examining pediatric eyes - modern medicine · examining pediatric eyes supplement to and ... (nsvd)...

the common eye problems

found in adults, developing

over decades of life as acquired

disease, are dif erent in

children. There is an old pediatrics adage

that “children are not little adults.” This is

certainly true when it comes to the pediat-

ric eye exam that many allied health care

personnel f nd themselves facing, often

with dread, on a weekly or daily basis.

Obtaining pertinent history—often

from a source other than the patient—and

relevant clinical information to help the

physician arrive at the proper diagnosis

and provide the appropriate treatment,

requires a dif erent and creative approach,

patience, and talent. Technical staf who

themselves are parents have a distinct

advantage: they are familiar with the

nuances of behavior in young children.

They know the various developmental

milestones, when children start to sit up,

stand, learn to walk, and start talking.

These milestones are an important part

of the pediatric history and often play an

equally important role in illuminating and

the underlying cause of clinical signs and

symptoms.

The pediatric eye exam can be broken

down into f ve basic components:

■ History and chief complaint

■ Sensorimotor evaluation

■ Visual acuity testing

■ External exam and pupillary evaluation

■ Instillation of dilating eye drops.

We will conclude with a brief review of

the more common causes of decreased

vision in infancy.

Preliminaries of an exam

The pediatric eye screening begins by

observing the child at ease, f rst in the

waiting area as you walk out to call and

greet him, then as he walks in to the exam

room with you. Introduce yourself. Of er a

handshake to adults and older children. Be

cognizant of the fact that some cultures

and religions do not shake hands. You

should become familiar with your patient

demographic and apply these concepts

accordingly. Comment to a child about

volume 04 | issue 1 | spring 2015

1

CLINICAL PEARLS FOR HELPING YOUR SMALLEST PATIENTS

EXAmininG PEDiAtRiC EyES

SUPPLEMENT TO AND

See Pediatrics on Page 3

Figures 1 and 2. The author using his hands to physically simulate the directions of eso-deviations and exo-deviations to help parents better understand.

2

By Alex Christoff, BS, Co, Cot

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clothes, toys, what they’re eating,

siblings, etc.

As you enter the exam room,

have the children and their

families take seats away from the

exam chair if possible, guarding

exam-chair time as a precious

commodity. Once the child is

seated in the exam chair, her

attention timer is ticking. If you

approach the interview and this

initial part of the exam with dread,

children will sense your tension

and become uncomfortable. It is

incumbent on you as the examiner

to gain the child’s conf dence and

trust, and you will want to do so

in a relaxed, open, honest, and

playfully engaging way.

Once the child is seated in the

exam chair, you should establish

and maintain eye contact. Sit at the

child’s eye level by lowering your

chair/exam stool and/or raising

the child’s exam chair. Maintaining

eye contact may or may not be

possible with autistic children

who often avoid eye contact

with others. You will want to

initiate verbal rapport with simple

questions comments, such as,

“How old are you?” Over-estimate

age and grade level. Ask about

siblings who came with her to the

appointment today. These quick

simple pearls warm the experience

for the child and her family, and for

you as the examiner.

It is important to remember

that as you work with children

you have to focus your exam.

Check what you need early on

while you have cooperation, and

save the more dif cult tasks for

last. You will have to develop a

dif erent vocabulary. For example,

say “magic sunglasses” when

introducing the anaglyphic glasses

of the Worth 4-Dot test and the

polarized glasses of the various

stereo acuity tests. Use “special

f ashlight” to describe your

retinoscope, and “funny hat” or

“coal miner’s hat” when describing

what the physician will do with

the indirect ophthalmoscope.

“Magnifying glass” is an apt

description of the magnifying

lens used with the indirect

ophthalmoscope, and suggest

“let’s ride the motorcycle/bicycle”

when it is necessary to do a slit

lamp exam.

Taking a history“When all else fails, take a history.”

These words were the sage advice

of J. Lawton Smith, MD. Former

ophthalmology resident at the

Wilmer Eye Institute in the 1950s,

Dr. Smith went on to become an

internationally recognized neuro-

ophthalmologist at the Bascom

Palmer Eye Institute in Miami.

