are recommended.
Additionally, when kids are fitted with multifocals at Children's Eye Doctors, "We check at two weeks of wear and again at two months to be able to follow and accommodate their needs," Charles says.
PAL POINTERS
Kids' multifocal problems can be varied, including:
- Visual acuity
- Frame fit
- Lens type/measurement glitches
"If the problem is poor acuity, I'll check the refraction and add power," says Vincente Simoncini, OD, of An Optical Galleria. "If the original Rx seems fine, I'll look at fitting height and monocular PDs."
The ability to make frame adjustments that accommodate minute eye-to-lens details can make the difference between patient acceptance and rejection. For adaptation success, kids' PALs can be fit around 1mm to 2mm higher than a standard bifocal and use a short-corridor PAL. But further adjustments may be needed.
"Especially when PALs are fitted higher to ensure the child is looking through the near zone for reading, there can be trouble at distance, such as the child having to tilt her head down to see clearly," notes Amy Endo, ABOM, CPOT, of the office of Edwin Y. Endo, OD in Aiea, Hawaii. "The usual way to remedy this is with extra pantoscopic tilt."
Although kids usually embrace new lens technology faster than adults, sometimes the PAL problem is that the child doesn't understand how the lens works. In that case, a product review is in order.
Simoncini notes: "Reviewing with the child the best way to use bifocals or PALs often reinforces what was taught when the eyewear was dispensed. It also reminds the child and the parents why a multifocal is the most important lens at this time." EB
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