examining pediatric eyes - modern medicine · examining pediatric eyes supplement to and ... (nsvd)...
TRANSCRIPT
the common eye problems
found in adults, developing
over decades of life as acquired
disease, are dif erent in
children. There is an old pediatrics adage
that “children are not little adults.” This is
certainly true when it comes to the pediat-
ric eye exam that many allied health care
personnel f nd themselves facing, often
with dread, on a weekly or daily basis.
Obtaining pertinent history—often
from a source other than the patient—and
relevant clinical information to help the
physician arrive at the proper diagnosis
and provide the appropriate treatment,
requires a dif erent and creative approach,
patience, and talent. Technical staf who
themselves are parents have a distinct
advantage: they are familiar with the
nuances of behavior in young children.
They know the various developmental
milestones, when children start to sit up,
stand, learn to walk, and start talking.
These milestones are an important part
of the pediatric history and often play an
equally important role in illuminating and
the underlying cause of clinical signs and
symptoms.
The pediatric eye exam can be broken
down into f ve basic components:
■ History and chief complaint
■ Sensorimotor evaluation
■ Visual acuity testing
■ External exam and pupillary evaluation
■ Instillation of dilating eye drops.
We will conclude with a brief review of
the more common causes of decreased
vision in infancy.
Preliminaries of an exam
The pediatric eye screening begins by
observing the child at ease, f rst in the
waiting area as you walk out to call and
greet him, then as he walks in to the exam
room with you. Introduce yourself. Of er a
handshake to adults and older children. Be
cognizant of the fact that some cultures
and religions do not shake hands. You
should become familiar with your patient
demographic and apply these concepts
accordingly. Comment to a child about
volume 04 | issue 1 | spring 2015
1
CLINICAL PEARLS FOR HELPING YOUR SMALLEST PATIENTS
EXAmininG PEDiAtRiC EyES
SUPPLEMENT TO AND
See Pediatrics on Page 3
Figures 1 and 2. The author using his hands to physically simulate the directions of eso-deviations and exo-deviations to help parents better understand.
2
By Alex Christoff, BS, Co, Cot
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clothes, toys, what they’re eating,
siblings, etc.
As you enter the exam room,
have the children and their
families take seats away from the
exam chair if possible, guarding
exam-chair time as a precious
commodity. Once the child is
seated in the exam chair, her
attention timer is ticking. If you
approach the interview and this
initial part of the exam with dread,
children will sense your tension
and become uncomfortable. It is
incumbent on you as the examiner
to gain the child’s conf dence and
trust, and you will want to do so
in a relaxed, open, honest, and
playfully engaging way.
Once the child is seated in the
exam chair, you should establish
and maintain eye contact. Sit at the
child’s eye level by lowering your
chair/exam stool and/or raising
the child’s exam chair. Maintaining
eye contact may or may not be
possible with autistic children
who often avoid eye contact
with others. You will want to
initiate verbal rapport with simple
questions comments, such as,
“How old are you?” Over-estimate
age and grade level. Ask about
siblings who came with her to the
appointment today. These quick
simple pearls warm the experience
for the child and her family, and for
you as the examiner.
It is important to remember
that as you work with children
you have to focus your exam.
Check what you need early on
while you have cooperation, and
save the more dif cult tasks for
last. You will have to develop a
dif erent vocabulary. For example,
say “magic sunglasses” when
introducing the anaglyphic glasses
of the Worth 4-Dot test and the
polarized glasses of the various
stereo acuity tests. Use “special
f ashlight” to describe your
retinoscope, and “funny hat” or
“coal miner’s hat” when describing
what the physician will do with
the indirect ophthalmoscope.
“Magnifying glass” is an apt
description of the magnifying
lens used with the indirect
ophthalmoscope, and suggest
“let’s ride the motorcycle/bicycle”
when it is necessary to do a slit
lamp exam.
Taking a history“When all else fails, take a history.”
These words were the sage advice
of J. Lawton Smith, MD. Former
ophthalmology resident at the
Wilmer Eye Institute in the 1950s,
Dr. Smith went on to become an
internationally recognized neuro-
ophthalmologist at the Bascom
Palmer Eye Institute in Miami.
