Working with children is fun.
It is vital to remember this. We also need to make it fun for them. Children of all ages are very good at detecting anxiety or unhappiness. There is no rush to get the information that is required. A little preparation will go a long way to making the task enjoyable and maximising the usable clinical information obtained.
PREPARATION
Firstly, prepare yourself. It is important to be relaxed and free of distractions. If you feel it will be of benefit, turn your phone to silent and certainly turn off notifications. Any clinical assessment will suffer if you are feeling hassled or are constantly disrupted.
Most children like toys and it is appropriate to have a variety. Make sure that they are not extremely small or have small parts that may be become detached, as this is a choking hazard for younger children. Toys that have flashing lights or sounds can be both a benefit and a distraction, depending on the child. Some children with neurodiversity will be troubled by bright flashing lights and loud sounds. I must admit that in my own consulting room, I have a handful of brightly coloured plastic toys that do not make any sound. With a lot of children, the main toy is the examiner and their voice and action. A video monitor with videos or images running on a loop can be useful. The screensaver setting on my visual acuity monitor defaults rapidly to a series of current cartoon characters. A box of toys in the corner of a consulting room can be useful for distracting children when you want to talk to the parents. However, it can act as a magnet when you are really wanting the child to sit in a chair on the parent’s lap for an examination.
Age-appropriate visual acuity tests are vital. In my practice we use Teller Acuity Cards, LEA paddles, and Cardiff Acuity Cards for assessing visual responses in preverbal children. For older children we use Kay pictures (with and without crowding bars) and then progress to single optotype (with and without crowding bars) before proceeding to linear optotype.
COMMUNICATION
Manner matters, this cannot be stated too many times.
It is important to use pitch and language appropriate for the age of child that you are examining. I think of children using the following communication formats or ‘languages’ as they get older. The first language is ‘babyese’; young children like random sounds as much as words. When examining a preverbal child, it is helpful to pitch your voice a little higher, using an almost singsong manner, and engage them with movements as well as a light or toy. A typical conversation with a six-month-old baby may go as follows, “Oppity bopity bup, do dah day, oppity boopity bow”. There is no room for feeling self-conscious!
Slightly older children speak fluent ‘toddlarian’, this age group likes simple sentences and often somewhat silly ones. The simplest of dad jokes or nonsense statements can be appropriate in this situation.
In this age group it is very important to use verbal encouragement and reinforcement when you want to elicit an appropriate response, such as fixation on a near target or tolerating alternative cover testing or the like. I find it useful to engage a child of this age with a discussion about any toy they are bringing into the room or clothes that they are wearing. These things are familiar to them and will help break the ice. Asking the name of a toy is also helpful. It is surprising how important a few words about, or even directed to, a soft toy can help settle an anxious toddler. It is never too early to explain what is going to be done. This is particularly useful when trying to examine a young child with a bright light such as retinoscopy, ophthalmoscopy or a portable slit lamp. The younger the child, the simpler the explanation needs to be. This can sometimes also be helpful for the parents who may not necessarily understand exactly what is being done.
From the preschool year through to the first couple of years at school, children become experts in ‘prepterian’. With this age group it is possible to have a more meaningful discussion. Questions about what they are doing at school or in kindergarten will often engage them and break the ice. These children are more susceptible to more complex dad jokes and patently ridiculous comments.
The final language I recognise for school-aged children is ‘adolestonian’. This is perhaps the most difficult as I suspect many of us (apart from schoolteachers) suppress our memory of adolescence. The conversations I find of the most use with this age group are about holidays, sport and on occasions, music. A general discussion of what they are finding interesting in the world is also sometimes useful. Although such conversation is perhaps not vital for undertaking an examination, it is important to create rapport. You then have some prospect of getting honest answers (read polysyllabic answers) to what they think about their vision; if they are having any difficulties, or indeed if they are troubled by appearance such as related to ptosis or strabismus et cetera.
Once children develop language skills, they increasingly develop agency. It is vital to explain what you are doing in an age-appropriate manner and to obtain assent before proceeding with any examination, especially if it is potentially uncomfortable or distressing.
Remember to ‘change the dial’ from whatever child language you are speaking when you address the parents. Parents will be put at ease when they see the effort you take to communicate with their child.
EXAMINATION PROPER
Most of the comments in this section are directed towards examining younger children. Older children will generally be compliant with most ophthalmic examinations, provided the procedure to be undertaken is explained.
With babies, do not be afraid of naptime. Although it is not possible to learn much about visual function when an infant is asleep, it is often very easy to do a good and detailed examination of ocular structure. A soundly sleeping infant will often allow very accurate retinoscopy and ophthalmoscopy. Allowance needs to be taken for Bell’s reflex and I often will do retinoscopy standing at the head of a sleeping infant so that I can more easily adjust for the eye position. The parents may be able to help you retract the eyelids. Make sure you re-orientate yourself if you document any astigmatism when working with what is effectively an upside[1]down child. Portable slit lamp examination and measurement of intraocular pressure can also be easily undertaken with the sleeping infant. With an iCare tonometer, I often get the parents to hold the child so that the face is vertical.
