EXAMINING CHILDREN: CHALLENGES AND REWARDS

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Here is a look at the equipment you’ll need when you see pediatric patients.

I’ll never forget the young boy who made my staff cry—for a good reason, that is. The patient was about 4 years old at the time, and his exam revealed significant hyperopia. He was shy and quiet and had difficulty interacting with others, which I suspect was related to his vision problems. He would not look people in the eye and always looked down. When he put on his first pair of glasses, he looked at his mother and told her how beautiful she was. My entire staff was in tears with that comment—along with the mom.
Experiences such as this are among the reasons I love examining children. Of course, examining children also can be challenging when you consider such issues as evaluating visual acuity, especially very young children, and dealing with their increased activity levels, decreased attention span and smaller physical size.

Setting up your practice for children begins in the reception space. There should be a small, dedicated area for children, with small chairs and tables, toys and some form of video entertainment.

After that, you’ll need to determine what equipment you’ll need. Then you can address the challenges and rewards of examining children in these four age groups: infants (ages 6 to 12 months), toddlers (ages 1 to 4 years), preschool to primary school (ages 5 to 8), and elementary and high school (ages 9 to teens).

INFANTS
You don’t need much extra equipment or modifications to an exam room. You’ll already have the basic diagnostic equipment: retinoscope, trial lenses, transilluminator or penlight, and a binocular indirect or direct ophthalmoscope. You’ll also need one or two small toys to get the infant’s attention, or you can use a toy that the parents bring.

One additional note: Don’t forget to register as an InfantSEE provider. InfantSEE, the public health program managed by Optometry’s Charity—The AOA Foundation, provides a one-time, comprehensive eye assessment to infants at no cost to families.

The challenges: You have to be quick. Because this is essentially a screening examination, retinoscopy is critical for detecting significant amounts of anisometropia, hyperopia, astigmatism and myopia. Central steady, and fix and follow findings in each eye will be adequate for measuring visual acuity. Pay close attention to determine unequal responses between the eyes.

Dilating drops will sting upon instillation, and 20 to 30 minutes are needed for the patient to dilate. Then, you must be quick (and occasionally a little forceful) so that the infant will keep his or her eyes open long enough to get an adequate view of the fundus.

The rewards: The biggest reward is being able to tell most parents that their child is fine and that you recommend another examination when he or she is 3 years old. Should you find a significant visual issue, the reward is that you found it at a young age, when it is potentially treatable.

A handheld tonometer, such as the ic100 from iCare USA, can be helpful when examining children.

TODDLERS
Toddlers are the most challenging age group of all. Besides your standard equipment, you’ll need toys, age-appropriate eye charts such as HOTV, which are available from several distributors, and videos. Some older toddlers can do well with an autorefractor as well as iCare USA’s ic100 tonometer when in the hands of an experienced technician.

Handheld slit lamps are useful. Or, you could go with a less expensive option, such as the old standby, namely the Burton slit lamp.

The challenges: Once again, “quick” is the operative word. Infants do not move; toddlers do. Some need to sit on a parent’s lap, while others can sit on their own.

In my office, an EPIC-5100 refraction workstation from Marco has proven useful with any child physically mature enough to sit in the patient chair. I have found that many 3-year-olds can be examined at this workstation. The ease of raising and lowering the table and phoropter to adjust for the height of the patient minimizes the risk of the child falling from a chair that is raised too high.

The rewards: As with infants, the reward here is being able to reassure parents that their child is fine and should return at age 5. If you find a significant visual issue, the reward is doing so while it can be treated and managed.

PRESCHOOL THROUGH PRIMARY SCHOOL
For the preschool through primary school age group, your standard acuity charts should be sufficient. Toys and videos are great, too.

You can use your autorefractor on most children this age. If you suspect that the refraction is questionable, you can perform a repeat autorefraction after dilation to double check your findings.
The challenges: There are fewer technical challenges with older children. However, there can be more diagnostic issues involving children wanting glasses, not wanting glasses and/or problems in school. Depending on your inclination, you can conduct more binocular vision and visual efficiency testing. If you look for these issues but are not sufficiently prepared to treat them, try to develop a good working relationship with a colleague who does.
The rewards: Detecting problems when a child is young can spare them so many problems related to vision disorders later, giving them the confidence to go forth and succeed.

Elementary and High School
For the older child and teen, nothing extra in the way of equipment is needed. I would recommend tolerance and patience. These patients can be lots of fun once you to get to know them.

The challenges: Sometimes the challenge here is the parent, not the child. Try to remember that the child is your patient, not the parent. This is the age at which patients become interested in contact lenses. The challenge here is determining who is a good candidate for contact lenses.

The rewards: These patients can be fun and lively. And, this age group is the most rewarding when being fit with contact lenses.

FEW MODIFICATIONS
For most eyecare practitioners, there are surprisingly few modifications in equipment needed to examine children. If you wish to examine children without specializing in pediatrics, you’ll need only a few extra tools, such as appropriate visual acuity targets, some small toys and videos to keep their attention, a handheld tonometer, a Burton lamp or portable slit lamp, and a lot of patience.

If you see any handicapped patients, some of the handheld and/or portable instruments will work well also. If you keep these items together in a drawer or cabinet then they will be available as needed. OO

Mary Lou French, OD, MEd, FAAO, is in private practice and is the owner of Children’s Eyecare, P.C. in Orland Park, IL.

WHERE TO FIND IT:
Icare USA
888.422.7313 | Icare-USA.com
InfantSEE
888.396.3937 | InfantSEE.org
InfantSEE@AOA.org
Marco
800.874.5274 | Marco.com

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