Children and their ophthalmic needs can differ greatly from the patients and ocular condi­ tions encountered in adult ophthalmology. Each childhood developmental level requires a dif fer ent examination approach. With proper preparation and a positive attitude, the ophthal­ mologist can find the examination of pediatric patients to be both enjoyable and rewarding.

Examinations are typically more successful when patients are relaxed. The outpatient clinic atmosphere should be welcoming, preferably with dedicated waiting area(s) for children and families. Many pediatric prac ti tion ers forego the traditional white coat because some children may be afraid of it. The examination begins as the practitioner enters the room and gathers impor tant information via observation about the child’s visual be hav ior, ability to am­ bulate, any abnormal head position, any dysmorphic features, familial disorders (note parents and siblings), and family social dynamics. A parent’s smartphone may contain photos and videos that prove useful in establishing a diagnosis and a condition’s progression over time.

Clinicians should introduce themselves to the child and family and establish and maintain eye contact with the child. Being relaxed, open, and playful during the examina­ tion helps create a “safe” environment. Gaining the child’s trust enables a faster and better examination, easier follow-up visits, and greater parental support. Family members may also need reassurance; parental anxiety may exacerbate the child’s anxiety. Asking children easy questions can help them feel confident; a simple joke can relax both child and par­ ent. It is impor tant to work with the child’s family, enlisting their help and respecting their concerns.

Children enjoy being regarded as “big” as well as correcting adults’ mistakes; pretending to grossly overestimate the patient’s age or grade level and then asking, “Is that right?” can boost a child’s confidence.

In addition to a standard medical history, the pediatric eye assessment includes rel­ evant prenatal/perinatal history (pregnancy or perinatal complications including prematu­ rity), developmental milestones, and family history of strabismus or other childhood eye disorders.

During the examination, the practitioner should sit at the child’s eye level; some children prefer sitting in a parent’s lap. Describe the examination to children in terms that they can understand. Because cooperation may be fleeting, the examination ele ments that are most critical for diagnosis and management are best addressed early. The most threatening parts of the examination should be performed last. A long examination lane with dif fer­ ent types of distance- fixation targets (including remotely activated videos and mechanical animals 6 meters from the examination chair) is optimal. It is best to have a variety of near- fixation targets with details that stimulate accommodation (a muscle light is not an accommodative target) (Fig 1-1).

Explain what is happening in terms familiar to a child, such as “I want to show you something special” instead of “I need to examine you.” Use “magic sunglasses” for the stereo glasses, “special flashlight” for the retinoscope, “funny hat” for the indirect ophthalmoscope, and “magnifying glass” for the indirect lens.

For a child who has difficulty cooperating with the examination, some combination of rest periods, persuasion, per sis tence, patience, and rewards is usually successful. It is impor tant to engage the child and caregivers in decisions regarding how to proceed. If a child is having a bad day, it may be best to stop the examination and schedule another appointment.

If an infant was fussy during the first visit, ask the caregiver to bring the infant to the follow-up visit hungry, and feed him or her during the examination. If dilation in the clinic is a barrier to successful examination, consider having parents give dilating drops at home ahead of time. Review pos si ble adverse effects.

Brief restraint may sometimes be needed, especially for eyedrop administration or fundoscopy in infants and younger children. Provide agency to the older child by offer­ ing a choice between helping and being held. Always consider the physical and emotional consequences of restraining a child and apologize to the child afterward if restraint is used. Depending on the nature of the ocular prob lem, a sedated examination or an exami­ nation under anesthesia may be considered.

A pattern of poor adherence to treatment and follow-up recommendations should alert providers to the possibility of neglect, or at least of barriers to care that may benefit from social ser vices (see Chapter 28 in this volume). Pediatric prac ti tion ers are obligated to report suspected neglect or abuse to the appropriate social agencies.

Note that the caregiver bringing a child to appointments may not be the child’s legal guardian and therefore may not be authorized to provide consent, such as for surgery.

A pediatric eye examination requires dif fer ent techniques and devices than an adult ex­ amination. For example, sensorimotor evaluation (which will be discussed in detail in Chapter 6) is often required. Sensorimotor examination should begin with the tests that are least dissociating with re spect to binocularity, such as stereoacuity testing, followed by motility testing; monocular visual acuity testing and pupil exams are dissociating and should be performed later in the examination, so as not to affect the sensorimotor exam.

The clinician’s approach to vision assessment varies depending on the child’s age, develop­ mental level, and cooperativeness.

In older children, recognition visual acuity is tested using linear letter optotypes when­ ever pos si ble. Sloan letters, consisting of C, D, H, K, N, O, R, S, V and Z, are ideal because they have been shown to be equally recognizable. The optotypes should be spaced so the distance between each optotype is no greater than the width of the optotypes on any given line (see BCSC Section 3, Clinical Optics and Vision Rehabilitation, for further discussion of visual acuity charts). Computerized visual acuity test systems allow for randomization of optotype pre sen ta tion, preventing memorization.

An adhesive patch is the most reliable occluder for monocular testing because it reduces the possibility that the child will “peek” around the occluder. A fogging occluder may be in­ dicated for patients with nystagmus (see Chapter 12). Patients with vision worse than 20/400 may need to move closer to the chart until they can see the 20/400 optotype, in which case, the numerator for the visual acuity is the distance in feet (eg, if the 20/400 optotype is only seen at 5 feet, and the chart is calibrated for 20 feet, visual acuity is noted as 5/400).

Younger and/or preliterate children may need to be tested with alternative optotypes, preferably the LEA symbols (Fig 1-2) or the reduced set of 4 letter optotypes known as the HOTV test. Allen figures, though commonly used, are not as well standardized, and may be culturally biased. Some children are confused by linear arrays and need to be shown single optotypes; in this case, the use of crowding bars (see Fig 1-2B) around each opto­ type is recommended, because testing with uncrowded optotypes will underestimate the actual visual acuity deficits in patients with amblyopia.