34 AE Spring 2011

Help! There’s aChild in My Chair

Running the Practice Technicians

Jane T. Shuman, COT, COE, OCS

Ophthalmology is bestknown as an adult spe-cialty area. As the babyboomer generationmatures, doctors are able

to limit their practices according tothis specialty and demand. Yet, peri-odically, even the most limited prac-tice will have a pediatric patient.What’s a tech to do?

Some personnel approach chil-dren more tentatively than they doadults; for one reason or another,they may not know how to relate tokids as patients and in turn, commu-nicate with the parent(s) instead.Depending on the age of the child,this may be appropriate. Check thefollowing guidelines for specific rec-ommendations about history-takingand work-ups.

Screening and HistoryWhen an infant or toddler is referredto the medical ophthalmologist, thepatient has probably been screenedby a pediatrician or optometrist; theparent may have a clear understand-ing of the rule-out possibilities. It’seven better when the referring doc-tor calls in advance or sends alonghis findings; this history defines thedirection of the medical visit.

When taking the history of apreschool child, it is important toget a perinatal history from the par-ent. This should include detailsabout the pregnancy (difficulty,weeks at birth) and the delivery(vaginal or Caesarean) and birth

AE Spring 2011 35

weight. If the child is preverbal,inquire as to visible rubbing of eyes,tearing, or turning. Inquire, too, ifthe child’s development is normalfor his or her age.

As the child goes throughschool, some of the history ques-tions can be directed to the patient,with confirmation from the parent.The doctor will need to know wherethe child sits in the classroom (front,back, etc.) and if s/he has troubleseeing the chalkboard, whiteboard,or SMART Board, or difficulty read-ing print (at near zone) or the com-puter screen (in the intermediatezone). The parent may have noticedthe child squinting for better dis-tance acuity. Success at sports maybe an indication of good hand-eyecoordination.

Parents of children should beencouraged to bring earlier photo-graphs with them to the visit. This isespecially pertinent if a turn is sus-pected or if a white pupil is noted.The earlier pictures will indicate thepresence or absence of an early eyeturn that may correspond to anamblyopia. In pre-digital photogra-phy, a red reflex in the pupils wasindicative of clear ocular media; awhite pupil will include the differen-tial diagnoses of congenital cataractor retinoblastoma. Photographstoday may have the red eye editedout, but a white pupil will still bevisible.

Work-UpWhen the patient is a child, thetechnician is faced with multiplepeople in the work-up lane. A parent

will be present with or without thepatient’s siblings, any of whom mayinterrupt the interview and testingprocess. The technician must takecharge of the exam, tactfully remind-ing them who the patient is. Becauseeveryone in the room has access tothe vision chart, visitors may beinclined to provide the patient withhints (“What is the first letter ofyour name?”) or be tempted to readthe chart out loud.

The technician must determinewhich distance chart is appropriatefor each patient. If this is an estab-lished patient, there should be anotation on the last visit note. Ifnot, ask the child and parent if heknows his letters. When the answeris a negative, the options includeTumbling Es, HOTV, or Allen cards.Visual acuity can be determinedusing a matching card; the child canwhisper answers to the parent orother creative measures can be estab-lished. Because children might haveshort attention spans, consider firstisolating the letters vertically andthen horizontally to determine visu-al acuity at distance.

Children can be quick, though.Therefore, it is critical that the felloweye be firmly occluded using anadhesive patch over the eye, not thelens of the glasses. If other means ofocclusion are used, such as anoccluder or palm of the hand, it isimportant to observe the placementand movement of the object block-ing the eye.

A successful approach to work-ing up young children is to make agame of the various tests. Encourage

guessing; kids want to get the rightanswers and may not be used to pro-viding responses when they areuncertain. Muscle function, colorvision, fusion, and binocularityshould be checked. This is also agood opportunity to screen youngersiblings for amblyopia (check the flyon the stereo test) and the presenceof the red reflex by flashing the tran-silluminator light into their pupils.

Dilating pupils is a necessarychallenge; no child wants drops inhis/her eyes. In addition to checkingthe periphery of the retina, a cyclo-plegic refraction should be done onall new pediatric patients to deter-mine the amount of accommoda-tion. Glasses may be prescribed onthe basis of the second manifest.

State-Required ScreeningsSeveral states require a vision screen-ing prior to starting kindergarten.The chief complaint will be different,but the history should follow thesame questions as the HPI of a med-ical exam to rule out any problems.It has been determined that reducedocular function can lead to learningdifficulties and early correction leadsto success in school. The parent whobrings a child for a mandated screen-ing might be less concerned than theparent who has been referred in, butwhen asymptomatic vision problemsare detected early, the child has agood chance of full function andachievement in school. AE

Ophthalmology is best known as an adultspecialty area. Yet, periodically, even the most limited practice will have apediatric patient. What’s a tech to do?

Jane T. Shuman, COT, COE,OCS (857-233-5891;Jshuman@eyetechs.com), ispresident of Eyetechs Inc.,Boston, Mass. Eyetechs is anationally recognized authorityon clinical flow, scheduling,and technician education.