Some students and OD’s would rather avoid pediatrics. Some of us love it so much that we’ve chosen to specialize in it! While the majority of people fall in the middle, children pose their own specific challenges. They may not be the cooperative, attentive adult with great responses you’re used to. In children, we often spend more time in the prelim and BV section and are less concerned about pathology as a whole. If you’re used to relying on your manifest to prescribe or are uncomfortable examining children (or patients who are nonverbal/have special needs), objective testing is your best friend!
This is a skill that we do on every patient to practice and often see it as a formality, thinking, “Why can’t I use their last chart Rx to start?” or, “I’ll just read their glasses/autorefract them.” Getting really good (and fast!) at retinoscopy on your cooperative patients sets you up to be better when you have a wiggly four year old in the chair. Young kids don’t understand refraction in general and even getting acuity can be a challenge. Often for kids younger than 6-7, I trial frame +1.50 or +2.00 (your working distance and an appropriate fog for the child) and use ret racks or loose lenses if the kid is especially grabby. Then there’s no need to do math to get the Rx – the gross is the net due to the appropriate plus in the frame. Check your work by putting your net in the trial frame *remove the fog!* and check VA as best you can.
Cover test is our go-to for assessing binocularity, tropes and phorias without the patient responding. However, it does require fixation. This can be difficult in some cases, so grab a friend or the parent if needed. A 4-year old is not going to find an isolated 20/40 letter interesting enough to focus on for distance cover test, but if mom stands in front of the mirror making silly faces or waving a toy, they should look in the appropriate spot. For near, put 2 stickers on each side of a fixation stick and flip it constantly, asking which character they see to ensure they’re still fixating. If CT fails, try the Hirschberg test. Using a transilluminator, aim the light at the nose and assess the corneal reflex (0.5 mm nasal OU is “normal”). Every mm of deviation is equivalent to about 22 prism diopters. Use your hand or thumb to cover test quickly while keeping the light steady and look for re-fixation to assess for large scale phorias. A gross assessment is better than no assessment.
For a grown patient with a potential vergence problem, doing smooth vergence is the norm. Using step vergences and a prism bar can be extremely useful on children, since you can see objectively when the patient’s eyes lose fusion (break) and they can subjectively tell you if they understand well. Keep in mind that this can also be used on an adult patient who isn’t
responding well. Fixation is also important here, so keep the attention of your patient.
NPC is a relatively quick and dirty way to check the vergence system of a child (or any patient in general). Many kids will be TTN or very close. Keeping their attention on the near target (stickers, sparkly pen caps, etc) of an appropriate size, “swing” the stick towards them and make sure they follow it-not unlike the way moms get babies to eat-”look at the plane! It’s going to touch your forehead!” If you find a receded NPC on a child with this method, repeat for precision. If still receded, place the patient in Red/Green glasses and use a transilluminator (non-accommodative target). If this test is WORSE than the original, suspect Convergence Insufficiency – more common than it seems, and a common reason kids will avoid reading.
Talking to the kids at the beginning of the exam and finding out what they like to do/watch/play with can help you out later. Use toys/lights/glow sticks etc. to keep them fixated on a certain point. During BIO, enlist a friend to hold a light or a toy in the quadrant you need them to look at, especially if you need both hands. If they can read letters or Lea, keep them reading as you do your testing (if appropriate). Make up stories about the letters or Lea symbols to keep your patient engaged and not just reading letters. It keeps them more interested and cooperative. Know when to give the child a break. Screaming, wiggling children may need to come back to finish their exam another day if they have been there for a few hours and are overly tired.
Most practitioners recommend using a cycloplegic agent to freeze accommodation of the child for later retinoscopy and/or refraction. This can reveal latent hyperopia and astigmatism. Trust your retinoscopy. If you’re getting more plus, it makes sense. The difference in timing between drops is the crucial point. When using tropicamide, this is what’s known as “wet ret.” The ret and refraction need to be completed within the 20-30 minute window post dilation, since the patient regains accommodation slowly after 30 minutes. Their pupils may stay enlarged much longer (4-8 hrs depending on iris color). Cyclopentolate requires you to WAIT at least 30+ minutes before doing ret, otherwise they will still accommodate through the drop. Make sure you chart correctly what kind of dilated ret you’re doing and time it appropriately to get the maximal effect. Cyclo has a longer effect (up to 24h), so educate before you drop. Deciding whether to prescribe the extra plus often found is the “art of prescribing” that will come in due time and is done case-by-case.
This may be the most difficult test, and yet probably the most important. How do you tell how well your patient can see if they have no ability to tell you? With verbal but preliterate children, Lea is the way to go. In the case of very small, nonverbal children, we often use Preferential Looking if we can. If Cardiff cards (image) are available, we place them in front of the child, doing our best to occlude (to get OD/OS/OU). Each card has an image with gradually smaller gratings, and the image is “more interesting” than the side of the card which is solid gray. If the child CAN see it, they will “preferentially look” at the image. We can get down to 20/20 using these. If this is not available or not working, try an OKN drum to see if they can follow it, or try a Fix and Follow using a light or toy. Any information about acuity is helpful when children are very small.
Getting drops into kids’ eyes can be very anxiety inducing for students. Even older kids or teenagers may have never been dilated and get nervous. When using proparacaine, mention the fact that “it’s a tingling drop” and “it will make your eyelids feel heavy.” If your 11-year old gets past that, the dilation drops won’t burn and they should be okay. For younger kids who aren’t having it at all, grab your attending or a friend and a bottle of tropicamide each. Lay the kid down and tell them that Spiderman/Spongebob/Ariel is on the ceiling to get them to look up…and drop simultaneously. If your kid is going to cry, they are going to cry whether you use proparacaine first or tropicamide/cyclo first. It’s better to get the big guns in first even though it’s going to sting. You can then say “I’ll wash it out!” and get some phenyl in there. Reward them then with mom, toy, etc. If you have a very young toddler or infant and there is no way you’re going to get drops into a tiny aperture, most clinics have a spray mixture of cyclo/trop/phenyl that will spread over the eye as the child blinks to ensure dilation. After the drop drama is over, they get a break for a while, which they generally appreciate. Even post-dilation, DFE on a normal child is usually quick and unremarkable.
Keep in mind that very small children may not be able to sit behind a slit lamp. However, you still need to examine their eyes’ health (ant and post seg). The Direct Scope can be used to examine the anterior segment of the eye on children. Simply dial UP the plus since the focal point you need to see is closer to you, requiring more convergence from the lenses of the scope. This is also useful when the child is dilated after BIO when you need to increase the magnification. Assessing a C:D is nearly impossible with BIO, but if you can’t get a 2 year old in a slit lamp for a 90/78 exam, you need an alternative. Practice with your Direct, and if you can get your hands on a Panoptic, TRY IT. If you plan on working with children, it’s worth it’s weight in gold.
This is a truth among all arms of medicine and true for optometry as well. This is why we spend more time on refraction/ret (looking for hyperopia they may be accommodating through) and BV testing (looking for tropias and high phorias which may cause a tropia or amblyopia later). Adults that are asymptomatic may have minimal testing in BV, but may have more pathology such as MGD or diabetic complications that are unlikely to manifest in a preschooler. The pediatric exam is more targeted to binocular function and helping them develop lifelong visual teaming skills. If properly examined and corrected, we will help them in school, instill confidence, and create lifelong learning skills.
Have any tips or tricks that you use while examining a child or infant? Please share in the comments below!
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