1040-5488/07/8409-0896/0 VOL. 84, NO. 9, PP.

896–902
OPTOMETRY AND VISION SCIENCE
Copyright © 2007 American Academy of Optometry

ORIGINAL ARTICLE

Contact Lenses in Pediatrics (CLIP) Study: Chair

Time and Ocular Health
JEFFREY J. WALLINE, OD, PhD, FAAO, LISA A. JONES, PhD, FAAO,
MARJORIE J. RAH, OD, PhD, FAAO, RUTH E. MANNY, OD, PhD, FAAO,
DAVID A. BERNTSEN, OD, MS, FAAO, MONICA CHITKARA, OD, AMBER GAUME, OD,
AILENE KIM, OD, NICOLE QUINN, OD, FAAO, and THE CLIP STUDY GROUP
The Ohio State University College of Optometry; Columbus, Ohio (JJW, LAJ, DAB, MC), New England College of Optometry, Boston,
Massachusetts (MJR, NQ), and University of Houston College of Optometry; Houston, Texas (REM, AG, AK)

ABSTRACT
Purpose. Despite several studies that show 8- to 11-year-old children are capable of wearing a various contact lens
modalities, parents often report that their eye care practitioner would not fit their child with contact lenses until the child
was about 13 years old. We conducted the Contact Lenses in Pediatrics (CLIP) Study to compare contact lens fitting and
follow-up between 8- to 12-year-old children and 13- to 17-year-old teenagers.
Methods. At the baseline visit, all subjects underwent a contact lens fitting, including visual acuity, a manifest refraction,
autorefraction, and biomicroscopy. Subjects then underwent contact lens insertion and removal training, which consisted
of talking about contact lens care as well as inserting and removing a contact lens three times. Subjects returned for
follow-up visits at 1 week, 1 month, and 3 months, and visual acuity, contact lens fit assessment, and biomicroscopy were
performed. The time of the fitting, the insertion and removal training, and each follow-up visit were measured individually
and added for a total chair time. Biomicroscopy examinations were conducted according to a standardized protocol.
Results. We enrolled 84 children and 85 teens in the study. Of the 169 subjects, 93 (55.0%) were female, 78 (46.2%) were
white, 44 (23.3%) were Hispanic, and 28 (17.6%) were black. The mean (⫾ SD) total chair time for children was 110.6 ⫾
39.2 min, significantly more than 95.3 ⫾ 25.2 min for teens (Student’s t-test, p ⫽ 0.003). Most of the difference was
caused by insertion and removal training, which lasted 41.9 ⫾ 32.0 min for children and 30.3 ⫾ 20.2 min for teens
(Student’s t-test, p ⫽ 0.01). The presence of conjunctival staining increased from 7.1% of the subjects at baseline to 19.9%
of the subjects at 3 months (␹2, p ⫽ 0.0006), but the changes were similar between children and teens. No other
biomicroscopy signs increased significantly over the 3-month period.
Conclusions. The total chair time for children is approximately 15 min longer than teens, but most of that difference is
explained by longer time spent teaching children insertion and removal. Because insertion and removal is generally
taught by staff members, the eye care practitioner’s time with the patient is similar between children and teens.
Furthermore, neither children nor teens experienced problems related to contact lens wear during the study. Eye care
practitioners should consider routinely offering contact lenses as a treatment option, even for children 8 years old.
(Optom Vis Sci 2007;84:896–902)

Key Words: contact lenses, pediatrics, silicone hydrogel, chair time, children, teenagers

C
hildren require contact lenses for a variety of reasons. They
may require contact lens wear because of aphakia,1– 8 ocu-
lar trauma,9,10 amblyopia therapy,10 –12 or refractive error.
Contact lenses for aphakia, trauma, and amblyopia therapy may be
medically necessary, but contact lenses for refractive error are generally
elective; so eye care practitioners, parents, and children must decide
together whether a child should be fitted for contact lens wear.
Many children require vision correction at an early age because
myopic refractive error typically develops at about 8 years of age.13,14
There is less consensus about the timing of a correction of moderate
hyperopic or astigmatic refractive errors, and these errors may not be
identified until children begin to perform concentrated near work
activities, typically around the age of 6 or 7 years. Contact lenses may
therefore be used to correct refractive error beginning early in life.

