Pediatric Prostheses and Contact Lenses: Balancing Function and Aesthetics

At the recently held 5th World Congress of Paediatric Ophthalmology & Strabismus (WCPOS V 2024) in Kuala Lumpur, Malaysia, experts from around the globe shared the latest breakthroughs in pediatric ocular prostheses and contact lenses, emphasizing the intricate balance between medical efficacy and patient comfort. 

From Dr. Tarjani Dave’s (India) innovative approaches to ocular prosthetics, which blend cutting-edge techniques with cosmetic finesse, to Mr. Vimal Mehra’s (India) insights into custom-made anophthalmic prostheses, the focus was clearly on personalized solutions that enhance both appearance and quality of life. 

The discussions extended to Dr. Devakani Suresh Kumar’s (UAE) detailed exploration of contact lens fitting for complex corneal conditions and Dr. Matjaž Mihelčič’s (Slovenia) work on managing nystagmus with rigid gas-permeable (RGP) lenses. Concluding the symposium, Dr. Neha Prashant (India) emphasized the vital role of empathetic communication with young patients, reminding us that successful treatment goes hand in hand with compassionate care.

Prosthetic aesthetics

Dr. Tarjani Dave’s lecture on the aesthetics of ocular and orbital prosthetics delved  into implant complications and cosmetic solutions. She highlighted her innovative techniques and treatments that ensure not just functional, but aesthetically pleasing outcomes for her young patients.

Unfortunately, implant complications do happen with prosthetics for the eye, including early and delayed implant exposures. “If exposure is seen in the initial post-op period, it’s largely an infection or tension on the wound,” she noted. For delayed exposures, which can occur years after surgery, Dr. Dave attributed these to a T cell-mediated immune response. “You will have to treat the patient by removing and replacing the implant.”

Dr. Dave also touched on the issue of implant migration, which has become more noticeable with the introduction of the sclera petals method. “Between the ‘sclera petals,’ the implant can move and migrate outside the intraconal space,” she explained. The solution isn’t simply replacing the implant, as it will likely migrate again. Instead, Dr. Dave recommends placing a second, customized implant to block the quadrant of migration.¹

One particularly interesting topic was the management of peri-implant cysts, which often present as proptosis of the prosthetic eye. Dr. Dave stressed the importance of ruling out intraocular tumors before treatment. If it isn’t due a tumor, she suggested simple aspiration followed by sclerotherapy.² 

Addressing post-enucleation socket syndrome, Dr. Dave described various volume correction techniques, such as secondary implants, dermis fat grafts and filler injections, along with lower eyelid tightening and ptosis correction. 

Anophthalmic prostheses

Continuing with the theme of aesthetic and functional solutions, Mr. Vimal Mehra, Director of Mehra’s Ocular Prosthetics (Thane, India), shed light on managing anophthalmic sockets in pediatric patients. 

One of the primary solutions is the creation of a custom prosthesis. These are meticulously crafted to match the patient’s other eye, providing both aesthetic and functional benefits. 

Another approach involves the use of serial, custom-made conformers, which expand progressively larger to maintain the socket’s shape and apply gentle pressure to help the orbit expand, promoting appropriate facial growth. 

Mr. Mehra concluded with a message on the importance of early intervention. “Management of congenital anophthalmos should be initiated as soon as possible after birth,” he said. “The first few years of life is a critical time period for potential growth of the orbit, and the absence of the globe can negatively affect this development.”

Corneal contact lenses

The importance of custom solutions was echoed in the lecture by Dr. Devakani Suresh Kumar (UAE), who gave a detailed exploration of contact lens fitting post-penetrating keratoplasty (PKP) and for managing pediatric keratoconus. 

Dr. Kumar began by emphasizing the importance of allowing the cornea to fully heal and stabilize before considering contact lens fitting. “Ensure that all sutures are removed if applicable, as they can affect the corneal shape,” she advised.

A thorough assessment of the patient’s visual acuity is essential, alongside corneal topography to map surface irregularities and measure curvature. Dr. Kumar highlighted the need to document any new haze or scarring, as well as the stromal condition, including scarring, haze, edema or signs of rejection.

