I move to the cover test, using the same toy and just my hand. An occluder is too distracting—the child will likely grab the paddle. I have a plethora of light-up toys to grab their attention (Figures 1 and 2). I check the extra-ocular muscles and near-point convergence with the small toy in hand, then let the child hold the toy himself. When he is looking down at the toy, a quick check of IOP via palpitation can be performed.
The cover test sometimes will not work for young children, so I attempt the Hirschberg method. To perform this, I place the Maddox rod in front of the patient, with the penlight behind the rod. I drag my penlight across the Maddox rod to make an interesting noise to draw attention to the red light. I assess the red reflex on the patient’s cornea to estimate strabismus. This works very well for those little patients with epicanthal folds who have pseudostrabismus.
If the child in your chair is verbal and over age 3, consider trying to obtain a more accurate vision recording. I use an adhesive eye patch to occlude one eye. I have taken plain eye patches and put simple drawings on the patches to let the patient pick the “sticker” she want to place over the eye. I prefer HOTV matching for my test of choice (Figure 3). I also use the occluded eye to gain visual fields. When the patient is too young to perform or understand counting fingers, I use a toy for visual fields and judge if the field is present by the patient’s eye movements. After I finish, I take the patch off and put it on the patient’s shirt as a reward.
A patient age 4 or older can move to the Snellen chart. I start simple for younger patients and present the letters one at a time. A full Snellen chart can be presented at age 6 or older. These are general guidelines, and there will be exceptions to all these rules, especially if there is a developmental delay. You will have to judge the patient response time and ability to communicate in order to assess which visual acuity test will give the most accuracy.
Check IOP by palpitation for patients under age 3; I use the Icare tonometer for patients that are older than three.
Finally, I assess the pupils. If a patient is over age 4, I begin the eye exam with stereopsis and color vision testing. These tests are not performed for younger patients due to difficulty in the comprehension of the test.
Every child under age 10 needs a cycloplegic refraction. Little ones are not fans of eye drops and sometimes even the parents need to be educated about the process, but dilation is a must. Pediatric patients usually accommodate very well, and this can throw off your refraction. The only way these little patients will get an accurate refractive correction is to cycloplege those eyes to control large accommodative amplitudes.
Do not fear this step and look to avoid it. To get a better dilation, ask the parent hold the child in her lap and wrap her arms around the patient in a bear hug to hold the patient’s arms down. This allows you to place in the eye drops with less resistance. Ask the patient to look superiorly—it is helpful to have a target for these kids to focus on. The ceiling above my exam chair has bright, friendly pictures of cartoon characters that I tell the patients to look at to help instillation of the drops.
Even the child who is kicking and crying during drop administration will be fine and forgive you five minutes later. The patient has to wait at least 30 minutes after the drops before the eye exam can be continued. It takes this long, at least, to fully relax the patient’s ciliary body. Let the patient have a break to relax after the stress of the eye drops. They may watch television, play a puzzle, or take a restroom break. I often encourage patients and their parents to leave the exam room during this time to get a break and have a fresh start when they re-enter in half an hour.