Optometry and Vision Science, Vol. 84, No. 9, September 2007

 Contact Lens Chair Time for Pre-Teens and Teens—Walline et al.
Anecdotally, many eye care practitioners fit teens with contact
lenses, but they will not fit children with contact lenses until they
are at least 12 to 13 years old. It has been proven that children as
young as 8 years are capable of wearing soft,15–19 gas perme-
able,16,20 –24 and corneal reshaping contact lenses,25–27 but a com-
parison of fitting children and fitting teens with contact lenses has
never been performed.
The reasons that eye care practitioners do not routinely fit chil-
dren younger than 12 or 13 years old may vary. They may perceive
that younger children will take longer to fit with contact lenses and
therefore cost the practice valuable chair time; that younger chil-
dren will experience greater adverse effects; that younger children
will not benefit from contact lens wear as much as teenagers; or that
younger children may not be mature enough to be responsible for
contact lens care.
Several studies have shown that children as young as 8 years old
are mature enough to care for their contact lenses independent of
parental intervention, and that children experience few adverse
side effects of contact lens wear.16,17,26,28 However, no investiga-
tions of chair time associated with contact lens fitting have been
conducted for children.
The purpose of this investigation was to compare the chair time
associated with soft contact lens fittings (fitting, insertion and re-
moval training, and three follow-up visits) and the ocular side
effects of contact lens wear between 8- to 12-year-old children and
13- to 17-year-old teens.
METHODS
This research was approved by the Institutional Review Boards
at each clinical site (Ohio State University College of Optometry,
New England College of Optometry, and University of Houston
College of Optometry), in accordance with the Declaration of
Helsinki. Following explanation of the nature and possible conse-
quences of the study, a legal guardian provided informed consent,
and the children provided informed assent. Each clinical center
recruited a similar number of children and teens to the study. To
ensure that all examiners used similar procedures, a Manual of
Procedures explained specifically how to conduct all measures, and
examiners met before study initiation to discuss procedures. The
examiners were certified via written tests on how to perform visual
acuity, autorefraction, biomicroscopy, contact lens fitting, and in-
sertion and removal training.
All subjects were between the ages of 8 and 17 years and
required vision correction to see optimally. Their ocular health
was not contraindicated for contact lens wear, they had 20/25
or better best-corrected visual acuity in each eye, and no previ-
ous contact lens wear experience. All spherical refractive errors
were between ⫹5.00 D and –9.00 D, and astigmatism was
less than –2.25 D, measured by noncycloplegic subjective
refraction.
At the baseline visit, all subjects underwent retinoscopy; a
manifest refraction; autorefraction and autokeratometry; high-
contrast, best-corrected, distance logMAR visual acuity accord-
ing to a standardized protocol; biomicroscopic examination;
contact lens fitting; and lens insertion and removal training. At
this visit, parents provided demographic information about
their children, and both the parent and subject completed sur-
Optometry and Vision Science, Vol. 84, No. 9, September 2007
897
veys about spectacle wear. If the children were not able to insert
and remove their contact lenses during the baseline visit, they
attended additional visits until they could perform the task
adequately. Insertion and removal training consisted of talking
about contact lens care as well as inserting and removing a
contact lens three times.
Subjects returned for follow-up visits at 1 week, 1 month, and 3
months after the last contact lens insertion and removal training
visit to perform high-contrast distance logMAR visual acuity with
contact lenses, undergo contact lens fit assessment and biomicro-
scopic evaluation, and to complete surveys. If a dilated fundus
examination had not been performed within the previous 12
months, one was performed at a follow-up visit.
Visual acuity was performed while the child stood 4 m from a
high-contrast logMAR visual acuity chart illuminated between 75
and 120 cd/m2. The subject wore the results of the refraction in a
trial frame at baseline, and his or her habitual contact lenses at all
follow-up visits. Beginning at the 20/50 line, subjects read the first
letter of every line until one letter was missed. They then read all
five letters in the line two lines above the letter they missed. If one
letter was missed, the subject read all five letters on the line
above and this continued until all five letters were read cor-
rectly. The subject then continued to read all five letters on
every line down the chart until three or more letters were missed
on a given line, and the number of letters read correctly was
recorded.
Noncycloplegic autorefraction was performed using the Grand
Seiko WR-5100K (Grand Seiko Co., Hiroshima, Japan) while the
child viewed 20/50 letters that were presented beyond the subject’s
far point on a Badal track. Ten readings were recorded and aver-
aged according to the methods proposed by Thibos.29 Autokera-
tometry readings were recorded from the autorefraction printout.
A biomicroscopic examination was performed and recorded on
all subjects. Corneal staining, conjunctival staining, bulbar red-
ness, and limbal redness were graded from 0 to 4 according to
CCLRU photographic standards.30 Infiltrates were graded as
present or absent. Microcysts were counted and given a grade as
follows: 1 ⫽ ⬍10, 2 ⫽ 11 to 24, 3 ⫽ 25 to 49, and 4 ⫽ 50 or more.
Neovascularization was recorded as the maximum distance from
the limbus that any vessel protruded into each cornea. Upper and
lower tarsal abnormalities were graded 1 to 4 as follows: 1 ⫽ slight
injection without texture, 2 ⫽ mild papillae/follicles ⬍1 mm in
diameter, 3 ⫽ significant papillae/follicles ⬍1 mm in diameter
and/or marked injection, 4 ⫽ localized or generalized papillae/
follicles greater than or equal to1 mm in diameter with or without
marked injection. Corneal edema was categorized as; 1 ⫽ barely
discernible localized corneal cloudiness; 2 ⫽ faint but definite
localized or generalized corneal cloudiness; 3 ⫽ significant local-
ized or generalized corneal cloudiness; or 4 ⫽ definite widespread
corneal cloudiness.
Subjects were fitted with either ACUVUE ADVANCE with
HYDRACLEAR or ACUVUE ADVANCE for Astigmatism
soft contact lenses (Johnson & Johnson Vision Care, Jackson-
ville, FL). All subjects with ⬍0.75 D of astigmatism were fitted
with ACUVUE ADVANCE with HYDRACLEAR. The 8.3
base curve was placed on the right eye, and the 8.7 base curve
was placed on the left eye when fitting spherical contact lenses
and the base curve of the lens with the best fit was ordered for
898 Contact Lens Chair Time for Pre-Teens and Teens—Walline et al.

