Exam
After the history, the patient can sit on the examination chair on the mother's lap. This makes the examination much more comfortable and less demanding for your little patient. It is helpful to get to your patient's eye level, which sometimes requires raising the patient's chair. Sometimes you won't get an accurate visual acuity (VA) or an accurate intraocular pressure (IOP), but you can get an accurate measurement.
Another good rule of thumb is to avoid trying to perform a particular test for more than two minutes, as the patient will get frustrated and so will you. For example, if you want IOP and can't get a reading after two minutes, move on to the next test.
Be flexible. If the patient is more comfortable out of the examination chair and on the side rail, move towards her and get on her level. Yes, even if it means getting down on your knees with tools at your side.
Once the child is ready to be examined, proceed to a gross assessment of the eyes and vision. If the child is less than 2 years old, I check visual acuity with fixation and follow. I cover one eye with my thumb and move the toy in front of him, then switch and cover the other eye. Is there resistance to the occlusion of one eye? Are there eye rolls or head tilts? Any of these should be recorded and the vision recorded as "fix and follow" or "fix, don't follow".
I move to the cover test, using the same toy and just my hand. The occluder is too distracting - the child is likely to grab the paddle. I have lots of light-up toys to get their attention (pictures 1 and 2). With a small toy in hand, I check the extraocular muscles and near-point convergence and let the child hold the toy on their own. While looking down at the toy, a quick IOP check can be done using palpitation.
The cover test sometimes doesn't work with young children, so I try the Hirschberg method. To do this, I place the Maddox rod in front of the patient, with the pen behind the rod. I drag the pencil over Maddox's rod to make an interesting sound to alert the red light. I assess the patient's corneal red reflex to estimate strabismus. This works very well for those small patients with epicanthal folds who have pseudostrabismus.
If the child in your chair is verbal and older than 3 years, consider trying to get a more accurate vision record. I use eye tape to close one eye. I took ordinary eye patches and drew simple designs on the patches for the patient to choose the "sticker" she wanted to place on her eye. I prefer the HOTV pairing for my choice test (Figure 3). I also use a covered eye to get fields of view. When the patient is too young to do or understand finger counting, I use a visual field toy and judge whether the field is present by the patient's eye movements. After I'm done, I remove the patch and place it on the patient's shirt as a reward.
A patient 4 years of age or older can move to the Snellen chart. I start simple for younger patients and introduce the letters one at a time. A full Snellen chart can be presented at age 6 or older. These are general guidelines and there will be exceptions to all of these rules, especially if there are development delays. You will need to assess the patient's response time and communication ability to judge which visual acuity test will provide the highest accuracy.
Check IOP for palpitations in patients younger than 3 years; I use the Icare tonometer for patients older than three years.
Finally, I evaluate the students. If the patient is over 4 years old, I will start the eye exam with stereopsis and color vision testing. These tests are not performed on younger patients due to difficulties in understanding the test.
Every child under 10 needs a cycloplegic refraction. Little ones are not fans of eye drops and sometimes even parents need to educate them on the process, but dilation is a must. Pediatric patients usually adapt very well, and this can throw off your refraction. The only way for these small patients to achieve accurate refractive correction is to cycloplegia these eyes to control large accommodative amplitudes.
Don't be afraid of this step and try to avoid it. For better dilation, ask the parent to hold the baby on the lap and wrap the patient around in a bear hug to hold the patient's arms down. This allows you to place in the eye drops with less resistance. Ask the patient to look superior - it is helpful for these children to have a target to focus on. On the ceiling above my exam chair are bright, friendly pictures of cartoon characters that I tell patients to look at to help with the drips.
Even a child who kicks and cries when you apply the drops will be fine and forgive you five minutes later. The patient must wait at least 30 minutes after the drops before the eye examination can be continued. At least that's how long it takes for the patient's ciliary body to fully relax. Allow the patient to rest after the stress of the eye drops. They can watch TV, play puzzles or take a break on the toilet.
After eye dilation, retinoscopy is performed outside the phoropter using a retinoscopy stand (Figure 4). A film can be shown to the patient at a distance while the refraction is being performed. Or I sing a tune or whistle for younger patients to get their attention. Externals are assessed using a pencil light or even binocular indirect ophthalmoscopy (BIO) if the patient is younger than 3 years old and cannot fit into a slit lamp.
Finally, the examination of the dilated fundus is performed with a 20 D and BIO lens. Again using my light up toys as a target for a patient gaze I take a quick look at the guts
In optical
Your optic should include smaller kid frames in kid-friendly colors on your frame plate. Be sure to include a few options in blue and a few options in pink, because in my experience kids choose those colors.
If your office doesn't have an optician or your clinic is too small to comfortably accommodate a wide selection of children's frames, refer your younger patients to pediatrician-friendly pediatric optician colleagues.
If you live in Milton and searching for a good place for pediatric examinations, please visit Milton optometry.
Advantages of pediatric examinations
I find that bringing more kids into my schedule makes my day go by faster and brings more excitement to my chair.
With a successful eye examination of a small patient, you can then add siblings and parents to the patient list and perform eye examinations for the whole family. Be sure to let your community know that you can perform eye exams on infants, toddlers, and any family member. When you are with your patient, ask the accompanying adult if any family members or children also need an eye exam.
A pediatric exam will definitely keep you on your toes because you never know what a little patient might do or say. Completing a thorough exam is important, but so is creating a positive experience through the child's eyes.
No comments yet