All medical histories should
begin by identifying the patient’s
chief complaint, preferably in as
close to their own words as the
electronic medical records of the
present day may allow. Examples
of a chief complaint include,
“decreased vision,” “headaches,”
“blurred vision,” or “double vision.”
The clinician will next want to
evaluate the history of present
illness, or HPI. For the parents, ask
who referred the child in to your
of ce and why. Sometimes the
simple question, “What can we
do for you today?” works best. Try
to establish when the problem
started (onset), how often the
problem is noticeable (frequency/
severity) and when the symptoms
manifest do themselves, how long
do they last (duration).
Who notices? Relatives,
teachers, the pediatrician?
Sometimes you can ask the child
simple question like, “Which eye
hurts?” or “Which is the bad eye?”
But avoid complex topics like
questions about double vision in
younger children because this is a
dif cult concept at best for most
preschoolers.
Expand your history with
questions about treatment and
what has been done to address
the problem. Was a more extensive
workup required that might have
included blood work or imaging
studies? And how has the problem
developed or changed in the
interim between the last of ce visit
and the most recent visit? Do the
parents know anything about the
problem? This is the Internet age,
and most parents have explored
their child’s eye problem online
before having sought treatment.
With the HPI, you are trying to
develop a dif erential diagnosis—
basically, a short list of possible
causes by def ning the problem
and making sense of the history. Of
course you will want to explore the
symptoms and signs observed by
the parents. Are they constant, or
PediatricsContinued from page 1
■ History and chief complaint
■ Sensorimotor evaluation
■ Visual acuity testing
■ External exam and pupillary evaluation
■ Instillation of dilating eye drops.
Components of a pediatric eye exam
Check what
you need
early on while
you have
cooperation,
and save the
more diffi cult
tasks for last.
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intermittent? When do they occur?
What time of day? Are they worse
at the end of day, or with fatigue?
Failed vision screening
history. Children often present to
the pediatric eyecare practitioner
because they failed a vision
screening at school or at their
pediatrician’s ofce. It is very
important for the technician to ask
when the child was tested. There
are obvious clinical implications
and expectations if the failed
screening was six months ago vs. a
few weeks ago.
What was wrong? What part
of the screening test did they fail?
Was it because of an observed
misalignment? Did she do poorly
on the visual acuity test? How was
vision measured? Was it an age-
appropriate test? Did the screener
use letters, numbers, pictures, and
isolated, linear, or single-surround
optotypes? As you will learn in
the pages that follow, all of these
elements factor in to how young
children perform on visual acuity
tests. In other words, a failed vision
screening may or may not really be
indicative of a real problem.
Strabismus history. When
it comes to strabismus, parents
will often use the term “lazy
eye” to mean strabismus and/
or amblyopia, the decreased
best-corrected visual acuity
often associated with strabismus.
Similarly, many parents use the
word “crossing” to refer to any
type of strabismus; esotropia,
exotropia, even in describing
vertical deviations. All of which
means the technician will have to
verify the direction of the observed
misalignment graphically with the
parents in order to make sense of
the history.
I use my hands to physically
simulate esotropia, or in-crossing
of the eyes by pointing to my
nose with both hands. Similarly
with a suspected exo-deviation,
I use both hands to point out
away from my ears to simulate
an outward drifting of the eyes
(Figures 1 and 2). Explore possible
strabismus more in your history
by asking which eye is seen to be
misaligned. Do the parents notice
any squinting? Bilateral squinting
is typically a sign of uncorrected
refractive error or ocular allergy,
while unilateral squinting is often
associated with strabismus. Ask
about eye rubbing. Does the
child always rub the same eye?
Who notices? Is it the parents, the
pediatrician, the child’s teachers,
other family members? Is eye
misalignment visible in family
photos? Is it constant, intermittent?
Is it happening at distance fxation,
with daydreaming, or at near
fxation, when the child attempts
to focus?
Diplopia history. Double
vision occurs when one fovea is
not directed at the same object
of regard as the other. While this
is quite common in older patients
with an acquired strabismus, it is
uncommon in young children with
an early-onset misalignment who
develop suppression, or the ability
to “turn of” the image from the
deviating eye. This phenomenon
occurs at the level of the brain’s
cerebral cortex. So double vision
in a pediatric patient, if it is real,
implies an acquired etiology and
may require special laboratory
tests or neuro-imaging studies
like MRI or a CT scan to explore a
possible neurological cause.
