• Seven Pediatric Ophthalmology Pearls

    Performing eye examinations on children can have its challenges, but also holds great rewards. I sometimes joke with my colleagues that performing eye examinations on children is close to veterinary medicine. At times, all you have to guide you is your observations during the course of the examination.

    While it can be challenging, experiencing the look on a child’s face when they can see clearly for the first time is priceless and serves as a motivating force for me to continue to do what I love: pediatric ophthalmology.

    Over the first five years of my practice, I have developed seven pearls that I have found to be helpful when examining children’s eyes.

    1. Smile and don’t be afraid to be a little silly when first entering the examination room. Children feed off of the emotions of others in the room. Depending on the child’s age, performing a little small talk, such as complementing a little girl on the sparkles on her shoes, will go a long way to gaining a more cooperative examination.
    2. Turn the examination into a time of playing “games.” Children love games, and if you can take them out of a doctor-office environment mentality, you will frequently gain more trust and more accurate information to guide your diagnosis and treatment.

      I find starting the examination with stereo testing helps in most children over three years of age and provides an enormous amount of information. Absence of stereo vision may just mean a shy child, but if it is present, typically it will tell you that there is nothing overly serious with the child’s visual system.
    3. Fixation toys are critical. I have a mentor who coined the phrase, “One toy equals one look.” Children will quickly become bored with the same fixation target, so changing things up frequently is essential to getting through the examination. Small spin globes with lights help with assessing versions and ductions. For motility, I find using small stickers on my nose works best when doing alternate cover testing. Make sure you have lots of them with different themes!
    4. Eyedrops from you are like a shot from their pediatrician. Typically, you cannot “talk” a child into letting you place dilation drops into their eyes. I will use the term “magic raindrops” when describing them to children, but I usually delegate this act to another office staff member. After spending minutes building trust with the child, it can all be lost at this point. Having one of my technicians serve as the “bad guy” works well to distance me from this experience.
    5. Concentrate your eyedrops. Most children require complete cycloplegia to obtain an accurate assessment of their refractive error. If you can put all the ingredients into one eyedrop, you will speed up the least favorite part of the exam for the child.

      There are many eyedrop recipes out there, but I prefer to use the following: 1 part 2% cyclopentolate, 1 part 10% phenylephrine and 2 parts tropicamide. They can be mixed into a single bottle using a needle and syringe. I often use proparicaine prior to this drop, as penetration into the eye seems to be better and results in better cycloplegia.
    6. Use an autorefractor on a child after the child’s eyes have been dilated. I find these devices most helpful with assessment of astigmatism in children. Despite using cycloplegic eye drops, children still can accommodate through them, which can result in falsely overly myopic sphere measurements. I use the autorefractor on my difficult, but somewhat cooperative, pediatric patients to guide me during retinoscopy.
    7. Reward the child at the end of the examination. Most young children love stickers. This tends to be a safe reward to give to them at the end of the exam when leaving the room. We have a “sticker station” at the exit where the child can pick out their favorite. I try to avoid toys and candy since there can be choking hazards and allergy issues. 

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    About the author: Aaron M. Miller, MD, is a pediatric ophthalmologist in the Houston area. A former editor of YO Info, he is completing a five-year term on the YO Committee and is the editor-in-chief of EyeWiki.