Pediatric Eye Exams: How Does My Doctor…

One of my absolute favorite questions in the realm of optometry is:
How are you able to do an eye exam on an infant?! They can’t even talk!
As a pediatric optometrist, I often quip back:
Exactly! Think of how much faster an exam would go without all the talking!

Okay, so that may be a bit of an exaggeration, but there were definitely days during residency when I would get thrown off by my patients actually being able to talk to me.
So, how does this process work?  Come with me and find out!

Pediatric Eye Exams 101

First things first: communication.
As adults, it’s easy to think of communication being the spoken or written word, but there’s so much more to it than that.
If you’re a parent, think back to the first years of your child’s life.  For quite a while, they probably weren’t able to speak – at least not coherently – but that didn’t mean that you couldn’t communicate.  Rather, you paid attention to their actions.  By observing and interacting, you could tell if your little one was tired, hungry, happy, frustrated, sick, or any of a million other feelings – without them uttering a single word!
These are the exact same skills that pediatric optometrists use when working with your young children: rather than relying on their words to describe vision, I watch their actions.
With that in mind, let’s take a look at the individual exam components!  To keep these posts at a reasonable length, I’ll discuss various portions of the exam over the course of several posts, so stay tuned for more updates!

Visual Acuity

In the normal eye exam, this would be the part where you’re told to look down at the end of the room and read the smallest letters that you can.
Except, obviously, most infants wouldn’t be able to understand these directions OR read letters.
BUT, they will (generally) pay attention to something that looks different – it’s a natural response!  So, we use this to our advantage.
My two favorite techniques for assessing vision in an infant/very young child are using Teller Acuity Cards (top) and Cardiff Acuity Cards (bottom).

As you can see, both sets of cards have an image on one half, and are a blank gray color on the other.  Due to the natural instinct of looking at a picture rather than a blank section of card, the child’s eyes will instinctively move so that they’re looking towards the image.
My job? Watch their eyes.
Okay, so it’s a little bit more complicated than that.
If I knew exactly where the image was, I would be biased to assume that that’s the direction that the child looked every time, falsely improving their vision.  So, with each attempt, and there are many, I spin the card around until I have no idea where the image is, and then let show it to the child while watching their eyes.  Once I’m confident with my guess as to where they looked, then I look at the card to confirm my guess.
*My card spinning skills have, on multiple occasions, evoked parent comments of, “you know, if this optometry thing doesn’t work out, you have a very promising career as a road-side sign-spinner!”  I’m admittedly never sure if I should take it as a compliment or not…*

Once my guess matches the image location 4/6 times on a single card, I move to the next hardest card, and repeat the cycle all over again, continuing until 4/6 is no longer achievable.  Each card has an equivalent 20/X measurement, that can be used for the purpose of explaining vision to parents and therapists, as well as monitoring over time.
Unfortunately, not all offices have these tests, as it costs ~$5000 for a set.  Rather, most offices use a method call “fix and follow” – which requires the child to do that – look directly at an object and follow it.  For a more precise measure, the size of these objects can be varied.
As children mature, more classic measures of acuity using matching or naming can be used – often first with just a few letters or numbers, and then progressing to the charts that you’re familiar with as adults!
If you have any questions or comments, feel free to contact me here – I’d love to hear from you!
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