“Checking for endothelial cell health is important,” she noted. Monitoring for keratic precipitates and corneal vascularization is also key to assessing the risk of rejection.

When it comes to choosing the right contact lens post-PKP, corneal topography plays a pivotal role. Dr. Kumar shared her recommendations for various lens designs based on specific corneal conditions:

• Traditional RGP lenses for normal topography and high-risk transplants with low endothelial cell counts.
• Large diameter, reverse geometry designs for flat central topography.
• Larger diameter lenses (10-12 mm) with a back optic zone diameter (8.50-9.00 mm) for proud graft topography.
• Reverse geometry lenses for oblate or plateau grafts and steepened corneas peripheral to the graft-host junction.
• Custom soft contact lenses, both spherical and toric, for tilted grafts.
• Soft lenses for those intolerant to other lens types.
• Scleral and hybrid lenses for almost all corneas.

“Large diameter RGPs are the best options for PKPs,” Dr. Kumar emphasized, noting that rigid corneal lenses are also suitable for early keratoconus, as children can often manage these lenses on their own. She pointed out that scleral lenses require more care, making rigid corneal lenses a better choice for most children.

Dr. Kumar then turned to contact lenses for pediatric keratoconus management: 

• Glasses or contact lenses for those with a normal corneal shape. 
• GP lens optics for an irregular corneal shape.
• Smaller diameter GP lenses for mild-to-moderate irregularities. 
• Larger diameter GP lenses, such as scleral designs, for significant irregularities. 
• Cross-linking can halt the progression of early stage keratoconus. 
• Hybrid, piggyback or scleral lenses for moderate stage keratoconus, with impression scleral lenses reserved for rare cases.
• Severe stages may necessitate a corneal transplant.

“High DK GP lenses are always recommended,” she concluded, highlighting their importance in providing adequate oxygen permeability for healthy corneal function.

Silencing nystagmus

Transitioning from corneal health to motion disorders, Dr. Matjaž Mihelčič, CEO of INOVA Vision Lab (Radovljica, Slovenia), delivered his talk on the use of RGP contact lenses for silencing nystagmus in children. 

He discussed the ideal candidates for RGP lenses, highlighting children with high ametropia, high astigmatism and irregular corneas. For nystagmus specifically, Dr. Mihelčič recommended RGP lenses for those with small amplitude and higher frequency nystagmus.

However, not all children are suitable candidates for RGP lenses, including “those that have [large angle] squints because of the centering of the lens, and those who have adopted extreme low point positions of gaze or postures.” He did not advise RGP lenses for children with larger visual field defects or deep amblyopia.

Dr. Mihelčič explained how RGP lenses help manage nystagmus through several mechanisms: haptic biofeedback, optical image stabilization and optical zone diameter alignment. 

Connecting with young eyes

Effective treatment involves not only technical expertise but also strong communication skills, as highlighted by Dr. Neha Prashant. She suggested creating a comfortable, engaging and empathetic environment for children and recommended toys and playing music to make the clinical setting less intimidating.

Involving children in age-appropriate decisions can significantly boost their autonomy and confidence. This approach fosters a strong emotional connection when combined with empathizing with the child’s emotions, asking open-ended questions and reflecting on their responses. 

Dr. Prashant also stressed the importance of customizing the approach to each patient. Paying attention to nonverbal cues such as eye contact, body language and facial expressions can provide insight into a child’s emotions and comfort level. 

References

1. Dave TV, Tiple S, Vempati S, et al. Low-cost three-dimensional printed orbital template-assisted patient-specific implants for the correction of spherical orbital implant migration. Indian J Ophthalmol. 2018;66(11):1600-1607.
2. Dave T, Taneja S, Tiple S, et al. Conjunctival retention cysts: Outcomes of aspiration and sclerotherapy with sodium tetradecyl sulfate. Ophthalmic Plast Reconstr Surg. 2019;35(2):165-169.

Editor’s Note: Reporting for this article occurred at the 5th World Congress of Paediatric Ophthalmology & Strabismus (WCPOS V 2024) from 11-13 July in Kuala Lumpur, Malaysia.