both eyes. If both contact lenses provided similar fits, then the TABLE 1.
flattest base curve was dispensed for both eyes. If only one Procedures timed during each visit
spherical lens was fitted, then the 8.3 base curve was attempted
first if the flattest corneal curvature was ⬎45.00 D. If visual Timed
Visit Procedure
portion
acuity was not correctable to 20/20 because of uncorrected
astigmatism or the subject had 1.00 D or more astigmatism, the Fitting Baseline Retinoscopy and subjective refraction
subject was fitted with ACUVUE ADVANCE for Astigmatism LogMAR visual acuity OD, OS, OU
contact lenses. All contact lenses had to settle for 15 min before Non-cycloplegic autorefraction
assessing the fit. If ACUVUE ADVANCE contact lenses did Biomicroscope examination with
not fit properly, examiners were allowed to fit any brand they fluorescein and upper lid eversion
thought was necessary. The subjects were all dispensed OPTI- Contact lens insertion
Wait 15 minutes for contact lens to
FREE RepleniSH with TearGlyde (Alcon, Ft. Worth, TX) mul-
settle
tipurpose disinfecting solution, but they were given AQuify Check fitting with biomicroscope
Multi-Purpose Solution (CIBA Vision, Duluth, GA) if they I/R training Baseline Discuss wear schedule, rules,
developed symptoms that were attributed to an allergy to the cleaning, and inversion check
original solution. Show how to remove and insert
Movement and centration of the contact lenses were assessed contact lenses
either 15 min after the fitting or during routine biomicroscopy Remove, insert contact lens three
examination when the subject reported for follow-up visits. Move- times (two times from 1 eye, once
ment of the lens was clinically assessed in 0.25-mm increments up from other)
to 1 mm in primary gaze and up gaze. Centration of the lens was Follow-up 1 week LogMAR visual acuity OD, OS, OU
recorded as covers the cornea, covers the cornea but decenters to 1 month Spherical over-refraction
3 months Spherocylindrical over-refraction if
limbus, or incomplete corneal coverage. Toric contact lenses rota-
spherical not 20/25 or better
tion was assessed fifteen minutes after insertion at the baseline visit Biomicroscope examination with
and at every follow-up visit, by lining the orientation of the slit fluorescein and upper lid eversion
lamp beam with the marking on the lens and recording the direc-
tion (nasal or temporal) and magnitude in degrees. I/R, insertion and removal.
To determine whether practitioners may predict patients who
are more likely to be successful contact lens wearers, examiners nificant variables from the univariate models first, and testing the
were asked to assess how easy they think the subject will be to fit remaining variables once again.
and teach insertion and removal before beginning the examination
(based on initial impressions only). They were to mark one of four
RESULTS
choices: “extremely easy,” “easy,” “difficult,” “extremely difficult.”
The procedures conducted for standardized protocols of fitting, We screened 176 children to enroll 169 subjects in the CLIP
insertion and removal training, and follow-up visits are included in Study between February 14, 2006 and July 12, 2006 at three
Table 1. The time of each procedure was measured with a stop- clinical centers. The reasons for exclusion were excessive cylinder
watch. If the insertion and removal training required more than (n ⫽ 3), emmetropia (n ⫽ 3), and sphere out of the allowable range
one visit, the time for each subsequent visit was added to get a total (n ⫽ 1). Subjects were grouped according to their age at the base-
time for the insertion and removal training. The total time was the line examination: children included 8 to 12 year olds, and teens
sum of all of the timed sessions. All times were rounded to the included 13 to 17 year olds. Seven subjects were fitted with contact
nearest half minute. lenses other than ACUVUE ADVANCE with HYDRACLEAR or
Serious adverse events were characterized as any unexpected ACUVUE ADVANCE for Astigmatism because of poor fit (n ⫽
event that occurred during the study and resulted in a loss of two or 6) or poor comfort (n ⫽ 1) with the original lens.
more lines of best-corrected visual acuity. A nonserious adverse Of the 338 eyes, 58 (17.2%) were initially fitted with ACUVUE
event was considered as anything that led to discontinuation of ADVANCE for astigmatism; 13 (22.4%) of the eyes that required
contact lens wear for a period of time but completely resolved. toric contact lenses were children’s eyes. Twelve subjects did not
The subjects received free contact lenses, solutions, and eye care complete the study, but there was not a significant difference in the
throughout the 3-month study. Each subject also received a $10 proportion of children (8%) or teens (6%) who were not captured
gift card at each follow-up visit, and a $50 gift card or savings bond at the last study visit. Data from the subjects who wore different
at the final visit. lenses and from subjects who did not report for the last visit were
Basic descriptive statistics were calculated using mean ⫾ stan- included in the analyses.
dard deviation (SD) for continuous variables and frequency tables The groups were similar with respect to gender, ethnicity,
for categorical variables. Differences were tested with a t-test anal- and parent and sibling spectacle wear (Table 2). On average, the
ysis for the continuous variables and the ␹2 or Fisher’s exact test for children reported receiving their glasses at an age of about 8
the categorical variables. To assess which variables were associated months younger than the teens. Fewer than half of the subjects
with amount of time required to fit children and teenagers with were white and approximately one-fourth of each group was
contact lenses, univariate regression models were fit using potential Hispanic. The two groups had similar average refractive errors,
covariates. Final multiple regression models were built using sig- with more than 2.00 D myopia and very little astigmatism, and

