Optometric disease management is so mainstream that there are limited encounters which seem that intimidating until a child with a challenge is in our chair, then all bets are off. A pediatric eye exam is a work of art which requires keen observation and efficiency. Unlike (most) adults, kids are often poor historians so it becomes the job of the skilled optometrist to manipulate the conventional exam, identify the problem and treat the patient.

Over the past couple of years, I have had the pleasure of working with the pediatric population. In that time, I came across some lingering questions that would arise based on history, patient responses or behavior. Similarly, there were a number of times when my colleagues would ponder over questions after a pediatric eye exam. The following is a list of the most frequently asked questions I have encountered. The answers include some techniques designed to help you achieve a smoother exam sequence. In addition, if things go south, these techniques can help you troubleshoot and get back on track.

Optometric disease management is so mainstream that there are limited encounters which seem that intimidating until a child with a challenge is in our chair, then all bets are off. A pediatric eye exam is a work of art which requires keen observation and efficiency. Unlike (most) adults, kids are often poor historians so it becomes the job of the skilled optometrist to manipulate the conventional exam, identify the problem and treat the patient.

Over the past couple of years, I have had the pleasure of working with the pediatric population. In that time, I came across some lingering questions that would arise based on history, patient responses or behavior. Similarly, there were a number of times when my colleagues would ponder over questions after a pediatric eye exam. The following is a list of the most frequently asked questions I have encountered. The answers include some techniques designed to help you achieve a smoother exam sequence. In addition, if things go south, these techniques can help you troubleshoot and get back on track.

What are pertinent questions to ask in the Case History?

In order to determine the visual status of the patient sitting in your chair, it is important to learn about their visual experience. Anomalous exam findings or behavior can often be traced back to delays during development. Vision impacts behavior so probing about a child’s social and spatial interactions is important in understanding the child’s visual schema. Here are some questions that can give you a better insight about how to direct your exam.

  • Pregnancy and delivery history: Any complications during this time that could impact the visual system so asking about birth history and delivery complications is always relevant.
  • Growth and development history: If a child did not meet his/her developmental milestones it’s possible that their visual system was impacted. In this case, they may require intervention such as vision or occupational therapy.
  • Educational history: If a child is falling behind in school, visual stress induced from uncorrected refractive error, binocular or accommodative issues may be part of the problem. Asking about educational history including reading issues can alert you to pay close attention to the accommodative and binocular system during the exam.
  • Behavioral pattern: As many behavioral optometrists have documented in the past, vision impacts behavior. A child who is unaware of where he/she is in space due to poor eye teaming skills can act out in many ways that might be misdiagnosed as behavioral challenges.
  • Medical history: Often times the visual system can be affected if the child has a congenital syndrome or had a history of hospitalization/trauma. Parents may not always understand the link between certain medical conditions and vision, but by getting a detailed medical history you could identify a visual problem. 

How do you measure Visual Acuities for different age groups?

Case history can help you develop an understanding of the developmental status of the child. To measure acuities, it will serve you well to have a variety of techniques in your arsenal in case one doesn’t work. Although writing “central, steady, maintained” seems tempting, attempt to get some quantitative form of acuity especially if the case history hints at a visual problem. Just like for adults, quantitative data analysis is better to monitor change. Yes, kids can vary from visit to visit based on focus and attention, but don’t underestimate their abilities! There are many methods that practitioners use, but here are some of my favorites. No matter which technique you decide to use, document it for consistency.

  • Lea Grating Paddles: These work great with infants and are not as bulky as Teller Acuity Cards so they are easier to store in your practice. The acuities are measured in cycles per degree at 57cm and can be adjusted by varying the working distance.
  • Cardiff Cards: This is a preferential looking test designed for the “harder to test”1-3-year-old kids. It contains familiar pictures which can help engage the patient. The cards are designed for 1-meter testing distance but can be used at 50 cm to encourage the child’s participation.
  • Lea symbols: For the cooperative toddlers, lea symbols are a hit. Matching the pictures to a similar printed layout can make the task easier. Lea symbols trump Allen pictures which frankly possess outdated symbols that are hard for even adults to recognize.
  • HOTV matching: As a child begins to learn the alphabet I often turn to HOTV matching for a better assessment of resolution acuity. Again, to make the task easier you can have a print out of the letters and ask the child to match similar letters.
  • Number acuity: Numbers are easier than letters for school-aged children because there are 10 choices (0-9) vs. 26 choices (A-Z). A child who shies away from letter acuity will often perform well with numbers.
  • Snellen acuity: This is the gold standard for acuities so attempt to use it when able. Kids as early as 4 years of age can surprise you with their knowledge of letters. Remember, don’t underestimate the child!

What is the best way to determine Refractive Status?

Case history and visual acuities can help you predict the refractive status of a child. It is important to accurately assess a child’s refractive status because early intervention can help a child succeed in school and in life. As Robert Kraskin alluded, the power of a lens is not in its numerical weight, but in the change, it can produce in the visual experience of the person.

