|The plusoptiX A09 autorefractor works particularly well with children as it uses a funny sound to capture the patient’s attention.|
|Optovue’s iVue SD-OCT may be known for managing patients with ocular disease but it works just as well with pediatric patients.|
|Heine’s portable BIO allows ECPs to perform the dilated fundus evaluation where the child is most comfortable.|
|The OCT, like this one from Carl Zeiss Meditec, Inc. is a valuable adjunctive test to dilation in evaluating suspected pathology.|
Pediatric exams can often be challenging and when potential pathology is involved, extremely stressful. Having the right equipment can make the test fun, educational for the patient, and give the practitioner more confidence in making the process less stressful. What follows is a sampling of equipment that can make both you and your young patients happier all around.
Many ECPs have embraced the technology of the Optos optomap‘ retinal exam (for more information, see “A Sharper Image“). In most offices, it’s positioned as a screening instrument to help the doctor detect retinal pathologies, with staff trained to promote the test to adults. This, however, applies just as well to children. With the optomap you get a full view of the fundus and review the image with the child and parent. This interaction, where the parent sees the technology firsthand, has resulted in a tremendous number of referrals and helped differentiate our practice.
We have, in fact, adopted a protocol where all children under 12 automatically get an optomap as part of their exam. Even with a cooperative child, we often struggle to see much more than the optic nerve and macula since most kids cannot or will not tolerate bright lights. Having an optomap diminishes this obstacle and allows us a view that otherwise would be difficult to obtain.
The optomap retinal exam does not take the place of dilation or looking with our own eyes. It can, however, help the ECP view the retina with a difficult patient as well as provide a tool for education. Fortunately, most of the time the optomap is just confirming what we are seeing or giving us peace of mind that we didn’t miss anything. In fact, a few months ago the importance of the optomap was once again apparent when our office conducted a comprehensive exam on a 12-year-old girl. During her dilated retinal portion, we noticed her optic nerve appeared slightly swollen. Luckily, three years earlier we had done an optomap retinal exam so we were able to compare the two images. Having this machine allowed us to confidently refer her for more testing and she was ultimately diagnosed with idiopathic optic nerve edema.
PLUSOPTIX PEDIATRIC AUTOREFRACTOR
We utilize the plusoptiX A09 as our primary autorefractor for all of our kids, but this instrument works particularly well with our special needs population. For one, it has a smiley face and uses a funny sound to capture the patient’s attention. It also offers a comfortable space between technician and patient.
Many kids with autism don’t like anything near their face and this permits us to get the information we need without upsetting them. It also works well for those too small to put their chin in a normal autorefractor as well as wheelchair-bound patients.
In our office protocols, we perform a cycloplegic refraction on every child. Sometimes with our small children and other autorefractors it takes just as long to get the child in position to start the test as it does to perform the test. Since the plusoptix autorefractor requires minimal positioning, getting an autorefractor measurement before and after dilation doesn’t require much time. It makes this part of the exam simple and easy.
OPTICAL COHERENCE TOMOGRAPHY
The OCT is a staple in many offices and is essential in managing patients with ocular disease such as macular degeneration and glaucoma. We, however, find it works just as well with our pediatric patients. As the volume of children in our practice grew, we naturally saw an increase in pathology of abnormal and congenital anomalies. OCTs, available from companies such as Carl Zeiss Meditec, Inc., Heidelberg Engineering, Inc., and Optovue, Inc., are helpful in diagnosing and managing these conditions.
A few years ago, for example, we examined a 13-year-old girl with IOPs of 35mmHg OD and 14mmHg OS after correction for corneal thickness. Her optic nerve cupping was asymmetric with 0.4/0.4 OD and 0.2/.2 OS. One of the advantages of the OCT in adults is its normative data comparison. This patient was young so the machine didn’t have norms for her age. Katie wanted to examine her nerve fiber layer to determine if she had an early onset of glaucoma and needed something to compare. In order to do this, we made her birthdate as if she were 18 so we could compare it to normal nerve fiber layer thickness. We have now followed this patient for three years co-managing her with a glaucoma specialist. Needless to say, we have found it a valuable adjunctive test to dilation in evaluating suspected pathology.
PORTABLE BINOCULAR INDIRECT OPHTHALMOSCOPE (BIO)
We have a separate children’s waiting area with recliners, a TV, and toys. We have found that keeping the kids here after dilation helps us to obtain a more thorough exam. Many times children are having so much fun they are hesitant to leave””especially when it means going into a confined exam room with lots of equipment!
The portable BIO, made by companies such as Keeler Instruments Inc. or Heine has become important because it allows us to be flexible with fidgety kids and perform the dilated fundus evaluation in the area of the office where the child is most comfortable. This portability, along with the entertaining space factor, allows us to check a child’s retina without creating too much anxiety. Again, happy kids make for happy parents and this kind of creativeness has become a major referral source for our practice.
If you have a practice with many pediatric patients, you’re probably already using retinoscopy bars (we use one from Bernell) which we find essential.
Like the portable BIO, we use them often in our kids’ waiting area to determine prescriptions while the child is entertained with a movie. We recently had an autistic patient with very high myopia and astigmatism; using the retinoscopy bars over his current glasses was a quick and easy way to update his prescription in the shortest and most efficient manner.
No doubt you’ve been there in some form or the other. There’s no doubt about it: Pediatric exams can be tricky, and with kids the clock is ticking. We often have a very limited window of cooperation to obtain quality information. However, with the right equipment and the right approach, pediatric exams can be easier and more rewarding for both the ECP and the patient.
Carl and Katie Spear have a five-location group private practice in Florida’s Panhandle.
|“‹WHERE TO FIND IT:|
|Carl Zeiss Meditec, Inc.
|Keeler Instruments, Inc.
|Heidelberg Engineering, Inc.