All medical histories should

begin by identifying the patient’s

chief complaint, preferably in as

close to their own words as the

electronic medical records of the

present day may allow. Examples

of a chief complaint include,

“decreased vision,” “headaches,”

“blurred vision,” or “double vision.”

The clinician will next want to

evaluate the history of present

illness, or HPI. For the parents, ask

who referred the child in to your

of ce and why. Sometimes the

simple question, “What can we

do for you today?” works best. Try

to establish when the problem

started (onset), how often the

problem is noticeable (frequency/

severity) and when the symptoms

manifest do themselves, how long

do they last (duration).

Who notices? Relatives,

teachers, the pediatrician?

Sometimes you can ask the child

simple question like, “Which eye

hurts?” or “Which is the bad eye?”

But avoid complex topics like

questions about double vision in

younger children because this is a

dif cult concept at best for most

preschoolers.

Expand your history with

questions about treatment and

what has been done to address

the problem. Was a more extensive

workup required that might have

included blood work or imaging

studies? And how has the problem

developed or changed in the

interim between the last of ce visit

and the most recent visit? Do the

parents know anything about the

problem? This is the Internet age,

and most parents have explored

their child’s eye problem online

before having sought treatment.

With the HPI, you are trying to

develop a dif erential diagnosis—

basically, a short list of possible

causes by def ning the problem

and making sense of the history. Of

course you will want to explore the

symptoms and signs observed by

the parents. Are they constant, or

PediatricsContinued from page 1

■ History and chief complaint

■ Sensorimotor evaluation

■ Visual acuity testing

■ External exam and pupillary evaluation

■ Instillation of dilating eye drops.

Components of a pediatric eye exam

Check what

you need

early on while

you have

cooperation,

and save the

more diffi cult

tasks for last.

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intermittent? When do they occur?

What time of day? Are they worse

at the end of day, or with fatigue?

Failed vision screening

history. Children often present to

the pediatric eyecare practitioner

because they failed a vision

screening at school or at their

pediatrician’s ofce. It is very

important for the technician to ask

when the child was tested. There

are obvious clinical implications

and expectations if the failed

screening was six months ago vs. a

few weeks ago.

What was wrong? What part

of the screening test did they fail?

Was it because of an observed

misalignment? Did she do poorly

on the visual acuity test? How was

vision measured? Was it an age-

appropriate test? Did the screener

use letters, numbers, pictures, and

isolated, linear, or single-surround

optotypes? As you will learn in

the pages that follow, all of these

elements factor in to how young

children perform on visual acuity

tests. In other words, a failed vision

screening may or may not really be

indicative of a real problem.

Strabismus history. When

it comes to strabismus, parents

will often use the term “lazy

eye” to mean strabismus and/

or amblyopia, the decreased

best-corrected visual acuity

often associated with strabismus.

Similarly, many parents use the

word “crossing” to refer to any

type of strabismus; esotropia,

exotropia, even in describing

vertical deviations. All of which

means the technician will have to

verify the direction of the observed

misalignment graphically with the

parents in order to make sense of

the history.

I use my hands to physically

simulate esotropia, or in-crossing

of the eyes by pointing to my

nose with both hands. Similarly

with a suspected exo-deviation,

I use both hands to point out

away from my ears to simulate

an outward drifting of the eyes

(Figures 1 and 2). Explore possible

strabismus more in your history

by asking which eye is seen to be

misaligned. Do the parents notice

any squinting? Bilateral squinting

is typically a sign of uncorrected

refractive error or ocular allergy,

while unilateral squinting is often

associated with strabismus. Ask

about eye rubbing. Does the

child always rub the same eye?

Who notices? Is it the parents, the

pediatrician, the child’s teachers,

other family members? Is eye

misalignment visible in family

photos? Is it constant, intermittent?

Is it happening at distance fxation,

with daydreaming, or at near

fxation, when the child attempts

to focus?

Diplopia history. Double

vision occurs when one fovea is

not directed at the same object

of regard as the other. While this

is quite common in older patients

with an acquired strabismus, it is

uncommon in young children with

an early-onset misalignment who

develop suppression, or the ability

to “turn of” the image from the

deviating eye. This phenomenon

occurs at the level of the brain’s

cerebral cortex. So double vision

in a pediatric patient, if it is real,

implies an acquired etiology and

may require special laboratory

tests or neuro-imaging studies

like MRI or a CT scan to explore a

possible neurological cause.

