CHAPTER 1

The Pediatric Eye Examination

Children are not merely small adults, and most ophthalmic problems in children differ from those in adults. Each developmental level in children requires a different approach to the ophthalmologic examination. Proper preparation and attitude can make the ophthalmologic examination of pediatric patients both enjoyable and rewarding.

Preparation

If possible, a small room or corner of the waiting area should be designated for children. Both the parents and other adult patients will be grateful for this separation. A small table and chairs, some books, and some toys are sufficient.

A dedicated long pediatric examination lane with different types of distance fixation targets is optimal. Having several small toys readily available for near fixation is useful for the 1 toy, 1 look rule (Fig 1-1). Light-colored plastic finger puppets become silent accommodative near targets that can also provide a corneal light reflex if placed over a muscle light or penlight.

Figure 1-1 Small toys and pictures and reduced letter and E charts are used as near fixation targets. (Reproduced with

permission from Haldi BA, Mets MB. Nonsurgical treatment of strabismus. Focal Points: Clinical Modules for Ophthalmologists. San Francisco: American Academy of Ophthalmology; 1997, module 4. Photograph courtesy of Betty Anne Haldi, CO.)

Because some children fear the white coat, many pediatric practitioners prefer not to wear one.

Examination: General Considerations and Strategies

When the patient is an infant, it is especially important to obtain information regarding the pregnancy and neonatal period, paying close attention to maternal health, gestational age at birth, birth weight, and neonatal history. The physician should also ask whether the child has reached applicable developmental milestones and whether there are any neurologic problems.

Past and present medications should be recorded, along with drug sensitivities and allergic responses. A family history regarding strabismus and other childhood eye disorders should be obtained. Previous ocular surgeries should be reviewed.

The examination begins with observation of the child as the practitioner enters the room. With practice, the practitioner may gather important information before the formal examination begins. Visual behavior, abnormal head position, dysmorphic features, ability to ambulate, familial disorders (note parents and siblings), and family social dynamics can be effectively observed at this time.

The practitioner should be seated at the child’s eye level—some children are more comfortable sitting in a parent’s lap. Introducing oneself to the child and the parent and establishing and maintaining eye contact with the child are important. Being relaxed, open, honest, and playfully