How to successfully perform a pediatric eye exam

I worked in general eye care for almost 10 years before I narrowed my scope to pediatric eye exams. Pediatric patients (under 18 years old) now make up 90 percent of my patients. My favorite eye exams always were those little patients-the ones whose feet hang off the exam chair and cannot fit into the slit lamp. They will keep you fully alert and your senses keen because you will never know what they will say next or when they will try to bolt out of the exam chair.

Although some optometrists think this sounds crazy or exhausting, I couldn’t imagine a more ideal scenario. These patients radiate joy when they put on their first pair of glasses and can see properly for the first time. They are also appreciative of your time and expertise (and of course the sticker reward at the end of the exam). When treating amblyopia and we have a success, they are so proud and feel accomplished right along with you.

When is the last time that you performed an eye exam for an energetic two-year-old? Does the thought scare you, or do you refer these patients to the nearest pediatric specialist? With just a little patience and a quick response time, you, too, can perform a 2-year-old eye exam as smoothly as an adult eye exam (sometimes even easier). I include the tests I perform along with some tips to make things go easier.

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Before the exam

To start, have an inviting area for children in the reception area. The office should have simple toys for kids to play with when they wait.

We have a wooden abacus, bead maze, and children’s books. My office allows children to take home a book from the waiting area; this receives a warm reception and offers an educational incentive. We rotate and replace the books as they leave the office.

In addition, each exam room has a box of toys tucked away for kids who need to be occupied while a family member or parent gets their eyes examined. My choice is toys you have to put together and take some time to complete, such as blocks or puzzles. This makes the visit to the eye doctor more pleasant for the patient and their little sidekicks.

Related: Share this pediatric vision checklist with your patients

When going into the reception area to greet the patient, make sure that you speak to the child first before the parent. “Hi, Little Joe Patient! I am so excited you are here today. Let’s go into this room over here.”

Be versed on all things pediatric so you can strike up a conversation, such as admiring the Ninja Turtle on his t-shirt, her sparkly sneakers, or the toy soldier in his hand.

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.

Related: Why you should offer children’s eyewear

The exam

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.”

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. 

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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.  

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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.

After the eyes have dilated, retinoscopy is performed outside of the phoropter with a retinoscopy rack (Figure 4). The patient can be shown a movie at a distance while the refraction is performed. Or I sing a tune or whistle for younger patients to capture their attention. Externals are assessed with a penlight or even the binocular indirect ophthalmoscopy (BIO) if the patient is under age 3 and cannot fit into the slit lamp.

Lastly, the dilated fundus exam is performed with a 20 D lens and a BIO. I again use my light-up toys as a target for patient gaze and quickly glance at the internals (Figures 5 and 6).

In the optical

Your optical should include smaller frames for children from in kid-friendly colors on your frame board. Be sure to include several choices in blue and several choices in pink because in my experience children choose those colors.

If your practice does not feature an optical or your dispensary area is too small to comfortably fit a wide selection of children’s frames, refer your younger patients to pediatric-friendly colleagues with a children’s optical.

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Benefits of pediatric exams

I have found that bringing more children into my schedule makes my day go faster and brings more excitement into my chair.

With a successful eye exam of a young patient, you can then add siblings and parents to your patient list and perform eye exams for the whole family. Be sure to inform your community you can perform eye examinations for babies, toddlers, and any member of the family. When you are with your patient, ask the accompanying adult if any family members or children need an eye exam as well.

A pediatric exam will certainly keep you on your toes because you never know what the young patient might do or say. Completing a thorough exam is important, but so is creating a positive experience through a child’s eyes.