When interviewing patients

of any age with a complaint of

double vision, one of the frst

questions the clinician should ask:

“Does the double vision go away

if you cover either eye?” Binocular

diplopia resolves with unilateral

occlusion, while monocular

diplopia, diplopia still present after

covering one eye and most often

due to refractive error, resolves in

almost all cases with a pinhole. You

should also ask the patient if the

double vision is worse in certain

positions of gaze, at a certain time

of day, or at rest.

Pregnancy and birth

history. Children who were

born prematurely have been

shown to have a substantially

higher incidence of strabismus,

amblyopia, and high refractive

errors compared to full term

controls.1 So for these reasons,

you will want to ask questions

about the pregnancy, birth, and

developmental history of all

pediatric patients.

For the pregnancy, you should

ask the mother or parents about

illicit drug use, consumption of

alcoholic beverages, whether

there was a problem with preterm

labor, maternal age, paternal age,

prematurity (a full-term delivery is

40 weeks), low birth weight, use

of supplemental oxygen, presence

of retinopathy of prematurity and

whether it regressed/resolved on

its own or if it required laser photo-

ablation, whether it was a normal

spontaneous vaginal delivery

(NSVD) or caesarean section, and

whether this was planned or

unplanned, and whether there

Children often

present to the

pediatric eyecare

practitioner because

they failed a vision

screening at school or

at their pediatrician’s

office.



Spring 2015 itech

were any labor complication.

Continue with questions about

birth complications, whether

there was an anoxic event/loss of

oxygen/delayed breathing, or any

breathing problems. You should

inquire as to whether there was

any trauma/instruments used

during the delivery (forceps,

suction), or any history of intra-

cranial hemorrhage, convulsions,

seizures, or known syndromes.

Developmental history.

Technicians who are parents

have a decided advantage here

because they are familiar with the

developmental milestones of their

own children. But there are a few

developmental milestones that

all technicians can easily learn to

help shed light on the observed

ophthalmic eye fndings as they

may contribute to a fnal diagnosis.

You should ask if the child has

met all of his or her milestones

to date. Familiarize yourself with

some of the basic components

of pediatric developmental

milestones, available online at the

website of the American Academy

of Pediatrics.2

Past medical history. Most

children are very healthy and take

few, if any, medications. However,

this may not be the case for

children seen in a tertiary care

facility or a hospital that is part of

a large inner city medical training

center. Conditions associated

with prematurity like retinopathy

of prematurity, hydrocephalus,

seizure disorders, anomalous birth

defects and syndromes, and other

health problems become more

common in these situations. If

you are employed in one of these

facilities, you need to come to

terms with the various ophthalmic

sequelae and the medications

associated with them so you know

what to ask if and when these

children present to your clinic.

Because these kids tend to have

a team of healthcare providers,

the past medical histories and

medications are often, but not

always, well documented in the

medical record.

Family history. Asking about

the family history for pediatric

patients is not only good

medicine, it is now mandated

by the federal government

as part of its Meaningful Use

criteria for afective utilization

of the information obtained by

ophthalmologists in the electronic

medical record, or EMR. Questions

about other individuals with

strabismus, nystagmus, amblyopia,

or history of early-childhood

patching or glasses should be

routine. Additionally, individuals

with childhood blindness,

glaucoma, cataract, or heritable

diseases should be documented in

the EMR.

Social history. Lastly, it is

also important to know the living

conditions at home because social

stressors like divorce, abuse, foster

parents, and institutionalization

due to developmental delay may

have implications for compliance

with prescribed glasses, patching,

use of eye drops, and attendance

at follow-up examinations. Ask

about who lives with the child,

especially if he is accompanied

by only one parent, grandparent,

older sibling, aunt, or uncle. Is

there smoking in the house? Are

the parents married, separated,

or divorced? Are there pets in or

around the house?

