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    Examining pediatric eyes

    Clinical pearls for helping your smallest patients

    The common eye problems found in adults, developing over decades of life as acquired disease, are different in children. There is an old pediatrics adage that “children are not little adults.” This is certainly true when it comes to the pediatric eye exam that many allied health care personnel find themselves facing, often with dread, on a weekly or daily basis.

    Obtaining pertinent history—often from a source other than the patient—and relevant clinical information to help the physician arrive at the proper diagnosis and provide the appropriate treatment, requires a different and creative approach, patience, and talent. Technical staff who themselves are parents have a distinct advantage: they are familiar with the nuances of behavior in young children. They know the various developmental milestones, when children start to sit up, stand, learn to walk, and start talking. These milestones are an important part of the pediatric history and often play an equally important role in illuminating and the underlying cause of clinical signs and symptoms.

    The pediatric eye exam can be broken down into five basic components:

    Preliminaries of an exam

    The pediatric eye screening begins by observing the child at ease, first in the waiting area as you walk out to call and greet him, then as he walks in to the exam room with you. Introduce yourself. Offer a handshake to adults and older children. Be cognizant of the fact that some cultures and religions do not shake hands. You should become familiar with your patient demographic and apply these concepts accordingly. Comment to a child about clothes, toys, what they’re eating, siblings, etc.

    As you enter the exam room, have the children and their families take seats away from the exam chair if possible, guarding exam-chair time as a precious commodity. Once the child is seated in the exam chair, her attention timer is ticking. If you approach the interview and this initial part of the exam with dread, children will sense your tension and become uncomfortable. It is incumbent on you as the examiner to gain the child’s confidence and trust, and you will want to do so in a relaxed, open, honest, and playfully engaging way.

    Once the child is seated in the exam chair, you should establish and maintain eye contact. Sit at the child’s eye level by lowering your chair/ exam stool and/or raising the child’s exam chair. Maintaining eye contact may or may not be possible with autistic children who often avoid eye contact with others. You will want to initiate verbal rapport with simple questions comments, such as, “How old are you?” Over-estimate age and grade level. Ask about siblings who came with her to the appointment today. These quick simple pearls warm the experience for the child and her family, and for you as the examiner.

    It is important to remember that as you work with children you have to focus your exam. Check what you need early on while you have cooperation, and save the more difficult tasks for last. You will have to develop a different vocabulary. For example, say “magic sunglasses’ when introducing the anaglyphic glasses of the Worth four-dot test and the polarized glasses of the various stereo acuity tests. Use “special flashlight’ to describe your retinoscope, and “funny hat” or “coal miner’s hat” when describing what the physician will do with the indirect ophthalmoscope. “Magnifying glass” is an apt description of the magnifying lens used with the indirect ophthalmoscope, and suggest “let’s ride the motorcycle/bicycle” when it is necessary to do a slit lamp exam.

    Next: Taking a history

    Alex Christoff, BS, CO, COT
    Alex Christoff is assistant professor of ophthalmology at The Wilmer Eye Institute at Johns Hopkins Hospital in Baltimore. E-mail him at ...


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