surprising number of 2-year-olds are interested in and willing to use the phoropter, especially if they can watch a cartoon during the refraction.

Fundus Examination

The fundus examination is frequently the final component of the pediatric eye examination. Although it can be challenging, particularly in young children, it is important to obtain an adequate view of the fundus regardless of the patient’s age. After appropriate dilation, infants and small children can be examined with the indirect ophthalmoscope using decreased illumination and a 28 D or 20 D lens. This may require restraint in some infants, particularly those being screened for retinopathy of prematurity (in which a topical anesthetic, use of an eyelid speculum, and scleral depression are needed for a complete retinal evaluation). For children older than 2–3 years, the practitioner can obtain brief but sufficient views of the optic nerve, macula, and surrounding retina by using diversionary targets such as illuminated toys and cartoons. Abnormal findings or incomplete evaluation may require examination under anesthesia.

Examination of the Uncooperative Child

Most infants and children can be accurately examined in the clinic setting. Even difficult children usually respond to some combination of rest periods, persuasion, persistence, bribery, and, if indicated, a repeat visit. There are times when, despite best attempts, significant concerns are present and adequate information cannot be obtained. In infants and younger children, brief restraint may prevail. However, the practitioner must consider the physical and emotional consequences of restraining a child, for both the patient and the parents. Depending on the nature of the ocular problem, a sedated examination or an examination under anesthesia may be the best solution.