Pediatric sensory motor examinationThe sensorimotor examination is

the key element in the pediatric

eye screening. The problems

that bring children in to see the

pediatric eyecare professional

include a number of diferent

types of strabismus, vergence

abnormalities, amblyopia, and

refractive dilemmas, all of which

can impact ocular alignment,

depth perception, and sensory

fusion. The examination typically

starts by assessing (sensory) fusion

frst and then measuring (motor)

alignment by prism and alternate

cover testing, both typically

performed by a trained specialist.

Sensory testing. Assessing

sensory fusion begins by

measuring gross binocular fusion

potential with the Worth 4-Dot

Test, which uses red/green

anaglyph glasses and a special

fashlight that displays four

lights—two green, one red, one

white. Convention dictates that

the patients wear the glasses with

the red lens over the right eye, if

there is a choice. The fashlight is

then shown to the patient at both

distance and near fxation, and she

is asked to report how many lights

are seen with both eyes open.

The response for binocular fusion

is four lights seen, in any color

arrangement. The response for

suppression is only one color seen,

either only two lights (red) for

The sensorimotor examination is

the key element. The problems that bring

children in can impact ocular alignment,

depth perception, and sensory fusion.



itech Spring 2015

suppression of the left eye or only

three lights (green) for suppression

of the right eye. A response of

fve lights seen is consistent with

diplopia or manifest strabismus.

Interpreting the results of the

Worth 4-Dot test should be done

with caution because the test

is dissociating, meaning it may

cause an otherwise controlled

or intermittent strabismus or

phoria to manifest itself as a tropic

deviation behind the darkened

anaglyph glasses. Children from

age 3 to less than 5 years of age

can be asked to just count the

lights on the fashlight by touching

them one at a time, usually just at

near fxation (Figure 3).

Near stereo acuity testing

assess fne sensory fusion ability,

requiring clear and equal acuity

in both eyes and fner motor

alignment than what is required

by the Worth 4-Dot test. There

are a number of near stereo tests

available, though the industry

standards are typically the Titmus

or Randot stereo tests from Stereo

Optical. In each test, the wings

of the fy are the most disparate

and easily perceived, even by

children as young as 2.5 or 3

years of age. The circles of the test

correspond to increasingly fne

stereo images—the more circles

that are seen, the fner the stereo

acuity, and the better the visual

acuity in each eye. We use the

animal fgures only for preschool

children. Many of these tests come

in pediatric versions as well, which

can enhance cooperation.

Measuring strabismus. In

assessing strabismus, there are

basically two ways to quantify

ocular misalignment. The prism

and alternate cover test utilizes

either bar and/or loose prisms and

some type of opaque occluder.

Often a child will not allow you to

approach him with an occluder,

so your hand, palm, or thumb,

though not preferable, will have

to do (Figure 4). Corneal light

refex estimating techniques are

based on the observed position

of a corneal light refex in relation

to the patient’s pupil in the

misaligned eye. These will be

discussed below. But let’s frst talk

about the basic type of strabismus

seen in the pediatric clinic.

When strabismus does present

itself, there are four types of

deviations with which the clinician

needs to become familiar. An

esotropia is an eye that deviates

in toward the nose, with a corneal

light refex temporal to the center

of the pupil. An exotropia is an

eye that deviates out away from

the nose, with a corneal light

refex nasal to the center of the

pupil. A hypertropia is an eye that

deviates up with a corneal light

refex inferior to the center of the

pupil. And a hypotropia is an eye

that deviates down with a corneal

light refex superior to the center

of the pupil. The term orthophoria

or orthotropia means that the eyes

appear straight with corneal light

refexes centered in both pupils

or by alternate prism and cover

testing.

Clinicians who routinely

perform sensorimotor evaluations

on younger children have to

fnd creative ways to maintain

the child’s interest. For distance

measurements, animated toys

and projected movies work well.

A parent or coworker can also

assist by standing at the end of

the exam lane, holding a fashing

toy, and calling the child’s name.

For near measurements, young

children are asked to sit on a family

member’s lap. The child usually

feels more secure there, and the

family member can then be asked

to hold a fxation stick or toy on

the examiner’s nose, leaving both

hands free to hold an occluder or

prism bar. Unfortunately, it is not

the scope of this article to discuss

the specifc details of how to

perform the prism and cover test.

