Small Eye Sizes

A guide to best practices for small eye sizes

By Karlen McLean, ABOC, NCLC

Kids are physically and mentally different from adults; even their eyes work differently. On the surface, fitting small faces and dispensing to kids may seem simpler or similar to downsized adult procedures.

That is far from the truth!

Kids' vision is a specialty where nuances can make or break a business and create raving fans or multiple redos and remakes.

Dispensing to kids is more complicated than down-sizing adult fitting techniques. Above image courtesy of Augen Optics

REALITY CHECK

There are some undisputable rules-of-thumb when dispensing kids' eyewear, according to Katheryn Dabbs Schramm, ABOC, RDO, CEO of A Child's View, Inc., a four-store pediatric dispensary in Southern California, and author of “Will My Child Actually Wear These Glasses?”

REALITY CHECK: The first priority is to be realistic. “An optician who fits a frame on a child—especially an infant or toddler—and expects to get more than a year's use is dreaming,” she says. “That would be like guaranteeing a pair of shoes to fit a youngster for more than a year.”

FITTING FRAMES: Frame fit, both front and temple, is crucial to comfort and wearing ability.

According to Dabbs Schramm, it's essential that frames fit the shape of the child's nose exactly with uniform touch throughout, because the bridge bears the “burden of fit.”

Frame width should be equal to the widest part of the face. Eyes should be vertically centered; bifocals are usually set to bisect the pupil, so the seg height should never exceed 3mm above. Decentration should be 3mm to 5mm in.

Nosepieces can be changed or adjusted to align the pupil with the vertical center of the frame, adds Paul McHale, an optician at Northeastern Eye Institute with headquarters in Scranton, Pa., and 17 retail optical locations.

TEMPLE TIPS: “Temple length should be accurate; if temples are too short, the glasses will slip or fall, and if temples are too long, they may be visible or rub and be uncomfortable,” says McHale.

He also notes that metal temples can be customized for length by removing the temple covers and snipping the desired length—approximately 5mm—and temple cover to match the shortened temple length.

Diane Charles, LDO-manager of Children's Eye Doctors and Woodlawn Optical in Redmond, Wash. near Seattle, offers an interesting kids' temple tip: “I don't like cable temples other than for very small infants,” she says.

Instead, she gets the longest size she can and wraps the temples like a cable. “Most little ones are hyperopes and, with the heavy weight of their lenses, the cables are too soft to support the weight,” Charles says. “With customized skull temples, gravity catches the temple on the back of the ear and allows for very little slipping.”

RIGHT RESTING:

Additionally, frames shouldn't rest on the cheeks or frontal bone. This can be a challenge with toddlers but is necessary to avoid poor fit and overall subpar eyewear performance.

The frames should not inhibit the natural growth of a child's facial features, especially the nose; and making up for poor fit with a strap or cord is a no-no. Frames should be age-appropriate, avoiding dispensing mistakes like rimless on an infant.

LENS CONSIDERATIONS: It can also pay to break out of the traditional lens mold.

In addition to selling polycarbonate and mostly Trivex, Woodlawn Optical also recommends high-index for kids, Rx depending, and with parent understanding as the key.

“Educating parents is what's most critical on frames and lenses—that is, thickness, materials, and what they can expect,” says Charles.

MEASURING PD

“Children's PDs increase at a rate of one to four millimeters a year,” Dabbs Schramm says. “Fitting accordingly will assure a properly fitting frame now and for about a year, when the Rx typically changes anyway.”

Measuring small eye sizes is a step-by-step process, Dabbs Schramm affirms.

Here are her tips for the best infants and kids eyewear measurement results:

1 Select the correct frame in the first place, because a good frame adjustment will not make up for a poorly fitting frame.
2 Take the PD twice using two different methods.
3 Use a finger puppet to gain the child's attention. Always take a “cover test” type of PD: cover one eye, measure the monocular PD, then cover the other eye and repeat.

This is essential as it's impossible to get an accurate PD when a young patient's eye turns.

4 Dot the center of the demonstration lens.
5 At A Child's View, Dabbs Schramm uses a special hand-held sliding lens device with crosshairs which are aligned.
6 Measure inner canthus to outer canthus (Dabbs Schramm doesn't prefer this method, but many dispensers do).

“When there's a convergence issue, a kid's inset is two unless the doctor specifies zero,” Dabbs Schramm advises.

“When working with infants, use a near PD; toddlers, use an intermediate PD, and with three-plus years, use a distance PD,” she adds.

Using tools not only for measurements but also to keep a kid's attention works to help capture proper PD numbers.

“I use a pupilometer for kids who are five-six and older; they love looking at the ‘Life-Saver' in the middle,” Charles relates. “I use a flashlight for the little ones. I give them one to play with and use one to take their PD. Kids love light!”

Make taking PDs both fun and functional, advises Donna Scott, optician at Northeastern Eye Institute. “Place a sticker on your nose to help kids focus when you're taking their PD,” she says. “Most small children don't like the pupilometer.” Scott also recommends singing at times, and letting kids hold a toy.

CAPTURING ATTENTION

Keeping a young child's attention can be problematic both in the exam room and the dispensary. But these top techniques can be helpful.

