Flashing back to my third year of optometry school, I remember seeing a 2-year-old patient on my schedule. To be honest, I was extremely intimidated by this, which was a bit odd to me. I mean, I had seen angry adult patients, rare complex cases, and confusing spectacle re-checks, none of which scared me. However, for some reason, the thought of doing a full comprehensive eye exam on a 2-year-old infant slightly terrified me, to put it lightly.
What tests can/should I do? What should this patient be able to see? What if they cry? What medications are contraindicated for this age? All of these questions along with the thought of, “I am terrible with kids,” were running through my head while I was waiting for the patient’s mother to finish the intake forms at the front desk.
Fast forward several years: I completed a residency in pediatric optometry and felt more comfortable than ever diagnosing and managing any pediatric patient that walked through the door.
As mentioned before, there are a wide variety of techniques that can be employed when doing a pediatric eye exam. And to make things even more confusing, these greatly differ for every age. To help with this, I’ve put together a general chart to make things a bit easier to digest when you don’t know what to do.
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Download the Pediatric Exam Cheat Sheet Now!
Use this cheat sheet to examine & prescribe for your youngest patients with ease.
Pediatric eye exam made easy
When conducting a pediatric eye exam, here is the key: If the patient can do the more complex test accurately and reliably, do that. If not, move down a step until you can get reliable data (reliability is the most important). The ages listed are for the technique that should be used for the average patient of that specific age group. However, keep in mind that developmental levels and comprehension can vary greatly depending on the setting you are practicing.
Prescribing for pediatric patients
Prescribing for pediatric patients can be scary. When in doubt, pick up the phone and call the pharmacy to see what they recommend. Some medications are weight-based and doing the calculations can vary greatly depending on the medication and age. For general use, I’ve built a simple chart for some common pediatric eye conditions that require medication prescribing.
Want the downloadable version of this cheat sheet? Download it here!
Top 3 tips for success
While there are guidelines for what to do in a pediatric eye exam and age based norms, the truly difficult part of a pediatric exam is building a rapport with the patient and their parents. Here are the top tips and tricks I picked up from my mentors.
Tip 1: Know your patient.
We all know there are some kids who are extremely shy and some who seem to be bouncing off the walls. With kids who are very shy, match their calm energy and be more gentle with how you speak and how you move your instruments. Lots of “whooshing” sound effects will go a long way as well. Vice versa, match the energy of your “of-the-walls” patient with exaggerated movements and a high volume voice.
Tip 2: Do not make dilating drops a big deal.
Kids are very good at detecting when an adult is nervous about something (ie. putting dilating drops in a kid). Instead of saying something like “I know this will hurt, be strong, it's alright.”, change your verbiage and energy to something more along the lines of “Here we go! One drop of water in each eye . . . Do you like movies? What is your favorite movie? Who's your favorite character?” etc.
Many times, if you do not make the drops a big deal, neither will the child. You can also liken this part of the exam to “splashing water in the eyes” from a previous bathing or swimming experience the child may have had.
Depending on patient cooperation and a variety of other factors, eye drops may be out of the question for that particular child on a given day. Further attempts at getting the eye drops in will likely end in the child screaming and washing out any eye drops with their tears (and creating negative memories of the eye doctor’s office). In difficult cases where eye drops are necessary despite poor patient cooperation, you can deploy another trick that is highly successful in most cases.
The trick here is to give the child’s parent or guardian the cycloplegic drops to bring home and instill into the child’s eyes (upon awakening) before their follow up visit with you in 1-2 weeks. Clinicians can give the parent a single-serving dose of cycloplegic drops by putting the drops in a contact lens case and using an empty preservative-free artificial tear vial to suck up the drops.
Tip 3: A little singing can go a long way
I will be the first to admit, I have little to no ability when it comes to singing. But lightly singing a familiar song (especially to infants) can remarkably calm them down when trying to get accurate retinoscopy readings or putting dilation drops in. Once you get past the awkwardness of singing in the exam room, the rest is easy !
Don't forget to download our Pediatric Exam and Prescribing Cheat Sheet!
Key takeaways
- Alter your exam to best fit the age of the patient.
- Don’t be afraid to match the energy level of the patient.
- When in doubt, check these guidelines I mentioned above and carry on.
Pediatric eye exams can seem daunting but they don’t have to be! There are many in the eyecare profession who don’t feel especially comfortable or confident seeing and managing these patients. With some minor tweaks to the normal adult comprehensive exam, these patients can add a lot to the versatility of a clinician. Not only do you get to change a child’s life, you also gain the strong rapport and relationship with them for years to come (plus likely the family of that patient too).