The take-home message is that

children tend to respond favorably

to animal puppets and toys, and of

interest, there seems to be some

science to support why.3

Despite our best eforts to

engage the patient, there will

times when a frightened or

uncooperative child will not

permit sensory testing or a prism

and alternate cover test. Other

Figure 3.Ask younger children to count lights on the fashlight when using the Worth 4-Dot Test.

3



Spring 2015 itech

times, a patient may have such

poor vision in one eye, that she

is unable to fxate well enough

to be measured with prism and

alternate cover testing. In these

circumstances, the clinician can use

a number of corneal light refex

tests to estimate and quantify the

observed strabismus.

To perform the Hirschberg

test, simply shine a bright penlight

or fxation light at the patient

from a distance of about arm’s

length. Observe the position of

the corneal light refexes from

the fashlight in each eye of the

patient. They should be centered

in each pupil if the eyes are

straight. However, if the light

refex is displaced near the pupil

margin in one eye, this represents

an approximate deviation of 15

degrees or 30.00 prism diopters

(PD). If the light refex in one

eye is displaced mid-iris, this

represents 30 degrees or 60.00 PD

of misalignment. And if the corneal

light refex in one eye is displaced

at the limbus, this represents

approximately 45 degrees or 90.00

PD of misalignment. It is up to the

examiner to identify the proper

type of strabismus or direction

of misalignment, but temporally

displaced corneal light refexes

correspond to eso-deviations,

medially displaced light refexes to

exo-deviations, inferiorly displaced

light refexes to hyper-deviations,

and superiorly displaced refexes

to hypo-deviations.

To estimate strabismus by

the modifed Krimsky test, the

examiner uses loose or bar prism

to eventually center the displaced

corneal light refex in the deviating

by trial and error, placing the

appropriate prism over the non-

deviating eye.

Abnormal head postures.

Children sometimes develop an

abnormal head posture called

torticollis (Figure 5), and their

families are asked by the child’s

pediatrician to have the patient

evaluated by a pediatric eye-care

specialist to determine if the

head position is being driven

by strabismus or some other

abnormality of binocular vision.

The strabismus measurements

required to diagnosis an ocular

abnormality in this situation are

not always possible in younger

children. But one of the quickest

and easiest ways to rule out an

abnormality of binocular vision is

to do a patch test. Simply place a

patch over one of the child’s eyes

and observe for 60 to 90 seconds,

asking the parents to restrain the

child’s arms if necessary to prevent

her from removing the patch. If

the head posture improves, this is

suggestive of an underlying ocular

abnormality of binocular vision

and requires further assessment

and more detailed measurements.

If the torticollis does not improve,

this is suggestive of a non-

ocular, perhaps musculoskeletal

abnormality, most often of the

sternocleidomastoid muscle on

the side of the neck toward the

head tilt.

Assessing visual acuity in childrenBirth to 2 to 3 months. If

the clinician is going to try

to measure vision in young

children, it’s important to frst

have an understanding of what

is considered normal, or age

appropriate visual acuity in the

pediatric population. Is a baby

born with 20/20 acuity? Not at all.

Birch and coworkers estimated,

through preferential looking

techniques, that vision at birth

is somewhere around 20/600,

developing rapidly in the frst

year of life and improving to

approximately 20/60 by 12 months

of age, and reaching an adult

normal of 20/20 by 60 months or 5

years of age.4

Newborn children are by

defnition visually inattentive and

immature. They will, however,

blink to a bright light shown close

to their eyes. Their eyes will also

pop open suddenly when the

room lights are fashed on and of,

a refex some clinicians call eye

popping, which tends to disappear

by around 6 months of age. Some

children will also respond with

saccadic eye movements to the

rotating stripes of the optokinetic

drum. This is just about all you can

expect from a neonate in his frst

several weeks of life.

Intermittent strabismus may

also be observed, but it should

not be present by 2 to 3 months

of age, correcting for prematurity.

Pupils become active, and

accommodation begins by 2

to 3 months of gestational age,

which you can demonstrate by

showing the child a target that

stimulates accommodation, the

multi-colored lights of the Worth

4-Dot fashlight, for example, and

observing the constriction of the

child’s pupils. Mid-dilated pupils

sluggishly responsive to light by

this age predicts reduced visual

acuity for age. Nystagmus in this

age group suggests abnormality

of the anterior visual pathway,

while the absence of nystagmus

in an otherwise visually inattentive

neonate is suggestive of cortical

visual impairment, or impairment

at the level of the brain.

