Children old enough to sit by themselves can usually be enticed to hold the “motorcycle handles” of the slit lamp long enough for a brief examination. A younger child may be po­ sitioned at the slit lamp while in a parent’s lap. Children unable or unwilling to cooperate for standard slit- lamp examination may be examined with a portable slit lamp, surgical loupes, or a 20.00 diopter (D) handheld lens used as a simple magnifier with illumination from an indirect ophthalmoscope.

It is not always easy or pos si ble to perform formal tonometry in children. Accurate to­ nometry requires a relaxed patient. Handheld devices such as the Icare tonometer (Icare Finland Oy) or Tono- Pen (Reichert Technologies) can be very useful for mea sur ing intra­ ocular pressure (IOP) in children. The Tono- Pen or the Perkins Tonometer (Haag- Streit USA) may be used to test infants when they are sleeping or feeding in the supine position.

Digital palpation, though not quantitative, can provide a gross assessment of IOP. Inter­ pretation requires practice and correlation with formal tonometry tests in the same patient.

Because of the relationship between accommodation and ocular convergence, refraction with cycloplegic agents is a particularly impor tant test in the evaluation of any patient who has issues relating to binocular vision and ocular motility.

Cyclopentolate hydrochloride (1%) is the preferred cycloplegic drug for routine use in children. Use of a weaker concentration of cyclopentolate (0.2% to 0.5%) is suggested in in­ fants. Tropicamide (0.5% or 1%) alone is usually not potent enough for complete cycloplegia in children. Atropine (1% drops or ointment) is used by some ophthalmologists, particularly in young children with accommodative esotropia or dark irides, but this drug causes pro­ longed blurring and is more often associated with adverse effects (see the section “Adverse effects of cycloplegic agents”). Although phenylephrine (2.5%) has no cycloplegic effect, it is often used in combination with 1 or more cycloplegic agents for maximum dilation.

T able 1-4 Common Cycloplegic Agents

Most young children are apprehensive about eyedrops. It may help improve the child’s cooperation for the remainder of the examination if someone other than the physician instills the eyedrops. Eyedrops may be described to the child as feeling “like a splash of swimming pool water.” Some prac ti tion ers administer a topical anesthetic drop first, while others use the cycloplegic drops alone; some use a compounded drop (containing more than 1 mydriatic/cycloplegic agent) or spray.

An anesthetic drop may be called a “tickle drop” and the child can be encouraged to laugh when it is administered.

Local allergic reactions to cycloplegic drugs may include conjunctivitis, edematous eyelids, and dermatitis. Cycloplegic agents may also cause nonallergic systemic symptoms, which may be more common in children with lighter irides; these include fever, dry mouth, flush­ ing, tachycardia, constipation, urinary retention, nausea, dizziness, and delirium. Treatment is discontinuation of the drug, with supportive mea sures as necessary. A severe reaction should be managed in an emergency care setting. Adverse effects are more common with atropine than other agents. Note that 1 drop of 1% atropine contains 0.5 mg of atropine. See also BCSC Section 2, Fundamentals and Princi ples of Ophthalmology, Part V: Ocular Pharmacology.

Refraction is generally performed after cycloplegia. Streak retinoscopy is an objective technique that can be used with children of any age; it is described in detail in Chapter 4 of BCSC Section 3, Clinical Optics and Vision Rehabilitation. Retinoscopy may be performed with loose trial lenses, or through a phoropter for children who are able to reliably partici­ pate. Accurate retinoscopy must be performed in the child’s visual axis and at a controlled working distance. Autorefractors may also be used after cycloplegia. Subjective phoropter refraction or refinement is an option for older children.

The fundus examination is typically done last and can be challenging in infants and tod­ dlers. It is helpful to reduce the illumination on the indirect ophthalmoscope. It is impor­ tant to obtain an adequate view of at least the optic nerve and macula. This is facilitated by distracting the child with a distant target or a toy held near the examiner’s head (to the examiner’s right for the child’s right eye). Examination for retinopathy of prematurity (ROP) constitutes a special situation in which it is essential to view the far ret i nal periph­ ery, which usually requires restraint, topical anesthesia, an eyelid speculum, and scleral depression (see Chapter 24 in this volume for discussion of ROP).

In the inpatient setting, it is impor tant to consult with the family and/or the nursing team regarding examination timing. When testing visual acuity using a near- vision testing card, use the recommended standardized testing distance, with habitual refractive correction if pos si ble, and do not test visual acuity at near after cycloplegia. Dilation may not be appro­ priate in patients requiring frequent neurologic assessment, including pupil assessment. Dilating eyedrops should be ordered and documented in the medi cation administration rec ord, and primary care team members should be informed if pupils were pharmacologi­ cally dilated. Impor tant findings should be communicated verbally to the primary team, in addition to being documented in the consultation report.