When interviewing patients
of any age with a complaint of
double vision, one of the frst
questions the clinician should ask:
“Does the double vision go away
if you cover either eye?” Binocular
diplopia resolves with unilateral
occlusion, while monocular
diplopia, diplopia still present after
covering one eye and most often
due to refractive error, resolves in
almost all cases with a pinhole. You
should also ask the patient if the
double vision is worse in certain
positions of gaze, at a certain time
of day, or at rest.
Pregnancy and birth
history. Children who were
born prematurely have been
shown to have a substantially
higher incidence of strabismus,
amblyopia, and high refractive
errors compared to full term
controls.1 So for these reasons,
you will want to ask questions
about the pregnancy, birth, and
developmental history of all
pediatric patients.
For the pregnancy, you should
ask the mother or parents about
illicit drug use, consumption of
alcoholic beverages, whether
there was a problem with preterm
labor, maternal age, paternal age,
prematurity (a full-term delivery is
40 weeks), low birth weight, use
of supplemental oxygen, presence
of retinopathy of prematurity and
whether it regressed/resolved on
its own or if it required laser photo-
ablation, whether it was a normal
spontaneous vaginal delivery
(NSVD) or caesarean section, and
whether this was planned or
unplanned, and whether there
Children often
present to the
pediatric eyecare
practitioner because
they failed a vision
screening at school or
at their pediatrician’s
office.
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were any labor complication.
Continue with questions about
birth complications, whether
there was an anoxic event/loss of
oxygen/delayed breathing, or any
breathing problems. You should
inquire as to whether there was
any trauma/instruments used
during the delivery (forceps,
suction), or any history of intra-
cranial hemorrhage, convulsions,
seizures, or known syndromes.
Developmental history.
Technicians who are parents
have a decided advantage here
because they are familiar with the
developmental milestones of their
own children. But there are a few
developmental milestones that
all technicians can easily learn to
help shed light on the observed
ophthalmic eye fndings as they
may contribute to a fnal diagnosis.
You should ask if the child has
met all of his or her milestones
to date. Familiarize yourself with
some of the basic components
of pediatric developmental
milestones, available online at the
website of the American Academy
of Pediatrics.2
Past medical history. Most
children are very healthy and take
few, if any, medications. However,
this may not be the case for
children seen in a tertiary care
facility or a hospital that is part of
a large inner city medical training
center. Conditions associated
with prematurity like retinopathy
of prematurity, hydrocephalus,
seizure disorders, anomalous birth
defects and syndromes, and other
health problems become more
common in these situations. If
you are employed in one of these
facilities, you need to come to
terms with the various ophthalmic
sequelae and the medications
associated with them so you know
what to ask if and when these
children present to your clinic.
Because these kids tend to have
a team of healthcare providers,
the past medical histories and
medications are often, but not
always, well documented in the
medical record.
Family history. Asking about
the family history for pediatric
patients is not only good
medicine, it is now mandated
by the federal government
as part of its Meaningful Use
criteria for afective utilization
of the information obtained by
ophthalmologists in the electronic
medical record, or EMR. Questions
about other individuals with
strabismus, nystagmus, amblyopia,
or history of early-childhood
patching or glasses should be
routine. Additionally, individuals
with childhood blindness,
glaucoma, cataract, or heritable
diseases should be documented in
the EMR.
Social history. Lastly, it is
also important to know the living
conditions at home because social
stressors like divorce, abuse, foster
parents, and institutionalization
due to developmental delay may
have implications for compliance
with prescribed glasses, patching,
use of eye drops, and attendance
at follow-up examinations. Ask
about who lives with the child,
especially if he is accompanied
by only one parent, grandparent,
older sibling, aunt, or uncle. Is
there smoking in the house? Are
the parents married, separated,
or divorced? Are there pets in or
around the house?