3 to 6 months. As children

approach 6 months of age,

they become extremely visually

attentive in the near range,

preferring faces over objects and

toys. They will sit on their parents’

laps and stare at you with an

astounding aplomb. Acuity can be

assessed for this age group in a



itech Spring 2015

Figure 4. Often a child will not allow you to approach him with an occluder, so your hand, palm, or thumb, though not preferable, will have to do.

Figure 5.Abnormal head posture called torticollis may indicate strabismus or some other abnormality of binocular vision or a non-ocular cause.

Figure 7.Demonstration of the “blink them in” technique for administering dilating eye drops in children.

Figure 6. Occluding can sometimes be a challenge. The author recommends special occlusive glasses designed for visual acuity testing in children.

5

number of ways, including forced

recognition grated acuity tests

like Teller Acuity Cards (Stereo

Optical) and by observing how

they fxate on and follow silent

fashing targets, like a fashing toy

star, through a smooth pursuit

with each eye. This is typically an

abduction movement out toward

the ear followed by adduction

back again toward the nose,

without losing fxation. Repeat if

necessary. Last, but certainly not

least, if all else fails, they can fxate

on and follow the examiner’s face

through the same smooth pursuit

movements!

One can also take advantage

of the vestibular ocular refex to

assess the visual pathways by

taking the child (make sure you ask

for permission from the parents!)

and holding her up in front of

you at eye level, face toward you,

spinning around gently in one

direction on a rotating stool. This

motion stimulates optokinetic

nystagmus (OKN) through the

inner ear. What you will see is the

child doing a smooth pursuit in

the opposite direction of the spin

as she watches the environment

rotating by behind you, then a fast

saccade back in the direction of

the spin, repeated over and over

again until you stop spinning. At

this point, a child with intact visual

acuity may exhibit a beat or two

of residual OKN, dampening in less

than 5 seconds. But in a child with

decreased or absent visual acuity,

the OKN will not dampen and

persist for more than 5 seconds.

6 to 36 months. Preverbal

children from 6 to 24 months of

age can be presented with a base

down prism in front of one eye,

typically 16.00 or 18.00 PD. With

both eyes open, this creates a

vertically diplopic second image

of a target at distance or near

fxation. This is called the induced

tropia test.5 If vision is intact,

and the child is not suppressing

visual input from the eye behind

the prism, you will see a vertical,

hypertropic shift in both eyes as

the child attempts to fxate on

the second image that appears

above the original fxation object

of interest. Absence of induced

vertical shift is suggestive of

amblyopia in the eye behind the

6

7

4



Spring 2015 itech

prism. This can be documented

in the chart as C for central (the

eye is straight), S for steady (no

nystagmus), and M for maintained

(fxation through the prism), or

CSM. If fxation is not maintained

for more than one to two seconds,

you would document this as

CSUM, for Central, Steady, Un-

Maintained.

After age 3: Recognition

visual acuity. Testing recognizable

optotypes, whether Allen or Lea

symbols, HOTV or Snellen letters,

can begin from 30 to 36 months,

depending on the cognitive ability

and cooperation of each child. The

author’s personal bias, based on

15 years of clinical experience, is

not to attempt recognition acuity

before 36 months due to variability

of maturity. Of course there are

always exceptions to every rule.

This age group will also peak

during the test, so occlusion of

the untested eye needs to be with

a tape patch or special occlusive

glasses designed for visual acuity

testing in children (Figure 6), or

adhesive tape directly over the

child’s eye, or on the lens of his

glasses. Single surround bars, also

called crowding bars, expedite

testing in the younger children and

have been shown to accurately

replicate the resolution challenge

of linear optotypes in amblyopic

patients while minimizing test time

in our most inattentive patients.6

You can help the child stay

engaged by turning the matching

card to the blank side and

advancing to the next letter. Point

at the screen and ask the child to

look at the screen, then fip the

card over to show the choices and

ask the child to match the shape

she sees.

