CLINICAL

  PEDIATRICS

GAIN A CHILD’S TRUST

IDENTIFY IMPEDIMENTS DURING A PEDIATRIC EYE EXAM

HELPING CHILDREN to see better begins with determining what they see. While this seems like an obvious statement, it is not always a straightforward matter when dealing with children. Let me give you an example, I examined a young child last week and couldn’t get her to commit to responding to the targets I presented. She was very shy, so I told her, in a soft voice, that she could whisper the answers to Mommy, and Mommy could tell me. That worked like a charm.

Here, I discuss some of the obstacles to determining what young patients actually see and how to circumvent them.

FRAME OF REFERENCE

It does not occur to children that what or how they see differs from what most other people see. It isn’t a topic of conversation around the sandbox or on the playground.

Squinting in children is usually a sign of refractive error when it happens without the sun. To work around this, present the child with a familiar frame of reference.

Ask the patient: “So tell me, Shannon. When you’re together with friends, can they see who is across the street before you? How about seeing the TV at home, Shannon? Do you have to get closer to see faces than your brother or sister?”

PERFECTIONISM

Some children are reluctant to venture a guess, even when prompted. They will read the eye chart, respond to depth perception tests and so forth with precision up to a certain point. But, as soon as things are even a little blurry or uncertain, they will shut down. For example: The child reads the larger letters on the chart very smoothly. “NKODZ, VZRNH, KCHOR,” then stops abruptly.

Ask the patient: “Well, Nicole, you read that last line so easily, why don’t you just take a guess at the first one on the next line?” Nicole reads the “N” fine, but hesitates on the next letter. If she says she’s not sure, ask her whether it looks more like an “S” or a “B.”

A little encouragement that it’s safe to guess often helps a child get her confidence back. The key that you’re looking for is a difference in performance between the two eyes, or better performance when appropriate lenses are in place.

INSECURITY

Other children are the opposite of the perfectionist. They will tell you whatever they think you want to hear, rather than trusting what they see.

Let’s say a child complains of seeing double, but you have no evidence from your exam that the child has a binocular problem. Take a pair of anaglyphic lenses, remove the red lens, and place it over the green. This has the same effect as covering one eye, but the child doesn’t know it. He should now report seeing only one image.

Once you have shown the child that there are some conditions in which double vision is impossible, he might then feel more comfortable telling you when he sees double and when he does not.

A perfectionist child stops reading the chart when it becomes blurry.

MALINGERING

Some children present with difficulties in seeing because of willful or unintended malingering. Although it is difficult to be patient with these children, showing empathy decreases the need for them to embellish what they have difficulty in seeing clearly.

The most obvious example is a child who is faking because her best friend just got glasses and she now wants glasses too. Present her with a lens flipper with plano lenses on one side and +0.25 or -0.25 on the other side. Have the child look through the plano side, and she will say that the chart is blurry. Flip to the minus side and say: “So Ella, does this make things look a lot better?” If the child can read to the 20/20 line with the lenses in place, you have a malingerer. If there is improvement only on the plus side of a line or two, and the child still can’t get beyond 20/40, there may be legitimate visual stress.

MAKING IT WORK

It is only after you are able to discern what the child sees that you are able to move forward with helping him or her to see his or her best. Remember the child who was so shy she whisper answers to her Mom? By the end of the exam, she was speaking directly to me and didn’t want to leave! OM

LEONARD J. PRESS O.D., F.A.A.O., F.C.O.V.D., is the optometric director of the Vision & Learning Center in Fair Lawn, N.J. He specializes in pediatric vision. Dr. Press completed his residency program in pediatric optometry at the Eye Institute of the Pennsylvania College of Optometry, and he served as chief of the pediatric unit of the Eye Institute. In addition, he’s a Diplomate of the AAO and has written three textbooks encompassing pediatric optometry and is a Diplomate in the Pediatric Optometry/Binocular Vision and Perception section of the AAO. Email him at visionlecture@gmail.com, or visit tinyurl.com/OMcomment to comment on this article.