Optometry and Vision Science, Vol. 84, No. 9, September 2007

 Contact Lens Chair Time for Pre-Teens and Teens—Walline et al. 899

TABLE 2. ing, and this did not differ significantly across time (␹ , p ⫽ 0.03).
2

Demographic characteristics of subjects Approximately 7% of subjects showed any grade of conjunctival

staining at baseline. The proportion of conjunctival staining dif-
Children Teens fered throughout the study (␹2, p ⫽ 0.0006) and was significantly
(n ⫽ 84) (n ⫽ 85) p
greater at all follow-up visits than baseline.
Age (years) 11.0 ⫾ 1.3 14.7 ⫾ 1.2 — Bulbar and limbal conjunctival injection were rare at baseline
% female 61.9 48.2 0.07 and did not differ significantly over the study period (␹2, p ⫽ 0.40
Ethnicity (%) 0.70 and 0.14, respectively). Upper and lower tarsal abnormalities were
Asian or Pacific 9.5 8.2 prevalent in this group of subjects, but did not differ significantly
Islander over 3 months (␹2, p ⫽ 0.40 and 0.76, respectively). Little corneal
Black, not of 14.3 18.8 edema or neovascularization were noted over the course of the
Hispanic origin
study and did not differ significantly throughout the study (Fisher’s
Hispanic 23.8 28.2
White, not of 48.8 43.5
exact test, p ⫽ 0.56 and 0.34, respectively). No microcysts or
Hispanic origin infiltrates were noted throughout the study.
Other or unknown 3.6 1.2 Contact lens fitting characteristics are shown in Table 5. In
Duration of spectacle 3.4 ⫾ 2.1 5.9 ⫾ 3.1 ⬍0.001 primary gaze, the vast majority of subjects exhibited ⬍0.5 mm
wear (years, movement of the contact lenses throughout the study. Most sub-
mean ⫾ SD) jects also exhibited complete corneal coverage with the contact
At least one parent 50.0 37.7 0.11 lenses. On average, the initial contact lens power was very close
wears contact to the power predicted from the spherical equivalent from the
lenses (%) manifest refraction, and ⬍10% of the subjects exhibited an
At least one sibling 19.1 17.9 0.18 over-refraction of more than ⫾0.50 D at the baseline visit. After
wears contact
the baseline visit, fewer than 5% of the subjects exhibited an
lenses (%)
over-refraction of more than ⫾0.50 D. When they were fitted
p values indicate significant differences or lack thereof between with a toric lens at the baseline visit, approximately half of them
children and teens. showed no rotation. The rest of the subjects were split between
nasal and temporal rotation. Typically, the rotation of the toric
TABLE 3. contact lens was between 5 and 10 degrees.
Ocular characteristics of the right eye of subjects Table 6 shows the mean (⫾standard deviation) time needed to
at baseline fit subjects, teach insertion and removal, and conduct follow-up
examinations. The fitting and all follow-up visit times were similar
Children Teens p
for children and teens. The only statistically significant differences
Refractive error (D, between children and teens were the insertion and removal train-
mean ⫾ SD) ing times and the overall times. The total time was approximately
M ⫺2.09 ⫾ 2.21 ⫺2.62 ⫾ 2.10 0.11 15 min greater for children than teens, and the primary reason for
J0 ⫺0.02 ⫾ 0.23 ⫹0.02 ⫾ 0.35 0.28 this difference was the extra 10 minutes it took children to learn
J45 ⫹0.01 ⫾ 0.22 ⫺0.04 ⫾ 0.23 0.14 insertion and removal of contact lenses. There were 16 extra visits
Best-corrected, distance
required for 15 subjects (seven children and eight teens). On aver-
VA (logMAR,
mean ⫾ SD)
age, the extra time required at the extra visits was 56.7 ⫾ 37.9 min
OD ⫹0.03 ⫾ 0.07 ⫹0.01 ⫾ 0.08 0.12 for children and 22.5 ⫾ 17.4 min for teens (Student’s t-test, p ⬍
OS ⫹0.03 ⫾ 0.08 ⫹0.00 ⫾ 0.08 0.07 0.0001).
OU 0.00 ⫾ 0.07 ⫺0.04 ⫾ 0.07 0.001 To determine factors that may lead to or may predict the total
Keratometry (D, time required for a young contact lens patient, we used univariate
mean ⫾ SD) regression models. Factors considered were gender, age (both con-
Steep K 44.73 ⫾ 1.55 44.85 ⫾ 1.52 0.62 tinuous and by group), spherical refractive error component, ex-
Flat K 43.71 ⫾ 1.47 43.84 ⫾ 1.56 0.59 aminer assessment of how easy a subject would be to fit before the
p values indicate significant differences or lack thereof between fitting, number of years of spectacle wear, whether a parent wore
children and teens. contact lenses, and whether a sibling wore contact lenses. There
were not enough toric lens wearers to determine whether fitting a
toric lens correlated with increased total time. In the univariate
their corneal curvatures were similar (Table 3). Although the analyses, age (both continuous and dichotomous) and ease of fit-
teens had statistically better binocular visual acuity, the mean ting assessment by the eye care practitioner were statistically sig-
difference was not clinically relevant. nificant, but none of the others were. In a multivariate model, these
There were no differences in the proportion of children and factors remained statistically significant. Age treated continuously
teens exhibiting the biomicroscopy signs in Table 4 or the contact with ease of fit yielded a slightly higher r2 value than child versus
lens fitting characteristics in Table 5, so all biomicroscopy and teenager. Based on the final model, adjusted for age, the least
contact lens fitting results will be described for the entire sample. square mean for the examiners’ assessment of “extremely easy to
At baseline, 3% of the subjects showed any grade of corneal stain- fit” subjects was 84.3 min, for “easy to fit” subjects it was 98.4 min,

