Corneal disorders caused or triggered by contact lens (CL) wear are called CL-related corneal disorders. The severity varies from asymptomatic or mild cases to severe cases leading to corneal ulcers. In recent years, CL use among elementary and junior high school students has increased, and the younger age of patients with CL-related disorders in ophthalmology clinics has become a problem.
The purposes of prescribing CLs in children are diverse.
For amblyopia treatment: Prescribed for aphakia (after congenital cataract surgery), high refractive errors, and high irregular astigmatism. Indicated from early infancy, with parents handling lens insertion and removal.
For refractive correction: Aimed at optical correction of myopia and astigmatism. Considering self-management ability, generally recommended from junior high school age onward.
For myopia progression control: Using multifocal soft CLs or orthokeratology to suppress axial elongation. May be indicated from upper elementary school grades (around 8–10 years old).
Sports and cosmetic purposes: Prescription for convenience during exercise or aesthetic reasons. Conduct after thoroughly evaluating age and management ability.
No clear age criteria have been established by ophthalmology societies, but self-management ability and parental cooperation are prerequisites.
Amblyopia treatment (aphakia): Can be worn from a few weeks after birth. Parents perform insertion and removal.
Myopia progression control (OrthoK, multifocal CL): Consider adaptation from middle to upper elementary school (around 8–10 years old).
General refractive correction: After evaluating self-management ability, the standard is junior high school age or older.
Decorative CL (color CL): Management risks are high, and prescription for children should generally be cautious.
QAt what age can contact lenses be used?
A
For amblyopia treatment (aphakia), they can be used from a few weeks after birth. Orthokeratology and multifocal CL for myopia progression control are considered from middle to upper elementary school (around 8–10 years old), and general refractive correction is standard from junior high school age onward. Self-management ability and parental cooperation are more important than age, and the ophthalmologist makes a comprehensive judgment.
CL-related corneal disorders cause foreign body sensation, discomfort, discharge, conjunctival injection, eye pain, tearing, blurred vision, and decreased visual acuity. Some cases are asymptomatic. In particular, if all three signs—conjunctival injection, discharge, and pain—are present, corneal infection may be developing, requiring caution.
Characteristic staining patterns are observed in corneal disorders caused by CL wear.
Mild pattern
3-9 o’clock staining: Seen in HCL wearers with dry eye or steep-fitting lenses. Epithelial damage at the 3 and 9 o’clock positions of the cornea.
Smile mark pattern: Characteristic of dry eye in SCL wearers. Presents as an arcuate staining pattern in the lower cornea.
Superior epithelial arcuate lesion (SEAL): Arcuate epithelial damage appears in the superior peripheral cornea when wearing rigid SCLs.
Ring-shaped corneal epithelial staining: Seen in cases of incompatibility between silicone hydrogel lenses and care solutions.
Severe Patterns
Corneal infiltrates: Present a continuous spectrum from non-infectious due to mechanical irritation to infectious.
Infectious corneal ulcer: Presents with the triad of hyperemia, discharge, and pain. Caused by Pseudomonas aeruginosa, Acanthamoeba, fungi, etc. A serious condition that can lead to poor visual prognosis.
Giant papillary conjunctivitis (GPC): Giant papillae form on the upper tarsal conjunctiva due to an allergic reaction. Itching and discharge are characteristic.
QWhat symptoms should prompt a child wearing contact lenses to see a doctor?
A
If the triad of redness, discharge, and pain is present, corneal infection is possible; immediately discontinue contact lens use and see an ophthalmologist. If foreign body sensation, blurred vision, or decreased vision persist, early consultation is recommended. Even without symptoms, regular eye exams (every 3–6 months) are important.