  • Retinoscopy vs. Autorefractor: It is my opinion that retinoscopy remains the gold standard to assess a child’s refractive status. Although values of an autorefractor can be similar to retinoscopy post cycloplegia, in a functional accommodative state the values can be significantly different. This is because a table mounted autorefractor requires the child to be still and focused in an enclosed environment to get the most accurate measurement. During retinoscopy, however, you as the clinician can manipulate your technique to account for those discrepancies.
  • Spot vs Streak: Since retinoscopy is my preferred technique, I will delve into the two major methods. There are two methods–spot retinoscopy vs. streak retinoscopy. Most optometrist that graduated past the year 2010 may not have ever heard of spot retinoscopy, I certainly hadn’t. However, I soon learned that each has its own merit. A spot retinoscope allows you to look at the reflex as a whole, center, and periphery while a streak retinoscope only focuses on the center of the retina. Comparatively, it is easier to determine the axis of astigmatism with a streak retinoscope vs. a spot retinoscope. I have attempted to use both in different scenarios. Whichever retinoscope you use, remember to note the color of the reflex and frequency of change in accommodation to accurately assess the refractive status of the child.
  • Bars vs. Lenses: Loose lenses or retinoscopy bars can be used to neutralize the reflex. I prefer to use bars for purpose of efficiency. It has been said that loose lenses are smaller so it won’t tempt the kids to grab for them, but in my experience kids grab for everything so I may as well use something that is going to make the process more efficient.
  • To cycloplege or not: Cycloplegia has been a topic of debate for many years in pediatric optometry. In my experience, cycloplegia can help you understand the refractive status of the child but it may not directly translate to what you prescribe. Patient with low myopia or moderate hyperopia are good candidates for cycloplegia because it can tell you about the true vs. adapted refractive error of the child. Binocularity also plays an important role in determining when to cycloplege. A child with a strabismus that may have an accommodative component should have a cycloplegic analysis to gain a better understanding of what to prescribe. Additionally, over time as children grow out of hyperopia, it is important to determine if the newfound myopic shift is true or adapted myopia due to environmental conditions; cycloplegia can help you here.

What are high yield tests for accommodation and binocularity?

Visual acuities tell you about what a child can see. Accommodative status and binocularity testing tell you about how much effort they require to see. Assessing accommodation and binocularity can help you identify factors that are contributing to reading issues. You can then design a prescription to address the child’s symptoms via lenses or vision therapy.

  • Stereopsis: This is my personal favorite because I feel it gives me a lot of information – a low maintenance and high yield technique. I often measure stereopsis twice, once at the beginning and once after using the prescription I have determined. An improvement in stereopsis can help me solidify a diagnostic prescription. In the presence of strabismus, the random dot stereogram can help you determine if a child is bifoveal and weather that strabismus is constant or intermittent. Presence of RDS eliminates eccentric fixation and anomalous retinal correspondence.
  • Cover test or Hirshberg: For an infant Hirschberg test with a penlight can tell you if there is a tropia present. Alternatively, using your finger or hand as a cover paddle can help you perform a cover test with a “non-threatening” device.
  • Monocular Estimate Method (M.E.M): Assessing accommodative status for a school-aged child is important because it gives insight into how much effort they require to see things clearly. M.E.M is an excellent objective test that can be used in children of all ages. It requires a near acuity card with words corresponding to a child’s reading abilities and a retinoscope. You can observe a change in the accommodative status as the child reaches his/her threshold.
  • Phorias and Ranges: Once again, don’t underestimate the child. A 6-year-old can perform phorias and ranges in the phoropter, sometimes even better than the adult patients. Children often tell you what they see without overthinking the answers so these tests can run smoothly with a clear set of instructions and demonstration. If a child is struggling with the test or not at the developmental level to perform it, use a free space maddox rod and prism bar to asses phorias and ranges respectively.

What should you prescribe?

It is important to take into account all factors, information from the history, refractive status and binocularity before deciding what to prescribe. Coming from a structural background, I was often tempted to prescribe what I found during the exam to treat the patient. However, over the past couple of years, I have learned to use a prescription as a means of understanding where the patient’s visual experience has been, how they have adapted to it now and where it will progress in the future. For example, a low myope may not always be a true myope. The myopia may be an adaptation due to an inability to coordinate their eyes. In such a case, prescribing a minus lens may push the patient towards a trend of increasing myopia over years to come. Retinoscopy would reveal the difference and help you correctly prescribe for this patient. Here are some pearls to consider when prescribing for a pediatric patient.

  • Hyperopia: Is it amblyogenic? Is the patient symptomatic? If the patient is symptomatic for reading difficulties a low hyperopic prescription based on your dry retinoscopy could help the patient reduce the amount of effort exerted while reading. If the patient has reduced acuities due to moderate to high refractive error, start out with the maximum plus that yields maximum best-corrected acuity.
  • Astigmatism: Is it corneal or lenticular? If it’s lenticular, it is true astigmatism or a spasm? This becomes tricky and here it becomes the job of the skilled optometrist to identify if the astigmatism is truly present or not. Low levels of against the rule astigmatism (i.e. -0.75×090) could be present to due fluctuating accommodation. Use your retinoscope to determine if the astigmatism is consistently present and prescribe accordingly.
  • Myopia: True myopia can often be present in children. However, don’t jump the gun to prescribe minus lenses in an asymptomatic child just because it helps them achieve a faster 20/20. Children are often hesitant to read small letters so encourage them to enter a relaxed accommodative state where they can achieve their best visual potential. Use your clinical judgment and retinoscopy skills to figure out whether the myopia is induced or true. Do not leave a true myope undercorrected; remember to assess the near phoria after prescribing a minus lens. Many myopic patients can benefit from an add to relieve the stress for reading.

Although time is of the essence when you are working with kids, it is important to take a comprehensive approach to best treat the patient. Pause to reflect on the case at hand and prescribe to set the child up for visual success. Vision should be effortless so consider prescribing lenses to improve reading efficiency in a child who is symptomatic. I’m sure there are several more questions that come up on a daily basis about a pediatric patient. Hopefully, this list answers some of the common ones. At the end of the day, use your best clinical judgment and remember to have a little fun in your pediatric exams!

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