History and Examination: General Considerations and Strategies
For the pediatric history, it is important to obtain information about the pregnancy and neonatal period, with attention to maternal health and the patient’s weight and gestational age at birth. The practitioner should ask whether the child has reached applicable developmental milestones, whether there are any neurologic problems, and whether there is a family history of strabismus or other childhood eye disorders.
The examination begins as the practitioner enters the room. An experienced practitioner may gather important information before formal examination begins. Visual behavior, abnormal head position, dysmorphic features, ability to ambulate, familial disorders (note parents and siblings), and family social dynamics can be effectively observed. A parent’s smartphone may contain photos and videos that prove useful in establishing a diagnosis and a condition’s progression over time.
Figure 1-1 Small toys, pictures, and eye charts are used as accommodative near fixation targets.
(Courtesy of Robert W. Hered, MD.)
The practitioner should sit at the child’s eye level; note that some children are more contented sitting in a parent’s lap. Introducing oneself to the child and family and establishing and maintaining eye contact with the child are important. Being relaxed, open, and playful during the examination helps create a “safe” environment. Gaining the child’s confidence can lead to a faster and better examination, easier follow-up visits, and greater parental support.
It is helpful to first address a young child with easy questions. For example, children enjoy being regarded as “big” and correcting adults when they are wrong. The practitioner can tell a child, “You look so grown up,” before grossly overestimating the patient’s age or grade level and asking, “Is that right?” A simple joke can relax both child and parent.
Because cooperation may be fleeting, the examination elements that are most critical for diagnosis and management should be addressed early. If binocular fusion is in doubt, it should be checked first, before being disrupted by other tests, including those for visual acuity. When possible, the most threatening parts of the examination should be performed last.
A different vocabulary should be developed for working with children, such as “I want to show you something special” instead of “I need to examine you.” Use “magic sunglasses” for the stereo glasses, “special flashlight” for the retinoscope, “funny hat” for the indirect ophthalmoscope, and “magnifying glass” for the indirect lens.
While checking vision, the practitioner can make the child feel successful by initially presenting objects that can be readily discerned and then saying, “That’s too easy—let’s try this one.” Confrontation visual field testing can be performed as a counting-fingers game. Children might be coaxed into a slit-lamp examination if told they can “drive the motorcycle” by grabbing the handles of the slit lamp. Pushing the “magic button” on the child’s nose while a distance fixation target is surreptitiously activated distracts and disarms the patient and allows for a more deliberate examination.
For examination of a difficult child, some combination of rest periods, persuasion, persistence, and rewards is usually successful. If a child is having a bad day, however, it is sometimes best to stop the examination and schedule another appointment. For the follow-up examination of an infant who was fussy during the first visit, ask the parent or other caregiver to bring the infant in hungry and then feed him or her during the examination. In infants and younger children, brief restraint may prevail. However, the practitioner must consider the physical and emotional consequences of restraining a child. Depending on the nature of the ocular problem, a sedated examination or an examination under anesthesia may be a better solution.
Excerpted from BCSC 2020-2021 series: Section 10 - Glaucoma. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.