Optometry and Vision Science, Vol. 84, No. 9, September 2007

900 Contact Lens Chair Time for Pre-Teens and Teens—Walline et al.

TABLE 4.
Percentages of right eyes with lid and corneal findings at each visit
Baseline 1 week 1 month 3 months
Children Teens Total Children Teens Total Children Teens Total Children Teens Total

Corneal staining (%) 2.4 3.5 3.0 6.6 15.2 11.0 11.8 7.5 9.6 5.6 6.3 6.0
Conjunctival staining (%) 4.8 9.4 7.1 21.1 17.7 19.4 19.7 26.6 23.2 11.7 22.2 19.9
Bulbar redness (%) 7.1 14.1 10.7 17.1 11.4 14.2 14.5 16.3 15.4 6.7 12.7 13.3
Limbal redness (%) 3.6 9.4 4.7 14.5 8.9 11.6 10.5 10.0 10.3 1.7 7.9 8.0
Microcysts (%) 0 0 0 0 0 0 0 0 0 0 0 0
Infiltrates (%) 0 0 0 0 0 0 0 0 0 0 1.3 6.7
Upper tarsal abnormalities (%) 30.5 28.9 29.7 32.0 29.5 30.7 34.7 28.8 31.6 26.4 26.6 26.5
Lower tarsal abnormalities (%) 26.2 15.3 20.7 17.1 18.0 17.5 21.3 18.8 20.0 13.9 20.3 17.2
Corneal edema (%) 0 2.4 1.2 1.3 2.5 1.9 0 2.5 1.3 1.4 0 0.7
Neovascularization (%) 0 2.4 1.2 1.3 3.8 2.6 0 3.8 2.0 0 0 0

TABLE 5.
Contact lens fitting characteristics for each eye at every visit
Baseline 1 week 1 month 3 months
Movement, primary gaze
(mm) Children Teens Total Children Teens Total Children Teens Total Children Teens Total