Pediatric sensory motor examinationThe sensorimotor examination is
the key element in the pediatric
eye screening. The problems
that bring children in to see the
pediatric eyecare professional
include a number of diferent
types of strabismus, vergence
abnormalities, amblyopia, and
refractive dilemmas, all of which
can impact ocular alignment,
depth perception, and sensory
fusion. The examination typically
starts by assessing (sensory) fusion
frst and then measuring (motor)
alignment by prism and alternate
cover testing, both typically
performed by a trained specialist.
Sensory testing. Assessing
sensory fusion begins by
measuring gross binocular fusion
potential with the Worth 4-Dot
Test, which uses red/green
anaglyph glasses and a special
fashlight that displays four
lights—two green, one red, one
white. Convention dictates that
the patients wear the glasses with
the red lens over the right eye, if
there is a choice. The fashlight is
then shown to the patient at both
distance and near fxation, and she
is asked to report how many lights
are seen with both eyes open.
The response for binocular fusion
is four lights seen, in any color
arrangement. The response for
suppression is only one color seen,
either only two lights (red) for
The sensorimotor examination is
the key element. The problems that bring
children in can impact ocular alignment,
depth perception, and sensory fusion.
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suppression of the left eye or only
three lights (green) for suppression
of the right eye. A response of
fve lights seen is consistent with
diplopia or manifest strabismus.
Interpreting the results of the
Worth 4-Dot test should be done
with caution because the test
is dissociating, meaning it may
cause an otherwise controlled
or intermittent strabismus or
phoria to manifest itself as a tropic
deviation behind the darkened
anaglyph glasses. Children from
age 3 to less than 5 years of age
can be asked to just count the
lights on the fashlight by touching
them one at a time, usually just at
near fxation (Figure 3).
Near stereo acuity testing
assess fne sensory fusion ability,
requiring clear and equal acuity
in both eyes and fner motor
alignment than what is required
by the Worth 4-Dot test. There
are a number of near stereo tests
available, though the industry
standards are typically the Titmus
or Randot stereo tests from Stereo
Optical. In each test, the wings
of the fy are the most disparate
and easily perceived, even by
children as young as 2.5 or 3
years of age. The circles of the test
correspond to increasingly fne
stereo images—the more circles
that are seen, the fner the stereo
acuity, and the better the visual
acuity in each eye. We use the
animal fgures only for preschool
children. Many of these tests come
in pediatric versions as well, which
can enhance cooperation.
Measuring strabismus. In
assessing strabismus, there are
basically two ways to quantify
ocular misalignment. The prism
and alternate cover test utilizes
either bar and/or loose prisms and
some type of opaque occluder.
Often a child will not allow you to
approach him with an occluder,
so your hand, palm, or thumb,
though not preferable, will have
to do (Figure 4). Corneal light
refex estimating techniques are
based on the observed position
of a corneal light refex in relation
to the patient’s pupil in the
misaligned eye. These will be
discussed below. But let’s frst talk
about the basic type of strabismus
seen in the pediatric clinic.
When strabismus does present
itself, there are four types of
deviations with which the clinician
needs to become familiar. An
esotropia is an eye that deviates
in toward the nose, with a corneal
light refex temporal to the center
of the pupil. An exotropia is an
eye that deviates out away from
the nose, with a corneal light
refex nasal to the center of the
pupil. A hypertropia is an eye that
deviates up with a corneal light
refex inferior to the center of the
pupil. And a hypotropia is an eye
that deviates down with a corneal
light refex superior to the center
of the pupil. The term orthophoria
or orthotropia means that the eyes
appear straight with corneal light
refexes centered in both pupils
or by alternate prism and cover
testing.
Clinicians who routinely
perform sensorimotor evaluations
on younger children have to
fnd creative ways to maintain
the child’s interest. For distance
measurements, animated toys
and projected movies work well.
A parent or coworker can also
assist by standing at the end of
the exam lane, holding a fashing
toy, and calling the child’s name.
For near measurements, young
children are asked to sit on a family
member’s lap. The child usually
feels more secure there, and the
family member can then be asked
to hold a fxation stick or toy on
the examiner’s nose, leaving both
hands free to hold an occluder or
prism bar. Unfortunately, it is not
the scope of this article to discuss
the specifc details of how to
perform the prism and cover test.
