Pediatric Eye Examination
In the nonpediatric eye clinic, the physician often views the presence of a small child in an examining lane with some anxiety, if not dread. Examination of a child is quite different from that of the adult. The history is largely from a source other than the patient, and the examination requires patience and talent. There are several tricks to make the visit go as smoothly and efficiently as possible
HISTORY
Although ancillary personnel are often relied on to take the history, this is best obtained by the physician who knows how to direct the line of questioning to the most useful information. The old adage that “the patient is always right” is especially true in the case of parents’ observations about their children. Most
of the history is obtained from the parents or the referring physician, but any input from the child is equally important. Many children will not complain of blurry vision or diplopia, but should they describe these symptoms one must be very alert to an acute process. This is also an invaluable time to observe the
child in an unobtrusive fashion and preliminarily assess head position, eye alignment, and overall appearance. Often this may be the extent of the physical examination that one can obtain; once children realize that attention is focused on them, they may become very uncooperative.
The problem precipitating the visit should be stated in the parents’ or child’s own words and then elaborated.
Requisitequestioning for all pediatric eye problems should clarify whether the problem is congenital or acquired and should specify the age of onset in the latter case. If the chief complaint is a visual
problem, it is helpful for the parents to specify what the child can or cannot see; that is, does the child respond to lights, faces, toys near or far, very small items? In cases of strabismus, the frequency and stability of the deviation and any associated head posture are important. Precipitating factors may include fatigue,illness, sunlight, and close or distance work. For nystagmus, medications and the past medical history may be pertinent. With cataracts, any history of trauma, medications, or associated medical conditions is important, as well as the family history. Tearing patients need to be questioned about any redness, photophobia,
or crusting of the lashes. In ptosis, the stability or variability is important, as is any associated chin elevation or general neuromuscular problems. For difficulties in school, it is helpful to determine if the problem is only visual or is related to a particular subject area (reading, spelling, writing, or math) and if
there are any stress factors in the child’s extracurricular life.Important aspects of past history include prenatal and perinatal problems, birth weight, gestational age, and mode of delivery. Any medical problems should be elicited, as well as current medication and allergies. Early development should be assessed by asking about specific developmental milestones, such as rolling over, sitting up, and walking. The Denver Developmental
Scale is a good reference for developmental norms.10 Later development can be ascertained by asking about scholastic level and performance.
Although ancillary personnel are often relied on to take the history, this is best obtained by the physician who knows how to direct the line of questioning to the most useful information. The old adage that “the patient is always right” is especially true in the case of parents’ observations about their children. Most
of the history is obtained from the parents or the referring physician, but any input from the child is equally important. Many children will not complain of blurry vision or diplopia, but should they describe these symptoms one must be very alert to an acute process. This is also an invaluable time to observe the
child in an unobtrusive fashion and preliminarily assess head position, eye alignment, and overall appearance. Often this may be the extent of the physical examination that one can obtain; once children realize that attention is focused on them, they may become very uncooperative.
The problem precipitating the visit should be stated in the parents’ or child’s own words and then elaborated.
Requisitequestioning for all pediatric eye problems should clarify whether the problem is congenital or acquired and should specify the age of onset in the latter case. If the chief complaint is a visual
problem, it is helpful for the parents to specify what the child can or cannot see; that is, does the child respond to lights, faces, toys near or far, very small items? In cases of strabismus, the frequency and stability of the deviation and any associated head posture are important. Precipitating factors may include fatigue,illness, sunlight, and close or distance work. For nystagmus, medications and the past medical history may be pertinent. With cataracts, any history of trauma, medications, or associated medical conditions is important, as well as the family history. Tearing patients need to be questioned about any redness, photophobia,
or crusting of the lashes. In ptosis, the stability or variability is important, as is any associated chin elevation or general neuromuscular problems. For difficulties in school, it is helpful to determine if the problem is only visual or is related to a particular subject area (reading, spelling, writing, or math) and if
there are any stress factors in the child’s extracurricular life.Important aspects of past history include prenatal and perinatal problems, birth weight, gestational age, and mode of delivery. Any medical problems should be elicited, as well as current medication and allergies. Early development should be assessed by asking about specific developmental milestones, such as rolling over, sitting up, and walking. The Denver Developmental
Scale is a good reference for developmental norms.10 Later development can be ascertained by asking about scholastic level and performance.
The family history is very important because often the young child does not have enough past history to be useful. The focus should be on the presence of strabismus, poor vision, and neurological problems. In the case of possible genetic disorders, the number and sex of siblings, possible consanguinity, and the number
and gestational age of any miscarriages should be documented.
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