% no movement 4.9 1.8 3.3 0.7 0 0.3 0 1.9 1.0 3.4 0 1.6
% ⱕ0.50 mm 82.2 89.8 86.0 95.9 86.2 90.8 89.3 72.8 83.4 93.1 91.3 92.2
% ⬎0.50 mm 12.9 8.4 10.6 3.4 13.8 8.8 10.7 20.3 15.6 3.4 8.7 6.2
Movement, up gaze (mm)
% no movement 1.2 0.6 0.9 0 0 0 0 0.7 0.3 0.7 0 0.3
% ⬎0.50 mm 21.6 24.7 23.1 23.1 30.5 26.8 36.9 32.2 34.6 20.0 23.9 22.0
Centration (%)
Covers cornea 79.2 74.6 76.9 87.2 85.5 86.4 85.7 89.4 87.7 84.1 84.0 84.0
Covers cornea, decenters 17.3 23.7 20.5 10.7 14.5 12.7 14.3 9.3 11.7 15.9 16.0 16.0
to limbus
Incomplete corneal 3.6 1.8 2.7 2.0 0 0.9 0 1.2 0.6 0 0 0
coverage
Over-refraction of spherical
lens
Mean ⫾ SD 0.08 ⫾ 0.56 ⫺0.01 ⫾ 0.24 0.03 ⫾ 0.43 0.0 ⫾ 0.17 ⫺0.04 ⫾ 0.19 ⫺0.01 ⫾ 0.18 ⫺0.01 ⫾ 0.14 ⫺0.01 ⫾ 0.19 ⫺0.01 ⫾ 0.17 ⫺0.04 ⫾ 0.18 ⫺0.03 ⫾ 0.18 ⫺0.03 ⫾ 0.18
% greater than ⫾0.50 D 9.5 7.1 8.3 3.9 1.9 2.9 0 2.4 1.3 4.1 4.3 4.2
Rotation at baseline after 15
minutes
% nasal 20 23.3 22.4
% temporal 20.0 25.5 24.1
% no rotation 60.0 51.2 53.4
Average (⫾SD) amount 8.3 ⫾ 5.8 5.0 ⫾ 2.3 5.8 ⫾ 3.4
nasal (°)
Average (⫾SD) amount 4.7 ⫾ 3.8 5.4 ⫾ 3.3 5.2 ⫾ 3.3
temporal (°)
Spherical 8.3 base curve at 43.3 45.9 44.5
baseline (%)

for “difficult to fit” subjects it was 109.8 min, and for subjects
assessed as “extremely difficult to fit” the least squares mean was
170.0 min.
DISCUSSION
Although several studies have proven that children are capable of
wearing a variety of contact lens modalities,16 –19,23–27 parents who
enroll their children in pediatric contact lens studies often report
that their eye care practitioner would not fit a child younger than
12 or 13 years with contact lenses. Eye care practitioners who fit
teens often refuse to fit children with contact lenses even though
there are no investigations reported in the literature that indicate
that children benefit less from contact lens wear than teens or that
they require more chair time.
If children require much more chair time than teens, experience
more adverse effects than teens, do not adapt to contact lens wear
as easily as teens, or do not benefit from contact lens wear as much
as teens, then doctors may be justified in waiting to fit patients
until they are older than 12 years.
In the current study, the total chair time required for contact
lens management was estimated to be on average 15 min greater
for children than teens. However, the greatest difference in time
occurred during the insertion and removal training. Many eye
care practitioners have staff members teaching contact lens in-
sertion and removal to patients. Under these circumstances, the
extra time required for fitting the child would not likely de-
crease the potential productivity of the doctor because optomet-
ric instruments are not required for teaching insertion and