The take-home message is that
children tend to respond favorably
to animal puppets and toys, and of
interest, there seems to be some
science to support why.3
Despite our best eforts to
engage the patient, there will
times when a frightened or
uncooperative child will not
permit sensory testing or a prism
and alternate cover test. Other
Figure 3.Ask younger children to count lights on the fashlight when using the Worth 4-Dot Test.
3
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times, a patient may have such
poor vision in one eye, that she
is unable to fxate well enough
to be measured with prism and
alternate cover testing. In these
circumstances, the clinician can use
a number of corneal light refex
tests to estimate and quantify the
observed strabismus.
To perform the Hirschberg
test, simply shine a bright penlight
or fxation light at the patient
from a distance of about arm’s
length. Observe the position of
the corneal light refexes from
the fashlight in each eye of the
patient. They should be centered
in each pupil if the eyes are
straight. However, if the light
refex is displaced near the pupil
margin in one eye, this represents
an approximate deviation of 15
degrees or 30.00 prism diopters
(PD). If the light refex in one
eye is displaced mid-iris, this
represents 30 degrees or 60.00 PD
of misalignment. And if the corneal
light refex in one eye is displaced
at the limbus, this represents
approximately 45 degrees or 90.00
PD of misalignment. It is up to the
examiner to identify the proper
type of strabismus or direction
of misalignment, but temporally
displaced corneal light refexes
correspond to eso-deviations,
medially displaced light refexes to
exo-deviations, inferiorly displaced
light refexes to hyper-deviations,
and superiorly displaced refexes
to hypo-deviations.
To estimate strabismus by
the modifed Krimsky test, the
examiner uses loose or bar prism
to eventually center the displaced
corneal light refex in the deviating
by trial and error, placing the
appropriate prism over the non-
deviating eye.
Abnormal head postures.
Children sometimes develop an
abnormal head posture called
torticollis (Figure 5), and their
families are asked by the child’s
pediatrician to have the patient
evaluated by a pediatric eye-care
specialist to determine if the
head position is being driven
by strabismus or some other
abnormality of binocular vision.
The strabismus measurements
required to diagnosis an ocular
abnormality in this situation are
not always possible in younger
children. But one of the quickest
and easiest ways to rule out an
abnormality of binocular vision is
to do a patch test. Simply place a
patch over one of the child’s eyes
and observe for 60 to 90 seconds,
asking the parents to restrain the
child’s arms if necessary to prevent
her from removing the patch. If
the head posture improves, this is
suggestive of an underlying ocular
abnormality of binocular vision
and requires further assessment
and more detailed measurements.
If the torticollis does not improve,
this is suggestive of a non-
ocular, perhaps musculoskeletal
abnormality, most often of the
sternocleidomastoid muscle on
the side of the neck toward the
head tilt.
Assessing visual acuity in childrenBirth to 2 to 3 months. If
the clinician is going to try
to measure vision in young
children, it’s important to frst
have an understanding of what
is considered normal, or age
appropriate visual acuity in the
pediatric population. Is a baby
born with 20/20 acuity? Not at all.
Birch and coworkers estimated,
through preferential looking
techniques, that vision at birth
is somewhere around 20/600,
developing rapidly in the frst
year of life and improving to
approximately 20/60 by 12 months
of age, and reaching an adult
normal of 20/20 by 60 months or 5
years of age.4
Newborn children are by
defnition visually inattentive and
immature. They will, however,
blink to a bright light shown close
to their eyes. Their eyes will also
pop open suddenly when the
room lights are fashed on and of,
a refex some clinicians call eye
popping, which tends to disappear
by around 6 months of age. Some
children will also respond with
saccadic eye movements to the
rotating stripes of the optokinetic
drum. This is just about all you can
expect from a neonate in his frst
several weeks of life.
Intermittent strabismus may
also be observed, but it should
not be present by 2 to 3 months
of age, correcting for prematurity.
Pupils become active, and
accommodation begins by 2
to 3 months of gestational age,
which you can demonstrate by
showing the child a target that
stimulates accommodation, the
multi-colored lights of the Worth
4-Dot fashlight, for example, and
observing the constriction of the
child’s pupils. Mid-dilated pupils
sluggishly responsive to light by
this age predicts reduced visual
acuity for age. Nystagmus in this
age group suggests abnormality
of the anterior visual pathway,
while the absence of nystagmus
in an otherwise visually inattentive
neonate is suggestive of cortical
visual impairment, or impairment
at the level of the brain.
