PEDIATRIC EYE EXAM
June 05, 2023 .jpg)
When it comes to having a young child in your examination chair, do you feel prepared? Do you know what to expect from a 3-year-old? 5-year-old? 12-year-old? If your answer is anything other than "completely prepared," let's take some time to go over important (and small!) details that will help you achieve the key elements of a pediatric examination.
ELEMENTS FOR A PEDIATRIC EYE EXAM
- History - Basic Elements
- Pediatric History - School, Development, Pregnancy/Birth History
- Visual Acuity (most school examination forms require both aided and unaided)
- Cover Test - Distance and Near (quantification when necessary)
- Stereopsis
- Color Vision* (required for most school examination forms)
- Near Point of Convergence
- Extraocular Muscles
- Confrontation Visual Fields
- Pupils
- Dry Retinoscopy/Dry Refraction (if possible)
- Anterior Segment Evaluation (if possible)
- Tonometry
- Posterior Segment Evaluation
- Wet Retinoscopy/Refraction
TIPS AND TRICKS
For preschoolers and infants, it's important to provide an incentive and inform the child in advance. Don't show all your cards right away. In other words, don't give candies and stickers as soon as the examination starts, as it takes away any advantage you have when you're actually trying to capture the attention and cooperation of the patient during procedures like retinoscopy or binocular indirect ophthalmoscopy.
Here are some notes that will serve you well:
- Autorefractor
Overestimates myopia, underestimates hyperopia
Children are notorious for focusing - use the car as a reference point (very useful for comparing pre- and post-cycling values)
- Subjective Refraction
Based on the child's maturity
Younger children - should place little emphasis on what you get for refraction
- Mohindra Retinoscopy
NO LIGHTS! The child should only see the light you are holding
Child looks at the light
Performed at 50 cm, do retinoscopy as usual
Adjustment by subtracting 1.25 D from what you found to obtain your final value
- Ocular Health
Most children will be grossly normal - not to the same extent as with adults
Looking for gross abnormalities (congenital glaucoma, coloboma, conjunctivitis, corneal or lens opacities*) *opacities, think Amblyopia from Deprivation.
- Pupillary reflex
Children usually look at lights or things that are visually interesting and mobile. A great way to do the cover test on a very young patient is to sit right in front of the child, with one hand on their forehead and the other holding the transilluminator. Then, with your thumb as the occluder, perform the cover test as usual. Your thumb is the perfect size to cover just enough of the child's eye to get an idea if there are tropias or phorias.
If the child gets distracted by your arm or hand, try covering and uncovering the transilluminator a few times. This flashes the light and draws the attention back to you.
- Burton Lamp
Adds more illumination to the front surface of the eye for a more detailed examination.
- Portable Slit Lamp
Alternatively, you can always try using a traditional slit lamp, but small children are usually too short to sit and reach the chin rest. Consider having them sit on their parent's lap for this.
- Intraocular Pressure
TonoPen (if able to stabilize the patient's head)
Tactile (using fingers)
Done most often in very young children
Looking for symmetry
Record as "Soft and Equal by palpation OR"
Goldmann Applanation Tonometry - depends on cooperation, but at least try with children over 10 years old
- Dilated Fundus Examination
Avoid the word "drops"
Here are some alternative phrases and tips for pediatric eye examinations:
Instead of saying "I'm going to put drops in your eyes," you can use alternative phrases like:
- "I'm going to put a sparkle in your eye."
- "I'm going to add a little shine to your eyes."
- "I'm going to put some special drops in your eyes."
To ensure cooperation, you can tell children that the examination can be done with their eyes closed, but make sure they blink enough to get the drops in.
For children with lower body weight, use the lowest potency of dilating drops possible.
If concerned about systemic absorption of the drops, have the patient perform nasolacrimal occlusion (pressing on the inner corner of the eye) to prevent the drops from entering the nose and being absorbed systemically.
Start examining the eye that is closest to the parent or caregiver, as children tend to lean toward the person holding them.