Speed is helpful when assessing infants, so to practise is valuable. It is suggested by some that you only get one look with one toy and then need to switch to another. I will frequently use lots of babbling or nonsense to continue to hold a young child’s attention at a task. I often find photographs helpful when assessing ocular alignment or anterior segment abnormalities in infants. Frequently the parents will have done the same and may have quite useful photographs to show you on their phone. It is also much easier to explain the concept of pseudo-strabismus with a photo.
Always be ambitious with your use of fundus photography; you will be amazed how a young child will allow fundus photography if you are quick and tell them a story about watching whatever fixation target your device uses.
With older children, examination needs to be made into a game and I will often evoke the concept of a magic wand or similar when undertaking retinoscopy for a toddler or early school-age child. Similarly, turning a slit lamp into a motorbike with a headlight facing the wrong way is often very useful to encourage a younger child to have a better anterior segment examination. It is important with these examinations to keep talking to the child. A steady run of reassuring commentary borders on hypnotism with some children and is well understood as distraction. It is amazing what can be obtained with distraction. Try not to use any language that may suggest something is uncomfortable or unpleasant.
Retinoscopy is very important when assessing children, particularly younger children, who are not compliant with auto refractors. I find it helpful to use loose lenses as I think these are less threatening to a younger child. Remember to work with ‘with reflexes’ when refining endpoints and use a relatively narrow streak. I find it very useful to do retinoscopy with both eyes open. One eye is watching the streak while the other is observing the child’s behaviour and fixation.
RESTRAINT
With a toddler there are some situations in which no amount of cajoling or encouragement will allow an examination that at times appears quite vital. One such situation is when concerns have been raised about the possibility of raised intracranial pressure or a fundal abnormality. If this occurs, it is first vital to explain to the parents why it is necessary for a certain examination to be undertaken. Once they have consented, I then ask the parents to do the restraining. I find it easiest to ask them to pin the arms at either side using a firm grip with one arm, and placing the other hand around the forehead to help stabilise the head. Then it is usually possible to use your non-dominant hand to retract the eyelids while you obtain a glimpse of the fundus. Clearly this is not ideal, but it can be incredibly useful, and it can avoid the necessity for an examination with sedation or the like. Restraint is almost never of any use when trying to undertake retinoscopy.
CYCLOPLEGIA
It is no mistake that this section immediately follows a discussion of restraint. Explanation to the parents about why this is being done is useful and beyond that, speed is helpful. Children should be warned about blur that is experienced after such drops.
SUMMARISATION
It is a good idea to tell a child that they have been “really helpful”, and you have got all the information (or at least some thereof ) that you need. This is reassuring for both the child and parents.
SPECIAL SITUATIONS
Adjustments will need to be made for older children who have physical disabilities that make it difficult for them to use equipment such as slit lamps, fundus photography, and optical coherence tomography. It is important not to infantilise these children, particularly when they are in adolescence. I find a portable slit lamp very valuable in this situation. Sometimes adjustments can be made to the headrests, and or tables of devices, to accommodate the child or their wheelchair et cetera.
Another group of children that have their challenges are the neurodiverse. These children need extra time and patience. Practise and repeated examinations will make this easier. One approach that can be very useful for these children is the concept of a ‘storyboard’. This is just a series of photos that shows how a particular piece of equipment is used. It can be used at home to familiarise or orientate the child to what is going to happen. It can greatly relieve anxiety related to all types of medical assessment.
CONCLUSION
Working with children is fun and enjoyable. It is important to adjust your mindset to the children that you are working with and adapt assessment to what is possible. Practise makes one faster: the first 10,000 retinoscopies are always the hardest! Be prepared to adapt your examination and be prepared to experiment.
Remember: manner matters and have fun.
Associate Professor James Elder is a highly experienced Melbourne-based ophthalmologist specialising in paediatric ophthalmology. Assoc Prof Elder graduated in medicine at University of Melbourne in 1981 and undertook ophthalmology training at the Royal Victorian Eye and Ear Hospital. He underwent advanced training in paediatric and genetic ophthalmology at the Royal Children’s Hospital before working at the Hospital for Sick Children in Toronto, Canada. He was the Director of the Department of Ophthalmology at the Royal Children’s Hospital from 1994 to 2009.
Assoc Prof Elder has surgical expertise in all facets of paediatric ophthalmology including infant cataract, childhood glaucoma, strabismus, oculoplastics and management of retinoblastoma. He has published widely in paediatric and genetic ophthalmology journals and is the author of numerous peer-reviewed articles.