3 to 6 months. As children
approach 6 months of age,
they become extremely visually
attentive in the near range,
preferring faces over objects and
toys. They will sit on their parents’
laps and stare at you with an
astounding aplomb. Acuity can be
assessed for this age group in a
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Figure 4. Often a child will not allow you to approach him with an occluder, so your hand, palm, or thumb, though not preferable, will have to do.
Figure 5.Abnormal head posture called torticollis may indicate strabismus or some other abnormality of binocular vision or a non-ocular cause.
Figure 7.Demonstration of the “blink them in” technique for administering dilating eye drops in children.
Figure 6. Occluding can sometimes be a challenge. The author recommends special occlusive glasses designed for visual acuity testing in children.
5
number of ways, including forced
recognition grated acuity tests
like Teller Acuity Cards (Stereo
Optical) and by observing how
they fxate on and follow silent
fashing targets, like a fashing toy
star, through a smooth pursuit
with each eye. This is typically an
abduction movement out toward
the ear followed by adduction
back again toward the nose,
without losing fxation. Repeat if
necessary. Last, but certainly not
least, if all else fails, they can fxate
on and follow the examiner’s face
through the same smooth pursuit
movements!
One can also take advantage
of the vestibular ocular refex to
assess the visual pathways by
taking the child (make sure you ask
for permission from the parents!)
and holding her up in front of
you at eye level, face toward you,
spinning around gently in one
direction on a rotating stool. This
motion stimulates optokinetic
nystagmus (OKN) through the
inner ear. What you will see is the
child doing a smooth pursuit in
the opposite direction of the spin
as she watches the environment
rotating by behind you, then a fast
saccade back in the direction of
the spin, repeated over and over
again until you stop spinning. At
this point, a child with intact visual
acuity may exhibit a beat or two
of residual OKN, dampening in less
than 5 seconds. But in a child with
decreased or absent visual acuity,
the OKN will not dampen and
persist for more than 5 seconds.
6 to 36 months. Preverbal
children from 6 to 24 months of
age can be presented with a base
down prism in front of one eye,
typically 16.00 or 18.00 PD. With
both eyes open, this creates a
vertically diplopic second image
of a target at distance or near
fxation. This is called the induced
tropia test.5 If vision is intact,
and the child is not suppressing
visual input from the eye behind
the prism, you will see a vertical,
hypertropic shift in both eyes as
the child attempts to fxate on
the second image that appears
above the original fxation object
of interest. Absence of induced
vertical shift is suggestive of
amblyopia in the eye behind the
6
7
4
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prism. This can be documented
in the chart as C for central (the
eye is straight), S for steady (no
nystagmus), and M for maintained
(fxation through the prism), or
CSM. If fxation is not maintained
for more than one to two seconds,
you would document this as
CSUM, for Central, Steady, Un-
Maintained.
After age 3: Recognition
visual acuity. Testing recognizable
optotypes, whether Allen or Lea
symbols, HOTV or Snellen letters,
can begin from 30 to 36 months,
depending on the cognitive ability
and cooperation of each child. The
author’s personal bias, based on
15 years of clinical experience, is
not to attempt recognition acuity
before 36 months due to variability
of maturity. Of course there are
always exceptions to every rule.
This age group will also peak
during the test, so occlusion of
the untested eye needs to be with
a tape patch or special occlusive
glasses designed for visual acuity
testing in children (Figure 6), or
adhesive tape directly over the
child’s eye, or on the lens of his
glasses. Single surround bars, also
called crowding bars, expedite
testing in the younger children and
have been shown to accurately
replicate the resolution challenge
of linear optotypes in amblyopic
patients while minimizing test time
in our most inattentive patients.6
You can help the child stay
engaged by turning the matching
card to the blank side and
advancing to the next letter. Point
at the screen and ask the child to
look at the screen, then fip the
card over to show the choices and
ask the child to match the shape
she sees.