Reusable SCLs have been reported to have a 3.84 times higher risk of Acanthamoeba keratitis (AK) compared to daily disposables (OR 3.84; 95% CI 1.75–8.43). 2)
Even with daily disposable lenses, the following factors increase risk. 2)
Risk factor
Odds ratio (OR)
Lack of regular check-ups
10.12
Reuse of daily disposable lenses
5.41
Overnight wear
3.93
Showering while wearing lenses
3.29
It is estimated that 30–62% of AK cases could be prevented by switching from reusable lenses to daily disposables (PAR% estimate).2)
In aphakia (after congenital cataract surgery), silicone hydrogel SCL or HCL is selected. HCL is suitable for high irregular astigmatism. Prescription is possible from early infancy, and parents perform lens insertion and removal. Appropriate CL wear aims to improve visual acuity in amblyopia.
Daily disposable SCL is recommended as the first choice. For high astigmatism, toric SCL or HCL is selected. Compliance with wearing time and regular follow-up are important.
Multifocal contact lenses with peripheral defocus control design have been confirmed to have significant myopia progression control effects in all 12 RCTs and comparative studies (11 of which are Level I). 1)
The 3-year RCT of MiSight 1 day (+2.00D add dual focus) (Chamberlain 2019) yielded the following results. 1)
Refractive progression: treatment group −0.51±0.64D, control group −1.24±0.61D (P<0.0001)
Axial elongation: treatment group +0.30±0.27mm, control group +0.62±0.30mm (P<0.0001)
Inhibition effects of 59% for refractive progression and 52% for axial elongation
No serious adverse events have been reported across the 12 clinical trials. 1) Data on optimal wearing period, long-term prognosis, and rebound after discontinuation are currently limited. 1)
A method in which a special rigid lens is worn during sleep to temporarily flatten the central cornea. It allows clear vision during the day without glasses or contact lenses, making it suitable for active children. It has been reported to suppress axial elongation by 32–59% over two years. 3)
In a Japanese multicenter study (1,438 patients), the incidence of microbial keratitis (MK) was 5.4 per 10,000 patient-years. 3) Because the lenses are worn overnight, special attention must be paid to the risk of corneal infection, and regular monitoring of corneal curvature and refractive changes is essential.
B. Treatment of Contact Lens-Related Corneal Disorders
Immediate discontinuation of contact lens wear: This is the most important initial step. If the cause is removed, non-infectious corneal disorders generally have a good prognosis.
Infectious keratitis: Start broad-spectrum antibiotic eye drops and adjust based on culture results. For Pseudomonas aeruginosa, use fluoroquinolones.
Acanthamoeba keratitis: Long-term use of polyhexamethylene biguanide (PHMB) and propamidine eye drops. Treatment is difficult and prognosis tends to be poor.
Non-infectious corneal epithelial disorders: Use anti-inflammatory eye drops (cautious use of steroids), artificial tears, and hyaluronic acid eye drops.
Dry eye-related: Provide lubrication with artificial tears and hyaluronic acid eye drops.
Daily disposable CLs are the most hygienic and recommended. They require no care and minimize hygiene management risks.
Provide thorough guidance to guardians (correct use of cleaning and storage solutions).
Ensure regular check-ups every 3–6 months. Continue periodic visits even if asymptomatic.
Set rules for use during school and extracurricular activities (e.g., removal for swimming).
Educate strictly against prolonged wear and continuing use despite eye pain.
Instruct to avoid bathing, swimming, or showering while wearing lenses.
QCan multifocal contact lenses really slow myopia progression in children?
A
Supported by Level I evidence. In a 3-year RCT of MiSight 1 day, refractive progression was suppressed by 59% and axial elongation by 52%. 1) All 12 clinical trials confirmed significant suppression effects, with no reports of serious adverse events. 1) However, data on optimal wearing duration and rebound after discontinuation are limited, and ongoing ophthalmological management is necessary.
QWhich is safer: daily disposable CLs or 2-week replacement CLs?
A
Daily disposable CLs are the safest in terms of hygiene. Compared to reusable SCLs, the risk of Acanthamoeba keratitis is reduced to about one-fourth (OR 3.84).2) They require no care and minimize hygiene management risks in children, so they are recommended as the first choice.
Corneal disorders caused by CL wear arise through four main mechanisms.
