How to assess eyes and vision in infants and preschool childrenBMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h1716 (Published 07 May 2015) Cite this as: BMJ 2015;350:h1716
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Blakie & Dutton’s helpful summary of paediatric ophthalmological examination techniques contains many useful tips. Understandably, since their article is intended for general clinicians, they caution against restraining children during the examination “to avert fear-induced Pavlovian reactions”.
Certainly, with gentle conversation, smiles, and encouragement, most children are incredibly co-operative with eye examinations, and I have removed corneal foreign bodies from 4 year-olds with no more than topical anaesthesia.
However, for infants and very young children restraint is sometimes necessary and, if done deftly and with the understanding co-operation of the child’s parent or guardian, may obviate the need for general anaesthesia or more prolonged investigations.
The Royal College of Ophthalmologists recommends that restraint only be used to exclude life-threatening signs, such as papilloedema, and that in all cases the child’s parent or guardian should be asked to give consent for their child to be restrained (1).
Although the general clinician may not feel justified in restraining a child, a working knowledge may be helpful for informing caregivers. For new-borns and babes-in-arms, lying the child supine along a parent’s lap - bottom against the parent’s abdomen, head resting on parent’s knees - means the parent can control the child’s legs and arms, leaving the clinician free to retract the lids and examine the eyes. For very wriggly babies, swaddling them in a towel may be helpful (2). Babies will cry at the bright light, so explaining this to parents beforehand, and reassuring them that the crying will stop once the light is removed, is key.
This is also a useful position in which to administer eye-drops: even if the eyes are tightly closed, apply the drops to the medial canthus to form a little pool, and as soon as the child relaxes their lids the drops will enter the conjunctival sac.
For larger infants, sitting them up on a parent’s lap, facing forwards so that the parent can wrap their arms around the child, can afford a quick glimpse of the eyes; but if things turn into a fight the examination will be fruitless.
One further note is the use of topical anaesthetic, which can in itself be a valuable diagnostic tool. If a child is happy to open a previously closed eye after a few drops of Proxymetacaine 0.5%, you can be confident that the symptoms are due to ocular surface pathology - an abrasion or foreign body, for example - rather than something intraocular. This can be very reassuring for clinician and parents alike, and once the eye is open and the child is feeling happier, it is usually possible to examine more fully.
1. Royal College of Ophthalmologists guidelines for the management of strabismus in childhood. March 2012
2. Mason I, Stevens S. Instilling eye drops and ointment in a baby or young child. Community Eye Health 2010; 23(72): 15.
Competing interests: No competing interests