From age 4, HOTV crowded

optotypes can be used with good

reliability, though every child is

developmentally diferent, and

sometimes the examiner has to

resort back to a matching version

of the test. Most children will

progress to full Snellen recognition

optotypes by age 5, though I tend

to minimize the attention required

with linear Snellen acuity testing

by using the single surround,

crowded optotypes until age 10,

again, depending on the child,

maturity, and intellectual abilities.

Checking pupilsAn important part of any complete

eye exam, this component of the

encounter, while straightforward

in adults, can be challenging

in inattentive children. A direct

ophthalmoscope is often helpful if

you have a less than cooperative

child because you can illuminate

the pupils from a more remote

distance and see a red refex in

addition to the corneal refexes

of the Hirschberg test. This is

also very useful in patients with

dark irides, as it makes the irido-

pupillary border a lot easier to see,

especially for those of us who are

presbyopic!

Giving eye dropsThe last step in the pediatric eye

exam is arguably one of the most

stressful. here are a few techniques

that will foster cooperation, help

minimize stress, and overall make

the process of instilling eye drops

less tumultuous for the patient, his

family, and you as the examiner.

My favorite technique is the

“blink them in” technique. I explain

to the child that we need to put

eye drops in her eyes. I then direct

her attention to a playful sticker

attached to the ceiling above her

head. I ask her to tilt her head

back, then close her eyes, which

is exactly opposite of what she is

expecting you to say. “Close your

eyes tight, and I’m going to put the

cold water on your eye lashes,” I

tell her. This seems to be accepted

by most children. “And when I

count to three, we’re going to do

a big blink, really fast.” I give her

a tissue and tell her that she can

wipe after she blinks. I also gently

hold the child’s chin up until she

blinks to avoid the drops streaming

of her face and into her lap (Figure

7). I explain to the parents that

while this is a messy technique

(drops run all over the place,

usually on the child’s clothes), it

really works. Give it a try.

Another technique is the

“kangaroo pouch” technique in

which you cajole the child into

looking up in a similar manner

and at a similar target as described

above, then place the drops in

cul-de-sac of his lower lids. The

lower lid cul-de-sac is much less

sensitive, and a great place to

instill an eye drop. I don’t have as

much use with this technique in

the younger children, but it does

work well with older children and

teenagers.

Despite these techniques

some children, especially infants

and toddlers younger than 36

months of age, will not cooperate

with instillation of drops. In these

cases, it is necessary to restrain

the child in order to properly instill

the drops. In doing so, you will

frst want to explain to the child’s

parents why you have to restrain

the child. Once parents agree,

small babies and very young

children can be placed on their

backs on the right arm of one

parent seated in the exam chair,

the child’s head toward the crook

of the parent’s elbow, feet across

the parent’s lap. Have the parent

hold the arms while you take care

of the head, lids, and instilling

drops. In older children, or bigger,

stronger kids who require restraint,

there is a real risk of injury to the

parent, the child, or even you as



itech Spring 2015

the examiner. A diferent technique

is recommended for these kids.

Have the child straddle the

parent’s lap facing toward the

parent, with one leg on either side

of the parent’s hips. Seat yourself

directly in front of the parent’s

knees, ask the parent to lean the

child backward onto your lap so

that he is prone on his back on

your legs and his head is in your

lap, facing the ceiling. You can

now ask the parent to restrain the

child’s arms and hands with their

hands, the legs are immobilized

around the parent’s hips, and you

have both hands free to restrain

the head, manipulate the lids, and

instill the drops.

Lastly, it is extremely important

for the technician to control the

dosing of dilating drops instilled

in the eyes of young children

because these medications can be

toxic,7 trigger seizures,8 and even

lead to cardiac arrest9 in neonates

and small children.

For newborn babies and

children younger than 6 months

of age, one drop of cyclomydril

(Alcon), which consists of

cyclopentolate hydrochloride 0.2%

and phenylephrine hydrochloride

1%, is my drop of choice. In

children with darkly pigmented

irides, I add an additional drop

of tropicamide 1% because it is a

better midriatic drop, though on

its own, a poor cycloplegic agent.

Starting at age 6 months

and progressing to age 16, instill

cyclopentolate 1% drops in

lighter-pigmented eyes, adding

tropicamide 1% or phenylephrine

2.5% drops for more darkly

pigmented eyes. Some children

who have had laser photo-ablative

surgery for threshold retinopathy

of prematurity may require all

three drops to dilate adequately

enough for the physician to see

into the eye.