Optometry and Vision Science, Vol. 84, No. 9, September 2007

 Contact Lens Chair Time for Pre-Teens and Teens—Walline et al.
TABLE 6.
Mean ⫾ standard deviation time (minutes) for each
protocol by age group
Children Teens p tors in the study said that they assessed the motivation, anxiety,
Fitting 43.3 ⫾ 9.3 41.3 ⫾ 9.0 0.17
I/R training 41.9 ⫾ 32.0 30.3 ⫾ 20.2 0.01
1-week follow-up 14.3 ⫾ 4.7 13.6 ⫾ 4.9 0.35
1-month follow-up 14.1 ⫾ 9.5 11.6 ⫾ 3.1 0.04
3-month follow-up 11.4 ⫾ 3.0 10.6 ⫾ 2.4 0.10
Total time 110.6 ⫾ 39.2 95.3 ⫾ 25.2 0.003
I/R, insertion and removal.
Significance differences between children and teens are ad-
justed for multiple comparisons (Bonferroni adjustment, p ⫽
0.008).
removal of contact lenses and because the doctor is available to
examine other patients while a child is learning to insert and
remove contact lenses.
The absolute time reported for each activity in this paper should
not be translated into chair time in a practice because a standard-
ized protocol was followed in this study that requires more time
than would be necessary in practice. For example, children under-
went a standardized visual acuity assessment with the right eye, left
eye, and both eyes that was in addition to Snellen visual acuity
checks. Furthermore, all contact lenses settled on the eye for 15
min before assessment, and this is rarely done in practice. The
times that are reported in this investigation are useful for compar-
ing times between children and teens, but they may overestimate
the actual time required to fit a typical young person with contact
lenses in practice.
Anatomically and physiologically, children’s and teens’ eyes are
very similar. We would not expect any group differences in how
eyes respond to contact lens wear unless they were associated with
differences in how the groups care for their contact lenses. No
serious adverse events were reported during the 3-month study,
and there were no obvious differences between the biomicroscopic
findings for children and teens. Five nonserious adverse events
were reported during the study: three cases of viral keratitis (two
teens and one child) and two cases of suspected contact lens over-
wear (one teen and one child). All cases resolved completely and
the subjects were able to resume contact lens wear. Overall, both
groups seemed to adequately care for their contact lenses, but the
potential for noncompliance may be further reduced by teaching
parents how to properly care for the contact lenses and encouraging
parental support.
Biomicroscopic signs, such as corneal and conjunctival staining,
increased from baseline to the 1-week and 1-month visits. The prev-
alence typically decreased to or below baseline prevalence by the
3-month visit. This indicates that there is an adaptation period for
contact lens wear, and initial corneal changes should not signify a need
to change contact lens material, solutions, or modality.
The fact that age as a continuous variable was more predictive of
total chair time than categorizing age as “child” vs. “teen” shows
that people may tend to gradually improve dexterity or become less
afraid of touching the eye with age rather than experiencing a
sudden shift in attitude or ability in adolescence. The regression
analyses also showed that eye care practitioners were able to deter-
Optometry and Vision Science, Vol. 84, No. 9, September 2007
901
mine whether it would take longer to work with a particular subject
based on their initial impression of the subject, therefore eye care
practitioners may use their judgment to help determine whether or
not a child should be fitted with contact lenses. Anecdotally, doc-
maturity, hygiene, and aperture size of the child as well as parental
enthusiasm to determine whether or not a child may be easy to fit
with contact lenses.
During the 3-month study, few differences between children
and teens were observed in terms of required chair time or adverse
effects of contact lens wear. However, the children and teens were
participating in a study and received free eye care and materials,
which may result in improved compliance for both groups. When
comparing the results of the two groups though, we can conclude
that eye care practitioners should not use specific criteria based on
age alone to determine whether or not a young person can be fitted
with contact lenses because children and teens physiologically ad-
just to contact lens wear similarly and both are capable of providing
adequate care for contact lenses. Thus, eye care practitioners
should consider fitting children younger than 12 or 13 years with
contact lenses.
ACKNOWLEDGEMENTS
Supported by the Vision Care Institute™, LLC
CLIP Study Group: Ohio State University College of Optometry, Colum-
bus, OH: Jeffrey J. Walline, OD, PhD (Principal Investigator); Monica
Chitkara, OD (Study Optometrist); David A. Berntsen OD, MS (Study
Optometrist); Stacy Long, BS (Study Coordinator).
University of Houston College of Optometry, Houston, TX: Ruth Manny,
OD, PhD (Principal Investigator); Amber Gaume, OD (Co-Investigator
and Study Optometrist); S. Ailene Kim OD (Study Optometrist); Giselle
M. Garza, BS (Study Coordinator).
New England College of Optometry, Boston, MA: Marjorie J. Rah, OD,
