Published in Pediatrics
How to Survive a Pediatric Optometry Exam
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There's something fun and exciting when it comes to seeing patients in a pediatric optometry exam, but it can also be challenging! Here are some tips.
Working at a family private practice, I have the great opportunity to see patients of all ages. But there’s something fun and exciting when it comes to seeing patients in a pediatric optometry exam. Their excitement to read letters because they’re a “big kid” now; watching the parents silently reading along and nodding as their child completes a line.
In school we learn which chart to use based on age and the refractive error guidelines for amblyopia. But it’s difficult to grasp the importance of interacting with parents and educating them until we are in practice ourselves. This guide is to provide some tips and tricks that go a long way. Combine that with patience and enthusiasm, and you’re all set to conquer the little one running around in your exam room.
Begin by making eye contact and greeting the patient. Though they may be 4, this is their eye exam and making them comfortable is key to a successful exam. I always ask the parent what brings them in. It could be as simple as a routine check before starting kindergarten or a concern for an eye turn. Remember, some parents may be just as nervous as their child. Subtly observe the child as you’re taking history from the parent and engaging with them. Is the young patient tilting or turning their head? How’s their coordination as they play with their parent’s phone?
Be flexible. Some patients won’t want to sit in the chair and would rather sit in mom’s lap or even in your chair. You have a job to do: if they’re not budging, mold your environment to perform the task at hand.
Instead of fussing over right and left and making a child nervous to pick the correct eye, I ask them to pick an eye to cover when we’re getting started. More often than not they will cover the eye that is not seeing as well so that they can read with their “good eye” first. This is a helpful indicator that they may be favoring an eye due to anisometropia or strabismus before you’ve even performed any testing. Note if they resist occluding an eye or try turning their head to peek through the eye that’s covered.
I always sit next to peds patients while taking acuities to motivate, create a sense of equality, and remain friendly. I don’t want to stand and hover over them. Our young patients are more aware of their vision than we think: you just have to ask leading questions. Make them comfortable and they are an open book. I’ve had a 5 year old patient tell me “I haven’t used this eye in a while,” once he covered his better seeing eye and another say, “Let’s check my good eye first.” Entering acuity results serve as a clue to dig deeper and are a reminder to note the difference in the reflex while performing retinoscopy — one of the most important tools for a pediatric examination.
After pediatric patients realize they won’t be getting any shots at the eye doctor’s office, I find they are most excited to sit behind the phoropter. I always shine the light in mom or dad’s eye first to show it won’t hurt and calm their nerves.
When performing retinoscopy, I start by reaching for the retinoscopy rack to obtain my first set of measurements. Moving the rack in front of the patient’s eye along with poor fixation may result in fluctuating retinoscopy findings and induce proximal accommodation. When this occurs, I’ll perform retinoscopy behind the phoropter if they are 4 years and older to get a second set of data and compare both results.
Continuously engage the patient by asking questions, since their attentiveness and fixation is key to scoping on axis and obtaining accurate objective measurements. I recently saw a 2 year old and we practiced counting to 10 while I performed retinoscopy, and his fixation drastically improved.
With luck, you will likely have a couple minutes to scope the eyes and determine their refractive error. Be confident and trust what you see, note when a reflex is more dim, and establish if it matches with their entering visual acuity. The patient’s parents are watching you with hopeful eyes and are awaiting to hear if their child needs glasses or not.
Your peds patient read 20/20 and has very little plus on retinoscopy. Don’t let out a sigh of relief just yet. Do you need to dilate this first-timer’s eyes?
Pediatric patients have large amplitudes of accommodation and you don’t know how much plus they are hiding until those drops are in. They may kick, they may scream and be heard by your next peds patient (yikes) but you’re getting those drops in.
The second you say drops, the patient’s eyelids become the strongest force in their body. Have the parent hold them in their lap and “hug” their arms. If the patient is sitting in their parent’s lap and leaning in, I always drop the eye that is closer to the parent because once those drops go in, the young patient will curl up into mom’s arms and you’re not seeing that eye again.
