Once in the exam room, I allow the patient to roam freely around the room or sit in the side chair with the parent while I collect the history. The little one is not going to want to sit in the exam chair for a long period of time, so why make it longer than it needs to be?
I begin by taking the medical history while watching the child’s eyes and how the vision seems to be functioning. Is there an apparent strabismus from across the room? It is important to know the birth history and if the child was born premature as well as medications. Ask the parent if there are concerns of the eye or the vision. I always ask if the parent (especially for patients under age 2) if the patient has watering eyes or photophobia. These questions are probing for signs of congenital glaucoma.
If the parent is concerned about strabismus and you do not see this in your office, ask the parent for cell phone pictures of the eye turn. Most parents have a phone full of photos of their children, and such images can be very telling and provide helpful information. Note that images can also be used as an educational tool, especially if the diagnosis is pseudostrabismus.
After the history, the patient can sit in the exam chair in Mom’s lap. That makes the exam much more comfortable and less overwhelming for your little patient. It is helpful to get on the eye level of your patient, which sometimes requires raising the chair of these patients. You sometimes are not going to get an exact visual acuity (VA) or the precise intraocular pressure (IOP), but you can get close measures.
Another good rule of thumb to avoid attempting to perform a particular test for over two minutes because the patient will become frustrated, and so will you. For example, if you want IOP and cannot get the measure after two minutes, move on to the next test.
Be flexible. If the patient is more comfortable out of exam chair and on the sidelines, then move to her and get on her level. Yes, even if that means getting on your knees with your instruments at your side.
Once the child is ready to be examined, move to a gross assessment of the eyes and the vision. If the child is less than age 2, I check visual acuity by fixate and follow. I cover one eye with my thumb and move a toy in front of him, then switch and cover the opposite eye. Is there resistance to occlusion of one eye? Is there an eye turn or a head tilt? Any of these must be noted, and the vision recorded as “fixate and follow” or “fixate, not follow.”