“Entertain the child the moment they enter the exam room,” advises Lisa Toole, OD, from Northeastern Eye Institute. Fun near fixation targets include wind-up toys that spin, while clapping and making noise allow for easy assessment for eye alignment, fixation patterns, and visual preferences. “A TV with DVD player is an excellent tool for amusement while doing retinoscopy and ophthalmoscopy,” she adds.

Other recommendations include having lens racks, prism bars, and stereo/suppression tools easily accessible. Optician McHale offers three to-dos that work for him:

1 Remove obstacles between you and the child.
2 Don't sit behind a desk. Stay eye level with the child.
3 Explain everything you're doing in a fun, enthusiastic and friendly manner.

Adds Eugene Fortini, optician, Northeastern Eye Institute, “Murals on the walls, cartoon characters in the room, and art on the ceiling help ease a child's nervousness and keep their attention. The ECPs' attitude is very important; always use the truth and be fun.”

Interacting properly with parents is a key component of kids' dispensing. Without parental help and understanding, visual child care is nearly impossible. And there can be a fine line to tread when it comes to balancing what kids and parents want.

“Calming parents and alleviating their fears and concerns makes the job easier, with fewer redos,” Charles affirms.

Getting parents to understand that letting kids choose their own frames is important, Charles adds. “I'm convinced that there are bushes at school filled with glasses. When parents call with reports of lost kids' glasses, I can tell you that nine times out of 10 it was the child who had to get something that mom and dad wanted rather than his or her choice.” EB

TOP TiPS

Opticians Eugene Fortini, Paul McHale, and Donna Scott at Northeastern Eye Institute, headquartered in Scranton, Pa., offer these kids' measurement tips and tricks: ■ Make sure kids are steady and focused straight ahead ■ Be patient to get the proper measurements ■ Double-check everything ■ Adjust frames before measuring ■ Avoid semi-rimless frames for mid- to high-Rx powers ■ Be cautious of clip-ons with high power Rx's: the clip may not fit a high-minus and can scratch the center of a high-plus lens ■ Center frames so the lenses are directly over the pupil, as small children tend to look over the frame (kids' natural focus is upward since they're smaller than adults and have to look up more often) ■ Overall measurements should be close or equal to the PD (eye size + bridge size = PD) Proper fitting of eyewear ensures future enjoyment. Image courtesy of Transitions Optical

PLUS TiPS

A radical yet practical tip for high-plus lens kids dispensing: Don't go with small frames (yes, you read that right). High-plus lens availability is limited now that intraocular implants (IOLs) have greatly reduced demand and the highest plus powers will be lenticular/aspheric lenticular lenses. Ideally, according to pediatric dispensing expert Katheryn Dabbs Schramm, ABOC, RDO, and CEO of A Child's View with four Southern California locations, “A child requiring an especially high-plus power should be fitted with a round frame equal in size (frame PD) to the child's PD.” This, she says, would result in lenses with maximum usable field, since the aperture would be equal nasally and temporally. “If fitted too small, the nasal cut will be through the thickest part of the lens, not the thinner aperture,” she points out. One of her pet peeves: selling aspheric lenses inappropriately. For example, to a two-year-old prescribed a +3.00D. “The center of an aspheric lens is spherical, so all the asphericity is cut off when edging a lens like this in such a small eye size,” she observes. “Often these lenses come out thicker than if they were non-aspheric!” Properly fit eyewear helps ensure optimal vision. Image courtesy of Augen Optics

WARRANTY POiNTERS

When offering product warranties it's best to have everything in writing, especially when it comes to kids' eyewear. These key sample points are so succinct that they can be printed on the back of a business card or small notecard for handout at dispensing: The price of your eyewear includes warranty at no additional charge. 1. Polycarbonate or Trivex lenses that are UV protective, scratch resistant, and impact resistant. 2. An unconditional breakage warranty for one year (X pair limit*). 3. Lost eyewear will be replaced at 50 percent of the original cost. (X pair limit). 4. An Rx change within 90 days of purchase will be made at no extra charge. *Fill in the X with the number that's right for your practice. Kids' eyewear is a family affair. Image courtesy of Vision-Ease Lens

PERFECT FiT

Released in May 2001, the “Comparison of Success in Contact Lens Wearers Fitted as Children vs. Teenagers” study examined 175 soft contact lens wearers ages 17 to 30 who wore contact lenses for the past 10 years, comparing the results of those fitted at ages 12 and under with patients fitted at ages 12 to 19. Of those surveyed, 49 percent were fitted as a child and 51 percent were fitted as a teenager. The following are key findings. 1 After 10 years of contact lens wear, patients were equally successful wearing contact lenses whether they were first fitted as children or teenagers, making the case that long-term successful contact lens wear is not dependent on the age of the initial fit. 2 Nearly 25 percent of both child and teen fits were able to wear contact lenses for as many hours as they wanted. Both reported wearing their contact lenses for more than 14 hours per day, of which more than 13 hours were comfortable. 3 Approximately 32 percent of child fits reported rubbing their contact lenses and 42 percent rinsing their lenses when cleaning them compared with 35 percent of teens who reported rubbing and 45 percent who reported rinsing their lenses. The proportion of child and teen fits who replaced their cases at least every six months was 53 percent in each group. Children who have a say in their eyewear selections tend to wear their glasses more. Image courtesy of PPG Industries/Trivex