PhD (Principal Investigator); Ronald K. Watanabe, OD (Study Optom-
etrist); Nicole B. Quinn, OD (Study Optometrist); Jason R. Chin, OD
(Study Optometrist); Kimberley W. Chan, OD (Study Optometrist);
Paulette Tattersall, Dip Pharm, MSc (Study Coordinator).
Optometry Coordinating Center, Columbus, OH: Lisa A. Jones, PhD
(Director); Loraine T. Sinnott, PhD (Senior Statistician); Linda Barrett
(Data Entry Technician).
Received December 4, 2006; accepted March 22, 2007.
REFERENCES
1. Levin AV, Edmonds SA, Nelson LB, Calhoun JH, Harley RD.
Extended-wear contact lenses for the treatment of pediatric aphakia.
Ophthalmology 1988;95:1107–13.
2. Nelson LB, Cutler SI, Calhoun JH, Wilson TW, Harley RD. Silsoft
extended wear contact lenses in pediatric aphakia. Ophthalmology
1985;92:1529–31.
3. Cutler SI, Nelson LB, Calhoun JH. Extended wear contact lenses in
pediatric aphakia. J Pediatr Ophthalmol Strabismus 1985;22:86–91.
4. Ozbek Z, Durak I, Berk TA. Contact lenses in the correction of
childhood aphakia. CLAOJ 2002;28:28–30.
5. Chia A, Johnson K, Martin F. Use of contact lenses to correct aphakia
in children. Clin Experiment Ophthalmol 2002;30:252–5.
6. Lightman JM, Marshall D Jr. Clinical evaluation of back optic radius
and power determination by age in pediatric aphakia due to congen-
ital cataract fitted with a Silicone Elaster contact lens. Optom Vis Sci
1996;73:22–7.
902 Contact Lens Chair Time for Pre-Teens and Teens—Walline et al.
7. Moore B. The fitting of contact lenses in aphakic infants. J Am
Optom Assoc 1985;56:180, 2–3.
8. Weissman BA. Fitting aphakic children with contact lenses. J Am
Optom Assoc 1983;54:235–7.
9. Shaughnessy MP, Ellis FJ, Jeffery AR, Szczotka L. Rigid gas-
permeable contact lenses are a safe and effective means of treating
refractive abnormalities in the pediatric population. CLAO J 2001;
27:195–201.
10. Jurkus JM. Contact lenses for children. Optom Clin 1996;5:91–104.
11. Joslin CE, McMahon TT, Kaufman LM. The effectiveness of oc-
cluder contact lenses in improving occlusion compliance in patients
that have failed traditional occlusion therapy. Optom Vis Sci 2002;
79:376–80.
12. Burger DS, London R. Soft opaque contact lenses in binocular vision
problems. J Am Optom Assoc 1993;64:176–80.
13. Blum HL, Peters HB, Bettman JW. Vision Screening for Elementary
Schools: The Orinda Study. Berkeley: University of California Press;
1959.
14. Goss DA. Cessation age of childhood myopia progression. Ophthal-
mic Physiol Opt 1987;7:195–7.
15. Walline JJ, Jones LA, Chitkara M, Coffey B, Jackson JM, Manny RE,
Rah MJ, Prinstein MJ, Zadnik K. The Adolescent and Child Health
Initiative to Encourage Vision Empowerment (ACHIEVE) study de-
sign and baseline data. Optom Vis Sci 2006;83:37–45.
16. Walline JJ, Jones LA, Mutti DO, Zadnik K. A randomized trial of the
effects of rigid contact lenses on myopia progression. Arch Ophthal-
mol 2004;122:1760–6.
17. Walline JJ, Long S, Zadnik K. Daily disposable contact lens wear in
myopic children. Optom Vis Sci 2004;81:255–9.
18. Soni PS, Horner DG, Jimenez L, Ross J, Rounds J. Will young
children comply and follow instructions to successfully wear soft con-
tact lenses? CLAOJ 1995;21:86–92.
19. Horner DG, Soni PS, Salmon TO, Swartz TS. Myopia progression in
adolescent wearers of soft contact lenses and spectacles. Optom Vis
Sci 1999;76:474–9.
20. Walline JJ, Jones LA, Mutti DO, Zadnik K. Use of a run-in period to
decrease loss to follow-up in the Contact Lens and Myopia Progres-
sion (CLAMP) study. Control Clin Trials 2003;24:711–8.
Optometry and Vision Science, Vol. 84, No. 9, September 2007
21. Stone J. The possible influence of contact lenses on myopia. Br J
Physiol Opt 1976;31:89–114.
22. Perrigin J, Perrigin D, Quintero S, Grosvenor T. Silicone-acrylate
contact lenses for myopia control: 3-year results. Optom Vis Sci
1990;67:764–9.
23. Khoo CY, Chong J, Rajan U. A 3-year study on the effect of RGP
contact lenses on myopic children. Singapore Med J 1999;40:
230–7.
24. Katz J, Schein OD, Levy B, Cruiscullo T, Saw SM, Rajan U, Chan
TK, Yew Khoo C, Chew SJ. A randomized trial of rigid gas permeable
contact lenses to reduce progression of children’s myopia. Am J Oph-
thalmol 2003;136:82–90.
25. Fan L, Jun J, Jia Q, Wangqing J, Xinjie M, Yi S. Clinical study of
orthokeratology in young myopic adolescents. Int Contact Lens Clin
1999;26:113–6.
26. Walline JJ, Rah MJ, Jones LA. The Children’s Overnight Orthokera-
tology Investigation (COOKI) pilot study. Optom Vis Sci 2004;81:
407–13.
27. Cho P, Cheung SW, Edwards M. The longitudinal orthokeratology
research in children (LORIC) in Hong Kong: a pilot study on refrac-
tive changes and myopic control. Curr Eye Res 2005;30:71–80.
28. Walline JJ, Jones LA, Mutti DO, Zadnik K. Predicting successful
RGP contact lens wearers. Optom Vis Sci 2001;78(Supp.):27.
29. Thibos LN, Wheeler W, Horner D. Power vectors: an application of
Fourier analysis to the description and statistical analysis of refractive
error. Optom Vis Sci 1997;74:367–75.
30. CCLRU Grading Scales. Appendix D In: Phillips AJ, Speedwel. L
Contact Lenses, 4th ed. Boston: Butterworth-Heinemann; 1997:
864–7.
Jeffrey J. Walline
The Ohio State University
College of Optometry
338 West Tenth Avenue
Columbus, OH 43210-1240
e-mail: walline.1@osu.edu