New graduates are usually thrown off guard with pediatric exams unless they’ve completed rotations or residencies in pediatrics. This is just the fear of the unknown.
The reality is that pediatric eye exams can be a lot easier than adult comprehensive eye exams. However, I have found there are ways I alter pediatric exams so they flow smoothly.
Here we will focus on tips for pediatric exams in terms of myopia management and what you can do to get the answers you need to thoroughly assess your pediatric patient.
- Talk to the patient: I have had numerous parents tell me that they appreciate that I address the patient and their concerns first, then the parent. This makes the patient understand that you are there to solve their problem. This also prevents patients and parents talking over one another when parents try to convey problems that the child perhaps doesn't think they have. Talking to the patient first helps you understand the patient’s concerns as well as their level of maturity. If they have no problem conveying their issues to you, then you know that you can proceed with the exam normally without modifications. However, if you gauge that the patient is not a good responder or historian, some tests need to be modified for adequate accuracy. Talking to the patient first also instills trust, and allows the child to become more cooperative during the examination. After addressing the child, address the parent or guardian to see if they have anything to add. If you feel that there is a hesitation to discuss in front of the child, ask the parent to speak in private towards the end of the exam.
- Ask about family history: Family history is an underlooked part of the exam but it should be emphasized. Ask about family history of any eye conditions, or if parents are nearsighted or farsighted, even if they’ve had LASIK. The risk of developing nearsightedness dramatically increases when one or both parents have a history of nearsightedness, so this can give you a lot of information about the child’s overall risk. This will also help you predict when to see the child back as well as when to intervene.
- Always perform a cycloplegic refraction: Though it seems tedious and yes, it takes more time, a cycloplegic refraction is essential in your pediatric patients. Do not limit this to your hyperopic or latent hyperopic patients because patients can be often misdiagnosed when they exhibit pseudo-myopia. This is the only way you will get a true evaluation of the child’s visual system to know how to proceed with a treatment plan.
- Don't forget the retinas: We often get consumed with kids and refractive error. Always check the retina thoroughly, especially if you have the luxury of cycloplegia. This will help you note everything that may be going on in the retina, even if it’s benign. This will prevent a lot of guesswork down the line trying to figure out if a potential lesion is new or if it was present at birth and won’t come as a surprise if the patient changes practitioners.
- Go with your gut: If something just doesn't feel right, don't be afraid to bring patients back another day. I often find that I’m splitting pediatric exams in half. Sometimes parents bring in children after school when they are already exhausted from the day. If things are just not making sense, have them come back for a follow-up and go from there! If things are still not adding up, consult your colleagues for help or refer when necessary.
Don’t be afraid of delving into pediatrics and myopia management. If the concept still seems foreign, start by seeing children ages 8 and up, then slowly decrease the age threshold as you get comfortable. You will find that having treatment options for kids with progressive refractive error is one of the most rewarding things you will do!
~ Dr. Amadian