It’s all fun and games with pediatric patients
The pediatric eye exam differs greatly from the adult eye exam-children are more than just tiny adults. To further that point, the whole dynamic of the exam is different because you are really interviewing and interacting with the family and not just the patient. In the pediatric arena, the family becomes your patient.
The pediatric eye exam differs greatly from the adult eye exam-children are more than just tiny adults. To further that point, the whole dynamic of the exam is different because you are really interviewing and interacting with the family and not just the patient. In the pediatric arena, the family becomes your patient.
The first step to eliciting a good exam is to build rapport with the patient and the family. Small children are often timid, hiding behind Mom or Dad’s leg, and shying from the big scary exam chair.
Let them shy away; you don’t need them in the chair to get your history and have a chat with Mom or Dad. Setting a relaxed tone for your interaction is reassuring to them. Aside from having to read an eye chart at a fixed distance, most other aspects of the exam can be done in a different seat, or even sitting on the floor. In a small child, history starts with the parents (this helps make the child comfortable and builds trust).
In an older child, history starts with the patient and is verified or added to by the parent. Children’s participation in their medical care should increase commensurate with their age. Autonomy is one of the pillars of medical ethics, and that extends to minor-aged patient.
Next, we move on to the physical exam. Have you ever written “unable” for the exam of the child who has come to your office?
Unless you work for a pediatric ophthalmologist, it may be standard operating procedure to write “unable” (or something similar) for the young child who has come in to your adult or general ophthalmology practice. Here is the most important tip in this article: Something is better than nothing.
In our youngest and least cooperative patients, we start with the most basic techniques and eventually graduate to the more sophisticated techniques used for examining adults.
Let’s review these techniques.
Visual acuity
Perhaps a 1-year-old cannot read the eye chart, but can he fix and follow? At the very least, is the child light averse or light perceptive? As children get older, the method of visual assessment becomes increasingly more sophisticated. The visual assessment technique evolves from light averse, to fix and follow, the preferential looking test, matching pictures, then finally graduating to the standard Snellen acuity chart that we use on adults.
First, assess if the patient is reactive to light. Next, see if she can fixate on the light and follow the stimulus. This is the fix and follow (F+F) technique. After that, the technique gets slightly more sophisticated. Is her gaze central, steady, and maintained (CSM) on the stimulus? Remember, these two techniques require only a target to fixate-no other special equipment.
Related:
In the pediatric ophthalmology practice, techs also utilize a type of visual assessment called the preferential looking test. For this test, the patient is shown large, rectangular cards. Stripes or pictures are docked to either the left or the right side of the card.
The Teller Acuity Cards use stripes, and Cardiff Cards use pictures. As you progress through the cards, the stripes or pictures grow fainter and fainter, requiring higher and higher levels of visual acuity to see. The cards are held face down so the examiner is blind to what is on the other side.
The examiner holds up the card to the patient and judges the side of the card where the patient preferred to look. Hence, this is named the “preferential looking test.” The fainter the stripes or pictures the patient responds to, the higher the level of visual acuity. If cooperation permits, you can also ask the child to point to the stripes or pictures. This level of interaction offers a greater level of accuracy.
Once the children begin interacting with you, you can start trying to check vision on the eye chart. Pre-verbal children can hold a card with the symbols on it and point to each symbol to match to the optotypes on the acuity chart. We begin by using pictures, instead of letters, for pre-literate children.
A similar, yet slightly more sophisticated method, is HOTV matching. The child holds a card with the letters H-O-T-V. The eye chart is matched to use only these letters.
Finally, we graduate them to the Snellen chart. The examiner must be forgiving and acknowledge that children may know most letters, but not all. If children are afraid to say the wrong letter, encourage them to trace the letter in the air. At times, children may lack the confidence to get started reading the letters, and you need to help them.
Young children need help getting started with many tasks, so give them the first letter on a Snellen line. This can help give them momentum to get started. Use lots of encouraging words. Offer lots of smiles and high fives. Give them praise when they are doing well to encourage them to keep participating.