1. Mechanical irritation
Direct contact between the CL and the corneal epithelium causes epithelial cell shedding and erosion. Improper fitting (too steep or too flat) increases mechanical irritation. This leads to characteristic staining patterns such as 3-9 o’clock staining and SEAL.
2. Hypoxia
The CL on the cornea restricts oxygen supply to the cornea. Hypoxia is particularly pronounced with prolonged wear or overnight wear of non-silicone SCLs. Hypoxia causes corneal edema, endothelial cell loss, and corneal neovascularization (pannus formation). Silicone hydrogel lenses reduce hypoxia risk due to high oxygen permeability (high Dk/t value).
3. Infection
Infectious keratitis develops when pathogens invade through microdefects in the corneal epithelium.
Pseudomonas aeruginosa: The most common causative organism of CL-related infectious keratitis. It forms rapidly progressing ulcers.
Acanthamoeba: A protozoan found in tap water, pool water, etc. Risk increases with reuse of soft contact lenses or water exposure. Characterized by severe pain and ring-shaped infiltration.
Fungi: Relatively rare but difficult to treat.
4. Allergic reaction
Allergic reactions to lens materials, care solutions, or deposits cause giant papillae on the upper tarsal conjunctiva (giant papillary conjunctivitis: GPC). Papillae on the upper eyelid with a diameter of 0.3 mm or more are defined as papillae.
Mechanism of myopia progression suppression with multifocal contact lenses
With single vision lenses, the image focuses on the retina in the center, but shifts behind the retina in the periphery (peripheral hyperopic defocus). This is thought to signal axial elongation, leading to myopia progression. 1)
Multifocal contact lenses reduce or eliminate peripheral hyperopic defocus by adding power in the periphery. 1)
Dual-focus design (e.g., MiSight): Central correction zone + concentric treatment zone (plus power). Focuses peripheral light in front of the retina, suppressing axial elongation signals.
Extended depth of focus (EDOF) design (e.g., MYLO): The entire lens has variable refractive power, providing more continuous defocus control. A 2-year RCT significantly suppressed axial elongation (SE: treatment group −0.62D vs control group −1.12D; AL: treatment group 0.37mm vs control group 0.67mm; P<0.001). 3)
The pediatric cornea is highly elastic, and adaptation to contact lens wear tends to be faster than in adults. However, if there is a habit of eye rubbing, repeated mechanical stimulation of the corneal epithelium poses a risk of keratoconus progression. It is important to instruct patients not to rub their eyes while wearing contact lenses.
Data on the optimal wearing period for multifocal CLs are currently limited. 1) Long-term follow-up data beyond 3 years and verification of myopia progression rebound after discontinuation of multifocal CLs are future challenges. 1)
Comparative studies of various optical designs, including extended depth of focus (EDOF) designs (e.g., MYLO), are ongoing. 3) Development of next-generation CLs aiming for more effective defocus control, such as power gradient designs and high-add multifocal designs, continues.
No serious adverse events have been reported in 12 multifocal CL clinical trials. 1) Regarding the long-term incidence of microbial keratitis in orthokeratology, further large-scale prospective studies are needed.
Cavuoto KM, Trivedi RH, Prakalapakorn SG, Oatts JT, Nallasamy S, Morrison DG, Pineles SL, Chang MY. Multifocal Soft Contact Lenses for the Treatment of Myopia Progression in Children: A Report by the American Academy of Ophthalmology. Ophthalmology. 2025;132(4):495-503. doi:10.1016/j.ophtha.2024.09.031. PMID:39503665; PMCID:PMC11930616.
Carnt N, Minassian DC, Dart JKG. Acanthamoeba Keratitis Risk Factors for Daily Wear Contact Lens Users: A Case-Control Study. Ophthalmology. 2023;130(1):48-55. doi:10.1016/j.ophtha.2022.08.002. PMID:35952937.
Yam JC, Zhang XJ, Zaabaar E, Wang Y, Gao Y, Zhang Y, et al. Interventions to reduce incidence and progression of myopia in children and adults. Progress in retinal and eye research. 2025;109:101410. doi:10.1016/j.preteyeres.2025.101410. PMID:41109517.
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