- Dilating agents commonly used:
Phenylephrine 2.5%: Direct-acting adrenergic agonist, provides rapid dilation with a short duration of action. Not recommended for children under 3 years of age or those with cardiovascular problems.Tropicamide 0.5%/1.0%: Anticholinergic antagonist that inhibits parasympathetic activity. Safest dilating agent available with rapid dilation and short duration. Both strengths are equally effective for dilation, but 0.5% has less cycloplegic effect. Peak dilation occurs in 20-35 minutes, and the effects last for approximately 6 hours.
Cyclopentolate: Preferred for cycloplegic refraction. Diminishes ciliary muscle activity and eliminates accommodation fluctuations. Also serves as a mydriatic for easier examination of the dilated fundus. Standard for children with high hyperopia, anisometropia greater than 1.00 D, or strabismus. Peak dilation occurs in 30-45 minutes, and the effects can last up to 24 hours.
Additional tips for dilated fundus examination (DFE):
- For darkly pigmented eyes, consider using both Tropicamide and Cyclopentolate.
- Administering both dilating drops may be necessary, especially in pediatric clinics.
- Use 0.5% Cyclopentolate for infants (<12 months) as their corneal sensitivity is often low.
- Use 1.0% Cyclopentolate for children (1 year or older), and consider combining it with 1.0% Tropicamide for individuals with dark irises.
- Avoid telling a child that the drops won't sting, as it may lead to a loss of trust if it does sting. Instead, use phrases like "It might tingle a little" or "It might feel a bit strange."
Tips for maximizing efficiency during retinoscopy:
- Determine if you need red or black retinoscopy bars (perform a lens-less retinoscopy).
- Determine the axis of astigmatism before placing the retinoscopy bars in front of the child.
- When using the phoropter, encourage the child to "look through the window" or find another way to maintain their interest in looking through the device.
- Ensure the child is comfortable. Position them as far back in the chair as possible, as it encourages relaxation and focus on the targets or videos behind you.
Minimizing Distractions:
- Ask the child to describe what they see on the red side and then on the green side.
- Have someone in the room change the Allen figures to keep the child distracted.
Assessing Visual Acuity in a 3-year-old:
- Use Lea symbols, as the child should be able to match them.
Posterior Segment Evaluation:
- Indirect ophthalmoscopy is usually the easiest method.
- Direct ophthalmoscopy can also be used.
- Alternative options include sedation, eyelid speculum, or more prolonged tests like MRI or CT.
Cooperation:
- If the child is hungry or tired, the exam may be more challenging.
- If the child is sleeping, you can still attempt the exam using a binocular indirect ophthalmoscope or direct ophthalmoscope.
School-Aged Children:
- Consider other factors like neurological or behavioral disorders if the child is being difficult.
- Ask about school performance and consider refractive error correction as a primary cause if the child avoids near tasks like reading.
Knowing When to Stop:
- If you can't guide the child's behavior or the results are unreliable, consider rescheduling.
- If the child is reacting negatively to dilating drops, reschedule and have the drops instilled before the appointment.
- Teach parents/guardians how to instill eye drops if needed.
Frequency of Exams:
- Birth to 2 years: seen at 6-12 months of age.
- Ages 3-5: at least once.
- Ages 6-18: before first grade, then annually.
- "At-risk" children should be seen as recommended by an ophthalmologist.
Pediatric Prescriptions:
- Normal myopia progression: -0.5D per year in school-aged children.
- Atropine for myopia control: use the lowest dosage to minimize side effects and rebound in one year.
- Suspected amblyopia should be followed up in 4-6 months for cycloplegic refraction.
- Visual improvement with spectacle correction plateaus at around 16 weeks (4 months).
- Avoid prescribing atropine and bifocals to be used simultaneously.
- Prescribe full astigmatism in the manifest refraction if the child is over 3.5 years old.
These are recommendations and exam techniques to assist clinicians and should not replace professional judgment. Care should always be based on individual patient cases and comply with state laws and regulations.
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