You need more than patience with patients ranging in age from newborns to young adults. Try these tips, tools and tests for kid-friendly exams.

Performing a pediatric eye examination can be extremely challenging. First, there is the issue that most children do not like any type of medical examination. You also have limited time before the child loses interest and no longer pays attention. So you need to have a game plan prior to going into the exam room.

You should review the chart as well as ensure that all the equipment needed is in the exam room. This includes: Lea cards, Cardiff cards, stereo acuity test equipment and toys to use for fixation.

The patient history is tremendously important in pediatrics. The examiner should inquire about anything unusual such as young patients constantly holding their head at an angle or crying when one eye is covered.

You may also want to ditch the white coat before entering the exam room. Most children equate a white coat with a shot and can quickly become scared upon seeing the examiner in a white lab coat. Small children may also become afraid when sitting alone in the examination chair. To decrease this nervousness, suggest having the patient sit on mom or dad’s lap. If the child is comfortable sitting alone, position  the examiner’s chair to stay on the same level.

Your demeanor when entering the room can make or break the examination. Upon entering, greet the child by name and introduce yourself. Make sure you stress that there will be no shots and that you are going to play some fun games. Never enter the room and solely address the parent or guardian.

Because infants are nonverbal, they cannot read the eye chart. Infants at birth are not able to see well because their visual system is not fully developed. The type of vision test performed depends on the age of the patient. At birth, an infant may only blink in response to light, so the examiner should check the patient’s response by shining a penlight into the infant’s eyes. The pupil response to the light stimulus should also be noted as well as the placement of the light reflex in the pupils. If you are able to get the child to look straight ahead, you can check the eyes for the red pupillary reflex by using an indirect ophthalmoscope and shining the light into both eyes at the same time.

As the child grows older and is able to track movement, the examiner can use a toy to test the child’s ability to follow a target. As the test object is moved, the examiner should document the ability to fixate and follow.

The examiner should also perform a cover testing to check ocular alignment. As each eye is covered, look for any movement of the fellow eye. Also watch how the child reacts to an eye being covered. If the child starts crying when one eye is covered but is fine with the other eye being covered this could indicate poor vision in one of the eyes.

Another test of a nonverbal infant’s vision is preferential looking. This test is performed using Teller acuity cards that are blank on one side with stripes of varying width on the other side. The examiner should sit at the level of the child and hold the cards in front of the child’s face. There is a small peephole through which the examiner can note the direction of gaze of the patient. Start with cards that have large stripes and change to cards with smaller and smaller stripes until they are so small that the child cannot see them and they blend together forming a gray background. Watch the child’s eyes and face to determine whether or not they can see the stripes.

If the child is cooperative, you should try to refract the patient by performing a retinoscopy. This is an objective measurement that uses a handheld instrument that projects a beam of light into the eye. The examiner determines the direction of movement of the red reflex and uses loose lenses to determine the refractive error. This test should be performed with the room light off and the examiner seated approximately 50 cm from the patient.

Lea paddles For older children with verbal skills and who can differentiate between shapes, Lea paddles can be used. Place the card with the shapes 10 feet away from the patient and ask what object they see on the card.

Cardiff Test
This is another test designed for toddlers aged one to three. The test presents two cards to the patient at a distance of 1 m. Each card is gray with a picture at either the top or bottom. The examiner presents the card at the patient’s eye level and notes the direction of gaze (up or down) depending on the location of the target. The end point is the last set of cards that are correctly seen.

Stereopsis Test The stereo acuity test is performed to determine depth perception, which requires both eyes to work together. If one eye is not functioning properly, the eyes are not able to see depth. This can occur in strabismus or amblyopia. The child wears polarized glasses and looks at a picture of a fly at about 16 in. away. The child is asked to pinch the wings of the fly. The test also contains three rows of animals in which one animal stands out in each row. Another test is a series of four dots arranged in a box. Ask the child to identify which dot “pops” up from the page.

For tweens and teens, visual acuity can be accessed by using the Snellen eye chart at a distance of 10 ft. or 6 m. Have the patient start reading the letters on the 20/50 line and proceed downward. The visual acuity is determined by the last line in which the patient can read over 50% of the letters correctly.

In addition, the child’s refractive error should be measured using an autorefractor or by performing retinoscopy. If the visual acuity is compromised, spectacle Rx or contact lenses can be prescribed. (See page 16 for advice on whether or not a child is mature enough to wear contact lenses.) Parents of the child should also be included in the decision-making as they would more likely know if their child is mature enough to handle the responsibilities associated with the care of contact lenses. Proceed cautiously if the parents are the ones pushing for contacts and not the teen. They may not be ready.

Janet Hunter, COMT, president of Eye Source, LLC, specializes in ophthalmic technician training.


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