please forgive us the rather sensationalist title for this article. We have aimed to collect together several of the examination techniques and aids which are used commonly in the clinical setting.
Children can have limited understanding of their situation, mistrust of strangers, can be frightened in the dark or by the instruments used to examine them, or can have a limited attention span, often shortened by hunger. Clinicians have therefore needed to adapt many techniques to overcome the challenges produced.
We have aimed to describe some of the less well-known examination methods that the authors have found most helpful and reliable in their clinical practice. Some of these methods can of course be used equally on adults should the need arise.
Flying Baby Technique
A table-mounted slit lamp can be used on patients of virtually all ages and sizes, depending on patient cooperation. The 'flying baby technique' is used for very young children who often can be positioned easily for examination if the parent holds the child in a horizontal position with the face looking forwards (Figure 1).
Portable Slit lamp
If positioning on a table-mounted slit lamp is not possible, an alternative for viewing the anterior segment in difficult positions is to use a portable slit lamp.
These can be found in a range of sizes: from dedicated instruments about the size of a pen, an alternative head to the battery handle of a direct ophthalmoscope, or the larger variety which have improved optics and incorporate their own binocular microscope (Figure 2).
direct ophthalmoscope using +15D
Another alternative to slit lamp examination is using a direct ophthalmoscope with a strong plus lens dialled in: this can be used to obtain a magnified view of the eyelids and anterior segment structures. Many direct ophthalmoscopes have a slit setting and a cobalt blue filter, both of which can be useful when examining in this way (Figure 3).
Digital camera (in The dark room)
Occasionally patients will not open their eyes to allow examination due to photophobia. In this circumstance the patient may well open their eyes in a darkened room, at which point a digital camera can be used (with a flash) to take a photograph of the eyes which is then available for instant evaluation.
packet of Smarties
This well-known brand of sweets comes in a brightly coloured tube, makes an appealing rattling sound, is widely available and inexpensive. Due to the product's almost universal recognition and their edibility they are a wonderful way of getting a tired and hungry child's attention, and assessing eye movements. Of course, you should not give a child any sweets without permission from their carer.
Goldmann tonometry
Goldmann applanation tonometry can be performed on some surprisingly young patients. This does, of course, rely on patient co-operation more than many techniques, but has the advantage over air-pulse tonometers of having no startling noise or sensation from the tonometer, and can therefore be preferable to a patient who has difficulty tolerating the puff of air. This is often best performed as the final part of slit lamp examination of the eye.
Indirect ophthalmoscopy
Indirect ophthalmoscopy can be achieved using a direct ophthalmoscope as the light source.
The optics are the same as when using the more familiar head apparatus,1 but the advantages are that the light is less bright, and the instruments look less threatening.
The technique is to hold the direct ophthalmoscope adjacent to your outer canthus (Figure 4), with enough co-axial light to easily see the red reflex. The 28D lens is then introduced as normal a few inches in front of the patient's eye. A fundal view can then be seen as with the normal indirect ophthalmoscope.
Discussion
As mentioned before, this list is not intended to be exhaustive, but the authors have used each of these techniques on many occasions when more conventional examination techniques have failed. Of course, no amount of ingenuity can be considered a substitute for a friendly and conscientious approach to both the child and their carer, as establishing trust and rapport is the best trick in the book.
Acknowledgments
The authors are by no means taking credit for developing these examination methods, and we would like to acknowledge our teachers and colleagues both from ophthalmology and allied professions who have contributed to this paper's contents.
References
1 Elkington AR, Frank HJ, Greaney MJ. Clinical Optics, 3rd ed. Oxford UK: Blackwell Science Ltd, 1999:173-179.
Alex Buller is specialist registrar in ophthalmology and Gerald Naylor is consultant in paediatric ophthalmology at Blackpool Victoria Hospital, Lancashireplease forgive us the rather sensationalist title for this article. We have aimed to collect together several of the examination techniques and aids which are used commonly in the clinical setting.