From age 4, HOTV crowded
optotypes can be used with good
reliability, though every child is
developmentally diferent, and
sometimes the examiner has to
resort back to a matching version
of the test. Most children will
progress to full Snellen recognition
optotypes by age 5, though I tend
to minimize the attention required
with linear Snellen acuity testing
by using the single surround,
crowded optotypes until age 10,
again, depending on the child,
maturity, and intellectual abilities.
Checking pupilsAn important part of any complete
eye exam, this component of the
encounter, while straightforward
in adults, can be challenging
in inattentive children. A direct
ophthalmoscope is often helpful if
you have a less than cooperative
child because you can illuminate
the pupils from a more remote
distance and see a red refex in
addition to the corneal refexes
of the Hirschberg test. This is
also very useful in patients with
dark irides, as it makes the irido-
pupillary border a lot easier to see,
especially for those of us who are
presbyopic!
Giving eye dropsThe last step in the pediatric eye
exam is arguably one of the most
stressful. here are a few techniques
that will foster cooperation, help
minimize stress, and overall make
the process of instilling eye drops
less tumultuous for the patient, his
family, and you as the examiner.
My favorite technique is the
“blink them in” technique. I explain
to the child that we need to put
eye drops in her eyes. I then direct
her attention to a playful sticker
attached to the ceiling above her
head. I ask her to tilt her head
back, then close her eyes, which
is exactly opposite of what she is
expecting you to say. “Close your
eyes tight, and I’m going to put the
cold water on your eye lashes,” I
tell her. This seems to be accepted
by most children. “And when I
count to three, we’re going to do
a big blink, really fast.” I give her
a tissue and tell her that she can
wipe after she blinks. I also gently
hold the child’s chin up until she
blinks to avoid the drops streaming
of her face and into her lap (Figure
7). I explain to the parents that
while this is a messy technique
(drops run all over the place,
usually on the child’s clothes), it
really works. Give it a try.
Another technique is the
“kangaroo pouch” technique in
which you cajole the child into
looking up in a similar manner
and at a similar target as described
above, then place the drops in
cul-de-sac of his lower lids. The
lower lid cul-de-sac is much less
sensitive, and a great place to
instill an eye drop. I don’t have as
much use with this technique in
the younger children, but it does
work well with older children and
teenagers.
Despite these techniques
some children, especially infants
and toddlers younger than 36
months of age, will not cooperate
with instillation of drops. In these
cases, it is necessary to restrain
the child in order to properly instill
the drops. In doing so, you will
frst want to explain to the child’s
parents why you have to restrain
the child. Once parents agree,
small babies and very young
children can be placed on their
backs on the right arm of one
parent seated in the exam chair,
the child’s head toward the crook
of the parent’s elbow, feet across
the parent’s lap. Have the parent
hold the arms while you take care
of the head, lids, and instilling
drops. In older children, or bigger,
stronger kids who require restraint,
there is a real risk of injury to the
parent, the child, or even you as
ES573412_OPTechsupp0315_009.pgs 02.21.2015 05:05 ADV blackyellowmagentacyan
10 I n f o . I n s p I r at I o n . C o m m u n i t y .
itech Spring 2015
the examiner. A diferent technique
is recommended for these kids.
Have the child straddle the
parent’s lap facing toward the
parent, with one leg on either side
of the parent’s hips. Seat yourself
directly in front of the parent’s
knees, ask the parent to lean the
child backward onto your lap so
that he is prone on his back on
your legs and his head is in your
lap, facing the ceiling. You can
now ask the parent to restrain the
child’s arms and hands with their
hands, the legs are immobilized
around the parent’s hips, and you
have both hands free to restrain
the head, manipulate the lids, and
instill the drops.
Lastly, it is extremely important
for the technician to control the
dosing of dilating drops instilled
in the eyes of young children
because these medications can be
toxic,7 trigger seizures,8 and even
lead to cardiac arrest9 in neonates
and small children.
For newborn babies and
children younger than 6 months
of age, one drop of cyclomydril
(Alcon), which consists of
cyclopentolate hydrochloride 0.2%
and phenylephrine hydrochloride
1%, is my drop of choice. In
children with darkly pigmented
irides, I add an additional drop
of tropicamide 1% because it is a
better midriatic drop, though on
its own, a poor cycloplegic agent.
