Pediatric patients present a special challenge, but they also present an opportunity to impact a life at an age where small improvements can yield huge benefits over a lifetime. With the right methods, pediatric exams can be enjoyable and effective.
Here are five pearls for conducting exams that I’ve learned from various mentors and refined through experience.
1. Mind the clock. Using the exam prioritization discussed last time, perform Must exam elements first, from least invasive to most invasive. Next, move-on to Intend elements, again, from least invasive to most invasive. Finish with Like elements. When you can’t obtain an exam element, document the exam attempt.
If the patient decompensates such that you can’t obtain a Must exam element, complete the exam on another day. Most parents are keenly aware when their child is “done” and appreciate sensitivity to this inconvenient reality. Parents are generally happy to pre-dilate their child at home prior to the follow-up exam, if given a prescription for atropine and instructions.
2. Dilate carefully. Aaron Miller, MD, discussed some of this in his prior articles for YO Info, but it bears repeating.
- It is critical to achieve full cycloplegia for refraction in any child with strabismus, amblyopia, headache or reading problems. This requires a combination of cyclopentolate 1% or 2% plus 25–30 minutes.
- Concentrated or compounded drops can aid in both mydriasis and patient comfort. There are numerous formulations of dilating drops for children. This has been effective in my practice: 6 parts cyclopentolate 2% + 3 parts tropicamide 1% + 2 parts phenylephrine 10% (check with your institution about regulations for mixing drops).
- The concentrated or compounded dilating drop generally is preceeded by a topical anesthetic.
- Administer concentrated drops via a small atomizer or spray bottle, which can be purchased from cosmetic companies. Although this wastes a bit of the medicine, it is faster, sprays against gravity and is easier to control than a bottle.
- Do not dilate the patient yourself; ask an assistant or another resident to dilate the patient.
- Avoid being present in the exam room when eyedrops are administered. It will be easier to do a Fundus exam and refraction when the child does not associate you with the trauma of the eyedrops.
- Don’t rush. Even if the patient’s eyes appear well-dilated 15 minutes after administration of drops, the cycloplegia may not yet be complete.
3. Train the patient. Establish a precedent whereby the patient follows your commands. Intermingle exam components with nonsense tasks, like “pat your belly.” Once the patient is used to following your instructions, most will consent to the exam automatically. For example:
- Ask patient to count something across the room (“count the bricks on that wall”). Congratulate his/her ability to count. Reward the child with a sticker or other small prize, if needed. Redirect patient back to exam.
- Use promise of small prizes to train compliance.
- “Clean” the child’s eyes with a tissue (gently touch tissue to closed eyes). Give the tissue to the patient. Tell the child to throw it away. Congratulate on what a great job he/she did throwing it away. Redirect back to exam.
- “Throw it away” is also helpful to distract other children in the room.
4. Take a selfie for patching compliance. Even vigilant parents can get confused about patching instructions. Too often, parents patch the wrong eye, remove glasses during patching, or patch for the incorrect amount of time.
I routinely ask parents to take a picture of the patient, with proper eye patched, glasses on, showing two fingers (for two hours of patching). This helps the parents remember which eye to patch, for how long and to keep the glasses on while patching. I also distribute paper instructions to parents, but the picture seems to be more effective.
5. Be prepared for pseudostrabismus doubters. Pseudostrabismus cases should be one of the easiest pediatric encounters of your career, but about 10 percent of parents feel suspicion instead of relief when told their child’s eyes are straight. Parents who feel the strabismus is obvious reject the notion of pseudostrabismus.
When this happens, I have tried numerous techniques to enhance their perception of the visit. Rarely have I reversed a parent’s suspicion with a long explanation, fancy photographs or a lesson with the direct ophthalmoscope. Some parents seem to arrive predisposed to mistrust you. Save your time; try the following:
- Reassure parents that you take their concerns seriously.
- Congratulate parents on how well their child performed during the exam.
- Repeat the exam in three months.
- Ask the parents to bring representative photos to the follow-up visit.
- Promise to review the photos with the parents during the follow-up visit.
- Follow through with aforementioned promise.
- Distribute patient information from the Academy's EyeSmart® program.
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For further reading, I recommend Dr. Miller’s excellent pediatric ophthalmology pearls.