In this short video, we review the examination techniques and basic equipment for performing a comprehensive pediatric eye examination.
Lecturer: Dr. Daniel Neely, Indiana University School of Medicine, Indianapolis, USA
DR NEELY: I’m Dr. Daniel Neely. In this short video, we will review the basic equipment and examination techniques for performing a comprehensive strabismus evaluation on a pediatric patient. I’ll also review a few things such as room setup and testing strategies. The first thing I’d like to discuss is basic room setup, and what are the fundamental pieces of equipment that you should have in the room to perform all elements of a comprehensive examination. Ideally, the room length will be longer. Six meters or 20 feet. This is particularly helpful when performing strabismus measurements for conditions such as exotropia. A power chair is also particularly helpful for elevating patients up to the appropriate examination height. If a power chair is not available, simply have the child sit on a parent’s lap. I find it useful to have all of the equipment within easy reach, consolidated off to one side or the other of the examination chair. To record your examination findings, it is also helpful to have a template which has specific strabismus elements. Measuring stereopsis should be the very first examination element performed. This is because occlusion will disrupt fusion. When testing visual acuity, the chart chosen must be calibrated to the length of your examination room. While Snellen optotypes are ideal, the optotypes used must be age appropriate. Occlusion with an adhesive patch is preferred over using a handheld occluder, a bare hand, or a paddle-type occluder. All of these can be cheated with. Optotypes should be presented as a full line rather than as single letters, which will tend to overestimate visual acuity. However, using crowd bars with a single letter optotype is an acceptable alternative. Matching cards can also be useful when testing younger children. Allen figure optotypes, while easy to test with, are not recommended, as they tend to overestimate visual acuity. LEA symbols are a better alternative, as they tend to be more uniformly constructed and consistent.
>> Why did you put it higher?
>> I put it higher so I could reach you. How about that? Let’s see. Do you want to look at some pictures today? Let’s get some pictures. Look what I have here. Look at all of my pictures! Somewhere on there is a duck. Can you point to the duck? You are so right! Can you find the house and point to the house? Yeah! Well, where is the Christmas tree? That’s right. How about the horse? Do you see the horse? Very good! Where is the car? That’s right. And I think I see a bear on there somewhere. Do you see a bear? Pretty close. What about this guy? Does he look like a bear? Yeah. Now, we’re gonna do some magic. We’re gonna put all of these pictures up here. Oh! Look up there. Can you tell me what that picture is?
>> It is a tree! What’s this picture?
>> Awesome job. What about this one?
>> Very good! What’s this one?
>> It’s a car. And what about that one? High five. Now, we’re gonna do a game with the pictures. We’re gonna play peekaboo, okay? So what we’re gonna do is we’re gonna put a peekaboo patch on our eye and look at pictures. All right? And then when we’re done with it, we’re gonna take it off. So we’re gonna do it on this eye right here. It may tickle your eyelashes a little bit. And there’s our peekaboo patch. Now, look up at my tree. Oh, we’ve got lots of them there. I have two pictures up there. Can you tell me what those two pictures are? What’s the first picture look like?
>> A house. And what’s beside the house?
>> You got it. I have three pictures. What are those three pictures?
>> A bear.
>> A bear. And what’s the last one?
>> Very good! Let’s see if we can see some smaller ones. How about those guys? I think the first one looks like a Christmas tree. What do you think? After we do this one, we will. Can you see the Christmas tree?
>> What’s beside the tree?
>> A cake?
>> A cake! You’re right. What’s the next one?
>> And a hand. Very good job. Okay. Okay. Now we’re gonna do this. Almost done. You are being so good with that.
>> Would you like some stickers?
>> It’s part of the game, buddy. Look up there. Do you see that?
>> Can you point to the same one here? You’re right. That’s the O. Look up at that one. Can you find the same match? It’s the T. Very good. What about that one? Awesome job. Can you find the… Yeah, there you go!
DR NEELY: For near fixation measurements, I prefer using a toy that I can hold in my mouth, while leaving my hands free to hold the prism bar and occluder. Both a horizontal and a vertical prism bar should be available. Also, it is useful to have handheld loose lenses when measuring vertical deviations or those deviations in small children. Halberg trial lens clips can be helpful when trying to determine if the patient needs more plus or would benefit from a bifocal. These are used to place additional plus lenses over a patient’s existing glasses. You then repeat their near measurements and see if it improves with the plus lens. If it does, then they may be a good candidate for a bifocal.