Starting at age 6 months
and progressing to age 16, instill
cyclopentolate 1% drops in
lighter-pigmented eyes, adding
tropicamide 1% or phenylephrine
2.5% drops for more darkly
pigmented eyes. Some children
who have had laser photo-ablative
surgery for threshold retinopathy
of prematurity may require all
three drops to dilate adequately
enough for the physician to see
into the eye.
Causes of decreased vision in infancyThe causes of decreased vision in
children, in addition to amblyopia
and refractive error, include
developmental malformations and
acquired lesions of eyes and visual
pathways. Clinical markers and
signs include the oculo-digital sign,
a habitual pressing on one or both
eyes by the child with their fnger
or fst. This behavior is specifc to
bilateral congenital or early-onset
blindness due to retinal diseases
and heritable retinal dystrophies,
predicting best-corrected visual
acuity usually 20/200 or less in the
afected eye. Index of suspicion
should be high in children greater
than 6 months who do not readily
make eye contact with you.
Congenital nystagmus is
commonly seen in disorders
of the anterior pathways, such
as ocular cutaneous albinism,
which involves the optic nerves.
Look for a compensatory head
posture, implying optimal acuity,
binocularity, and functional vision.
Nystagmus is typically absent in
cortical visual impairment (CVI).
Large, slow, roving nystagmus
or eye movements are often
associated with poor vision and/
or visual loss before the age of
6 months. These types of eye
movements are not seen in CVI.10
End on a happy note There are many challenges
associated with examining children
in the eye clinic. Indeed, it is one
part science, two parts art, and
mastering the required skills takes
skill, patience, practice, having the
right tools, and perhaps above
all, having the right attitude. After
a challenging session with any
child, end on a high note and
reward her for a job well done,
after making sure that is fne with
her parents, with a lollipop, or a
playful sticker she can wear out of
the ofce when she leaves. Treat
your pediatric patients the way
you would want someone to treat
your child, or you, for that matter.
Use dignity, empathy, and respect,
and they and their families will
remember you for it.◗
References1. Kushner, BJ. (1982). Strabismus and
amblyopia associated with regressed retinopa-
thy of prematurity. Arch Ophthalmol. 1982
Feb;100(2):256-61.
2. Hagan JF, Shaw JS, Duncan P, et al. 2008.
Bright Futures: Guidelines for Health Supervi-
sion of Infants, Children, and Adolescents, Third
Edition. Pocket Guide. Elk Grove Village, IL:
American Academy of Pediatrics. Available
at http://brightfutures.aap.org/pdfs/bf3%20
pocket%20guide_fnal.pdf. Accessed 2/18/15.
3. Mormann FA, Dubois J, Kornblith S, et al. A
category-specifc response to animals in the
right human amygdala. Nat Neurosci. 2011
Aug 28;14(10);1247-9.
4. Birch EE. Visual acuity testing in infants
and young children. Ophthalmol Clin North
Am. 1989;2:369-89.
5. Frank JW. The clinical usefulness of the
induced tropia test for amblyopia. Am Orthopt
J. 33(1983):60-9.
6. Peskin MA. Threshold visual acuity testing
of preschool children using the crowded
HOTV and Lea Symbols acuity tests. J AA-
POS. 2003;7(6):396–9.
7. Adcock EW 3rd. Cyclopentolate (Cyclogyl)
toxicity in pediatric patients. J Pediatr. 1971
Jul;79(1):127-9.
8. Demayo AP, Reidenberg MM. Reidenberg
Grand Mal Seizure in a Child 30 Minutes
After Cyclogyl (Cyclopentolate and 10% Neo-
Synephrine (Phenylephrine Hydrochloride)
Eye Drops Were Instilled. Pediatrics. 2004
May;113(5):499-500.
9. Lee JM, Kodsi SR, Gafar MA, et al.
Cardiopulmonary arrest following administra-
tion of Cyclomydril eyedrops for outpatient
retinopathy of prematurity screening. J AAPOS,
2014 Apr;18(2):183-4.
10. Brodsky MC, Baker RS, Hamed LM. Pediat-
ric Neuro-Ophthalmology. New York: Springer
Press, 1996.
Alex Christof is
assistant professor
of ophthalmology
at The Wilmer Eye
Institute at Johns
Hopkins Hospital
in Baltimore.
E-mail him at
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