• Clinical Pearls for Pediatric Ophthalmology

    Whether you are currently in your residency or in the early years of practice, providing children’s eye care requires a unique approach. Many ophthalmologists fear the child on their schedule due to the additional time required and complexities that comes with this examination. However, with the right approach and charm, caring for children can be a very rewarding and fun experience.

    Listed below are eight pearls for performing a pediatric eye examination that should help you obtain the results you desire — not to mention a happy child leaving your office.

    1. First impressions mean everything. Prior to entering the exam room, take a moment to mentally shift gears from adult to pediatric eye care. I make an effort to not wear a white coat into the examination room to disassociate myself from the child’s pediatrician or family practice office experience, which typically involves shots. Try to smile at the child and exude a warm atmosphere. If old enough, I try to shake the child’s hand or give them a “high five.” I make a point to notice and comment to the child on their outfits, shoes, or whatever seems to be an interest to them. This helps “break the ice” and encourages better interaction with you during the examination process.
    2. Strategically position yourself in the room. Make yourself viewable to both the child and parent. When obtaining the history from the family, I always try to sit at the level of the child and sit in an area of the room where both the child and their parent can see my face at the same time. This frequently requires raising the child’s examination chair, which in my office is magically transformed into a “rocket ship seat” for the child. While obtaining information from the parent, you can easily begin a peripheral examination with attention to eye alignment, head positioning and other facial features.
    3. Obtain a good history from the family. Children sometimes have a difficult time explaining their problems and, frequently, are entirely unaware of the purpose of the visit. Plus, they have a short attention span and the most critical components to your examination should be obtained first. Therefore, the order of your examination of a child will frequently change based on the history provided.
    4. Games, toys and fun. At the beginning of my examination process, I make a point to explain to the child that we are going to play some “games” that will help me better understand their eyes. Children love having fun with games and looking at flashing or colorful toys. My favorites are spin toys, flashing ducks, and small stickers. I typically start the examination by testing for stereo acuity — this is a fun test for a child that also provides an enormous amount of information with regard to their visual acuity.
    5. Patch the eyes when testing for visual acuity. On the first visit, I nearly always use an adhesive patch to check visual acuity. Simply putting a tissue or hand over one eye is not recommended. Children want to please their parents and the doctor, and they will innocently cheat on the eye examination to do so. By properly positioning an adhesive patch, you can ensure a more accurate assessment of vision in the pediatric population. I make this into a “pirate game” and try to quickly reach the best visual threshold with each eye.
    6. Use other office staff for dilation. Nothing breaks down the trust you have built up with the child quicker than putting dilation drops in their eyes. I make an effort to have my technician place the drops in the child’s eyes after I have left the room. Unfortunately for my office staff, they get to be the “bad guy” during the visit. As far as dilation drops, mixing them into a single bottle can improve the success of your dilation. Many different pediatric dilation drop “cocktails” exist with the goal of obtaining a thorough cycloplegia.
    7. Focus on the critical parts of a pediatric eye examination. While every patient will have a unique presentation, there are some baseline critical examination components to focus on in the pediatric patient. After visual acuity and the motility examination, the cycloplegic refraction and optic nerve evaluation are the most critical. It can be difficult to obtain a confrontational visual field, and nearly impossible to obtain an applanation intraocular pressure in a child. I always document my inability to obtain these components, then revisit them if deemed necessary by my other examination findings.
    8. Reward good cooperation and behavior with “prizes.” Mentioning a prize to the child during the examination process can aid in obtaining better cooperation. In my office, I give out stickers at the end of my visit. Other physicians give out candy or small toys. Regardless of the reward type, a more positive memory of the visit will be formed with a parting gift, as well as praise by you of their effort and cooperation.

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    About the author: Aaron M. Miller, MD, is a member of the YO Committee. He practices in Houston, where he specializes in pediatric ophthalmology and strabismus.