>> Stand up between mom’s feet for a second. We’ll go for a little ride here for a minute. Up, up, up, up, up, up. Rest your chin right there. Can you rest your chin right there? Down just a little bit. Okay. Look right here at my ear. Good. Look right here. There you go. Pss-pss-pss-pss! Okay. Now we have this. And keep watching the movie.
>> Look down here at Nemo. Good job. Where is Nemo?
>> Now we’ve got this little flashlight. Sh-sh-sh-sh.
DR NEELY: I think it cannot be stressed enough that good retinoscopy skills are critical to being a competent pediatric ophthalmologist. My personal favorite retinoscope is the Welch Allyn, because it tends to be brighter and easier to manipulate. I also generally feel that it is easier to perform refraction in children using either loose lenses or a skiascopy bar. The ability to use a binocular indirect ophthalmoscope is another one of those indispensable skills for a pediatric ophthalmologist. Now that we’ve looked at the equipment requirements, let’s take a look at the actual examination technique and put it to use.
>> Put those on, and then we’re gonna look at a fly. My fly is in a book. Look at my fly right there. Can you reach out there and pinch its wings? Can you grab it? There you go. Good job. Now I’m gonna show you some animals. Look at these guys right here. Does one of those animals pop out of the book? Can you put your finger on the one that pops out? Very good job. Now we’re gonna look at another one. Look at these guys. Which one pops out there? Very good. And what about here? Which one pops out? Good job. Now, we have some ducks up here. Look at those ducks. Put your finger on the duck that pops out. That one right there? And then let’s try these guys. Which one pops out? A little bit of all of them. Okay. Let’s do one more right here. Is there one there that pops out? Very good job. Let’s take these off. Can you put your finger on the one that’s the same? You’re right. Good job. Which one matches? It’s the V. Very good. Which one matches there? That’s right. And what about there? Where is the match? Good job. Let’s do one last one. Where is that one? Look real close. There you go! Good job! Very good. Awesome job.
>> You see this? Do you like animals? Do you know who this is? Look over there. And this? Who is this? Is this a monkey? Look at the monkey right here. Look at him. Look at the monkey. Look at him up here. Where is he? Good. Ch-ch-ch-ch-ch. And where did he go now? Look at him way down there. Way down. Let’s go way up. Way up high. One more. Good. All right. We’re gonna put that guy right there. Watch him, watch him, good. And look at him now. Watch him. Watch him, watch him. Watch him, watch him. Good, good, good. Good, good, good. Okay, now… We’re gonna look through this little window, okay? You see the window? Look at Tigger’s nose. Watch his nose. Watch his nose. Keep looking, keep looking, keep looking, keep looking. You’re doing great. Keep watching his nose. Keep watching his nose. Keep looking. Watch him. What color is his nose? Is it pink? Brown? Yeah. All right. Now… A single… Picture. Yeah. Now we’re gonna look way down there. Do you see that picture? What’s that picture?
>> Yeah? Look at it. Is it a horse?
>> Watch the horse. Can you still see it?
>> Good job. Where is the horsey? Look up here.
>> Watch the horse. There he is. There he is. Watch him. Keep looking. Keep looking. Keep looking. Beautiful. Nice job. And… Kitty, kitty, kitty, kitty! (clicking tongue) Look at me. Ch-ch-ch-ch-ch. Good, good, good. And now we’ve got to put two of them together. And look right here. Ch-ch-ch-ch-ch. Perfect. Can you see my ear? Can you see my ear wiggle? Is there a mouse in my ear? One more. Is there a mouse? Do you see a mouse over here? Good job. All right. High five. Beautiful job.
So that is the comprehensive examination technique of the pediatric strabismus patient. I hope that you have found this information to be useful. If you’d like to learn more, please go to the Orbis Cybersight library and look at the courses. We have complete courses on pediatric ophthalmology and adult strabismus evaluation and treatment. It’s been my pleasure, and I wish you well.