Extra steps can make a pediatric ophthalmology exam successful

Examining a child may be a daunting process for a comprehensive ophthalmologist.

“The last time you might have examined a child was in residence, and for some people, kids really scare them, even if you have your own,” Rupa Wong, MD, said in a presentation at the Real World Ophthalmology meeting. “Examining them in the office, especially an eye exam, can be really challenging.”

Wong gave some practical tips on how to make a pediatric examination less intimidating.

Have toys and movies

Showing a movie during an exam helps with fixation because it keeps the patient’s attention better than a pen or a finger.

“It really does help to have a distance fixation target that kids are interested in,” Wong said. “I have these cheap $20 Amazon flashlight toys. They help because they show you the pupillary light reflex, and you can assess for any strabismus very quickly.”

Explain everything

Wong said it can be easy to go on autopilot during an exam, but it can help to explain every step of the process because children like to know what is coming.

“Of course, your adult patients want explanations too, but you need to take the time to explain to children,” she said. “It helps you develop that relationship and that rapport with the patient, as well as the parents.”

Use mixed drops

Many children do not like to have drops put in their eyes, so streamlining the process makes it easier for the patient and the physician.

“I buy a drop that is a combination of cyclopentolate, tropicamide and phenylephrine that’s all in one bottle mixed by [a compounding pharmacy],” Wong said.

She also uses a small spray bottle that allows her to apply the drops to the child’s eyelashes so it can seep into the eyes.

“If you have trouble putting drops in kids, that’s a really easy way to do it,” she said.

Talk and examine at the same time

Wong said children tend to have limited attention, so it is important to be as efficient as possible. She said it helps to talk to them during the exam.

“If I’m doing a covered-uncovered test, I’m talking. ‘How’s school? Did you start classes already? What’s going on?’” she said. “You’re really trying to maximize and be as efficient as possible with children because you have such a small amount of time. You never know if they’re going to just turn the corner and decide not to cooperate again.”

Accept that the exam might not be comprehensive

Because of limited time, a child may not get as complete of an examination as an adult, but this is acceptable.

“Just know that you are not going to be able to get every single thing as perfectly as you want to,” Wong said. “You’re really trying to hit the high points. Make sure that the child doesn’t have strabismus, get a good refraction and get a good look at the posterior pole. At the very least, you’re trying to just check off all the boxes of making sure that you’re not missing something that could kill or blind a patient.”

Listen to the parents

Having an extra person in the exam room might be difficult, but Wong said parents are an important part of the process.

“Parents are always the biggest advocates for patients,” she said. “Always make sure that the parents feel heard, that they know you’re listening to them and that you’re taking their concerns seriously.”

Practice retinoscopy

Although her staff uses an autorefractor after the patient is dilated, Wong said she finds that using retinoscopy is faster with children.

“If your clinic is running behind or you have a kid, you can’t use an autorefractor. Make sure you can use [retinoscopy],” she said.