You survived the first part of a pediatrics exam, determined their refractive error, and fought the patient’s tears to get the dilating drops in. All of that just for a sticker to make them smile. After all that is said and done, what’s next?
You determined their cycloplegic refractive error and think the hardest part is over. Not quite yet. Now is the time to educate parents. This education is a major stepping stone to promote glasses wear and vision development. I’ve compiled a list of FAQs and how to guide parents through the process of their child’s need for glasses.
“Why can’t my son read that with his glasses on?”
Glasses are viewed as the magical solution, not just in pediatrics but with the geriatric population with existing ocular disease as well. Discussing the visual acuity expected based on the patient’s age and existing refractive error can ease the minds of parents, set expectations, and motivate them to help in the development of their child’s vision. Don’t leave it up to Google; explain to parents the type of prescription their child has and how it affects their vision at all distances.
If you’re worried about compliance, this is the perfect opportunity to schedule a visual acuity check in 6-8 weeks to rule out refractive amblyopia and measure their deviation if a strabismus is present. These follow-up visits serve as another opportunity to reinforce the importance of glasses wear at a young age.
“Is my child nearsighted or farsighted? You said farsighted, so why does she need them full time?”
Your +4.00D patient just read 20/20 uncorrected and mom doesn’t get why she needs glasses. Hyperopia can be a tricky beast, and I’ll make analogies for the parents to understand. I tell them that seeing for the daughter, “Is like running without shoes on. She can do it but she’ll get tired quickly and won’t get very far.” Once parents realize their kids are over-focusing to see, and it’s creating strain on their eyes on a daily basis, they are quick to appreciate the need for glasses wear for their child.
“He just had an exam 3 months ago, why did he fail the school screening again? These glasses aren’t working”
I’ve lost count of how many parents have scheduled appointments for their children because their son or daughter have failed a school screening WITHOUT their current glasses on. The parents come in befuddled and claim the glasses aren’t working until they see their child read in front of them. I’ll fill out the form from the school nurse, re-educate the parents, and inform them they didn’t pass because their glasses weren’t on.
On the other hand, there will be a subset of patients who will fail WITH their glasses on due to their refractive error, and parents will think something is wrong with their prescription. This usually occurs in patients with refractive amblyopia who have been lost to follow-up, and are not wearing their glasses as prescribed.
This is an opportunity to educate the parents and the young patient on the importance of helping both eyes work together and see equally. I’ll casually list fun jobs a child may want or for pre-teens, nudge them towards compliance by discussing driving and getting their license. Don’t let them slip away again: schedule a follow up visit or initiate treatment for their amblyopia.
“What do you mean she doesn’t need glasses?”
Yes you. Have your answer ready.
A conversation of patient education for pediatric patients is not complete without discussing the hurdle of telling parents their child — aka Malingering Molly — does not need glasses. Some parents are on your side. They’ll wink at you as you’re about to discuss the results of the exam to show they knew the final results all along. But there will undoubtedly be a few parents who are convinced their child needs glasses.
There have been times where I’ve even shown the parents the phoropter with the lens values at zero or minimal powers once the refraction is complete. Or put a +0.12 lens in front of the patient’s eyes and say “Can you read this now?” and the vision has suddenly improved by 5 lines. The doubt will persist through the demonstrations you’ve exhausted and subtle gestures you’ve made to the parent during the exam. I always present the option of parents receiving a second opinion for their child, since you want patients and parents to leave as comfortable as possible though they may not agree with the final results.
If you educate the parents the first time they walk through your door, you’re already promoting compliance and encouraging return for follow-up visits. You will lose patients to follow-up, and re-examine the patient a year later for their annual to unfortunately find their visual acuity has not improved. Re-educate, find a way to connect to the patient and their parents, and initiate treatment then and there if you fear losing them for another year.
It’s our job to equip our patients not only with corrective lenses to improve vision but with the knowledge, tools, and resources to increase their quality of life.
What is your number one tip for a pediatrics exam? What are some common questions parents ask you during exams?