Children can have limited understanding of their situation, mistrust of strangers, can be frightened in the dark or by the instruments used to examine them, or can have a limited attention span, often shortened by hunger. Clinicians have therefore needed to adapt many techniques to overcome the challenges produced.
We have aimed to describe some of the less well-known examination methods that the authors have found most helpful and reliable in their clinical practice. Some of these methods can of course be used equally on adults should the need arise.
Flying Baby Technique
A table-mounted slit lamp can be used on patients of virtually all ages and sizes, depending on patient cooperation. The 'flying baby technique' is used for very young children who often can be positioned easily for examination if the parent holds the child in a horizontal position with the face looking forwards (Figure 1).
Portable Slit lamp
If positioning on a table-mounted slit lamp is not possible, an alternative for viewing the anterior segment in difficult positions is to use a portable slit lamp.
These can be found in a range of sizes: from dedicated instruments about the size of a pen, an alternative head to the battery handle of a direct ophthalmoscope, or the larger variety which have improved optics and incorporate their own binocular microscope (Figure 2).
direct ophthalmoscope using +15D
Another alternative to slit lamp examination is using a direct ophthalmoscope with a strong plus lens dialled in: this can be used to obtain a magnified view of the eyelids and anterior segment structures. Many direct ophthalmoscopes have a slit setting and a cobalt blue filter, both of which can be useful when examining in this way (Figure 3).
Digital camera (in The dark room)
Occasionally patients will not open their eyes to allow examination due to photophobia. In this circumstance the patient may well open their eyes in a darkened room, at which point a digital camera can be used (with a flash) to take a photograph of the eyes which is then available for instant evaluation.
packet of Smarties
This well-known brand of sweets comes in a brightly coloured tube, makes an appealing rattling sound, is widely available and inexpensive. Due to the product's almost universal recognition and their edibility they are a wonderful way of getting a tired and hungry child's attention, and assessing eye movements. Of course, you should not give a child any sweets without permission from their carer.
Goldmann tonometry
Goldmann applanation tonometry can be performed on some surprisingly young patients. This does, of course, rely on patient co-operation more than many techniques, but has the advantage over air-pulse tonometers of having no startling noise or sensation from the tonometer, and can therefore be preferable to a patient who has difficulty tolerating the puff of air. This is often best performed as the final part of slit lamp examination of the eye.
Indirect ophthalmoscopy
Indirect ophthalmoscopy can be achieved using a direct ophthalmoscope as the light source.
The optics are the same as when using the more familiar head apparatus,1 but the advantages are that the light is less bright, and the instruments look less threatening.
The technique is to hold the direct ophthalmoscope adjacent to your outer canthus (Figure 4), with enough co-axial light to easily see the red reflex. The 28D lens is then introduced as normal a few inches in front of the patient's eye. A fundal view can then be seen as with the normal indirect ophthalmoscope.
Discussion
As mentioned before, this list is not intended to be exhaustive, but the authors have used each of these techniques on many occasions when more conventional examination techniques have failed. Of course, no amount of ingenuity can be considered a substitute for a friendly and conscientious approach to both the child and their carer, as establishing trust and rapport is the best trick in the book.
Acknowledgments
The authors are by no means taking credit for developing these examination methods, and we would like to acknowledge our teachers and colleagues both from ophthalmology and allied professions who have contributed to this paper's contents.
References
1 Elkington AR, Frank HJ, Greaney MJ. Clinical Optics, 3rd ed. Oxford UK: Blackwell Science Ltd, 1999:173-179.
Alex Buller is specialist registrar in ophthalmology and Gerald Naylor is consultant in paediatric ophthalmology at Blackpool Victoria Hospital, Lancashire
Alex Buller and Gerald Naylor describe some ophthalmic paediatric examination techniques that are not often included in textbooks but which are helpful in overcoming the challenges that can be encountered when examining children