Causes of decreased vision in infancyThe causes of decreased vision in

children, in addition to amblyopia

and refractive error, include

developmental malformations and

acquired lesions of eyes and visual

pathways. Clinical markers and

signs include the oculo-digital sign,

a habitual pressing on one or both

eyes by the child with their fnger

or fst. This behavior is specifc to

bilateral congenital or early-onset

blindness due to retinal diseases

and heritable retinal dystrophies,

predicting best-corrected visual

acuity usually 20/200 or less in the

afected eye. Index of suspicion

should be high in children greater

than 6 months who do not readily

make eye contact with you.

Congenital nystagmus is

commonly seen in disorders

of the anterior pathways, such

as ocular cutaneous albinism,

which involves the optic nerves.

Look for a compensatory head

posture, implying optimal acuity,

binocularity, and functional vision.

Nystagmus is typically absent in

cortical visual impairment (CVI).

Large, slow, roving nystagmus

or eye movements are often

associated with poor vision and/

or visual loss before the age of

6 months. These types of eye

movements are not seen in CVI.10

End on a happy note There are many challenges

associated with examining children

in the eye clinic. Indeed, it is one

part science, two parts art, and

mastering the required skills takes

skill, patience, practice, having the

right tools, and perhaps above

all, having the right attitude. After

a challenging session with any

child, end on a high note and

reward her for a job well done,

after making sure that is fne with

her parents, with a lollipop, or a

playful sticker she can wear out of

the ofce when she leaves. Treat

your pediatric patients the way

you would want someone to treat

your child, or you, for that matter.

Use dignity, empathy, and respect,

and they and their families will

remember you for it.◗

References1. Kushner, BJ. (1982). Strabismus and

amblyopia associated with regressed retinopa-

thy of prematurity. Arch Ophthalmol. 1982

Feb;100(2):256-61.

2. Hagan JF, Shaw JS, Duncan P, et al. 2008.

Bright Futures: Guidelines for Health Supervi-

sion of Infants, Children, and Adolescents, Third

Edition. Pocket Guide. Elk Grove Village, IL:

American Academy of Pediatrics. Available

at http://brightfutures.aap.org/pdfs/bf3%20

pocket%20guide_fnal.pdf. Accessed 2/18/15.

3. Mormann FA, Dubois J, Kornblith S, et al. A

category-specifc response to animals in the

right human amygdala. Nat Neurosci. 2011

Aug 28;14(10);1247-9.

4. Birch EE. Visual acuity testing in infants

and young children. Ophthalmol Clin North

Am. 1989;2:369-89.

5. Frank JW. The clinical usefulness of the

induced tropia test for amblyopia. Am Orthopt

J. 33(1983):60-9.

6. Peskin MA. Threshold visual acuity testing

of preschool children using the crowded

HOTV and Lea Symbols acuity tests. J AA-

POS. 2003;7(6):396–9.

7. Adcock EW 3rd. Cyclopentolate (Cyclogyl)

toxicity in pediatric patients. J Pediatr. 1971

Jul;79(1):127-9.

8. Demayo AP, Reidenberg MM. Reidenberg

Grand Mal Seizure in a Child 30 Minutes

After Cyclogyl (Cyclopentolate and 10% Neo-

Synephrine (Phenylephrine Hydrochloride)

Eye Drops Were Instilled. Pediatrics. 2004

May;113(5):499-500.

9. Lee JM, Kodsi SR, Gafar MA, et al.

Cardiopulmonary arrest following administra-

tion of Cyclomydril eyedrops for outpatient

retinopathy of prematurity screening. J AAPOS,

2014 Apr;18(2):183-4.

10. Brodsky MC, Baker RS, Hamed LM. Pediat-

ric Neuro-Ophthalmology. New York: Springer

Press, 1996.

Alex Christof is

assistant professor

of ophthalmology

at The Wilmer Eye

Institute at Johns

Hopkins Hospital

in Baltimore.

E-mail him at

[email protected]


mailto:[email protected]

http://brightfutures.aap.org/pdfs/bf3%20pocket%20guide_final.pdf

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