Medical Model

Children’s Medical Eyecare Services: Turn the Entire Family into Patients

By JeanMarie Davis, OD


Monitoring and treating the eye health of children is a practice-builder that brings in whole families as patients. The key: Let parents know your office treats pink eye and other eye conditions that commonly affect their kids.

The children who visit your practice sometimes have eyecare needs that extend beyond your routine refraction for eyewear and contact lenses. Like adults, children also sometimes need attention for conditions like allergic conjunctivitis, vernal conjunctivitis, viral conjunctivitis and keratoconjunctivitis. Educating parents that you treat these conditions so they turn to you first instead of the family doctor or emergency room can be a practice-builder that brings in a whole family of patients. Raise awareness (with parents) of the importance of maintaining eye health in children: let them know that the OD is the expert to turn to first. Train staff and make your office kid-friendly. Rewards to your practice can be exponential–including bringing in siblings, parents and friends of the family. Communicate that you treat these conditions and use the vernacular, such as “pink eye,” when discussing them.

Offering children’s fashions in the optical dispensary is important, but is only half of what what you need to do to cater to young patients. You also need to educate parents that you’re the one to take children to when conditions like eye infections are experienced.

Educate Parents that Not Just Adults and Elderly Have Eye Health Needs

With more education regarding the importance of good eyesight and annual eye exams in children, more parents are interested in bringing their children in for eye exams at younger ages. This is a great opportunity to grow your practice. Working with local pediatricians can generate a large referral base of kids, particularly before the school year, allergy seasons and cold and flu season. Pediatricians do not have the specialized knowledge or proper instrumentation to differentiate between the different types if conjunctivitis or infection and will be happy to refer their patients to you, especially if you provide a report for their records. This is quick and easy to do with most electronic records.

Make Instrumentation Work for Child Patients

With a few exceptions, the instrumentation for a child’s exam is the same as you would use for an adult. However, you may want to make some special adaptations to make it more fun for your young patients and possibly easier for you. The slit lamp, phoropter and auto refractor will be the same. You may want to have a booster seat for smaller children. The eye chart can be the same for older school age children, but there are some other charts that are designed for children who do not know their letters and numbers. For example, these charts may have pictures or tumbling E’s.

While it is possible to use an air puff tonometer on older children, I advise against this. When I was in practice I found that this most often traumatizes the children more than any other part of the exam and can have lasting negative effects. I had the best response with Goldmann tonometry. That may be hard to believe, but it works very well. It does, though, require a gentle approach with children. Another instrument that works well for taking pressures is a tonopen. Having interesting focal points for kids to look at is helpful. It keeps their attention, keeps them distracted and helps put them at ease. Focal points can be anything colorful and fun such as stuffed animals. Finger puppets and little toy dogs that bark were some of my favorite “tools” to use to keep children’s attention occupied while an exam was conducted. It is also helpful to have something that lights up for children to look at. Even the red-green filter on the projector can be useful.

Keep Children Calm During Testing

Children require a soft approach from the doctor. They need to feel comfortable and reassured. This starts from the moment they walk into the office. It is important to have a staff that can interact well with children and parents. It does not take much. Train staff to smile and ask the child’s name, address the child by their name and talk to them briefly by asking them something simple like how old they are, what grade they are in or if they have any brothers and sisters.

Create Child-Friendly Atmosphere
Having a relaxing environment helps, but I did not find it necessary to have a play area. I found it better to let the children sit quietly instead of having them run around a play area and become hyper-active. Most parents these days bring some sort of electronic device for children to play with. If the parent has not provided the child with an electronic device like an iPad, your staff can give the child a simple blank piece of paper and a pen, or you could keep a few coloring books and crayons in the office. If often doesn’t take much to keep a child’s attention. For instance, if you give a child a colored pencil and let them keep it, they may be happy enough about it to forget most of their anxiety.

It’s nice to have a few distractions on hand for children patients, but children often are fine with no toys or distractions provided by the office. I went many years without providing anything for children to play with and it worked out just fine. It is important to keep order. Children should be encouraged to be quiet and calm. Running around and/or screaming is not safe and makes them and other patients anxious and uncomfortable. Most children in my practice behaved very well. The few that did not were almost always responsive to some friendly, calm instruction from our staff and their parents to sit down quietly while they waited.

Watch Your Approach with Children in the Exam Room

The most important aspect of examining children is how you interact with them. Have the expectation that they will behave and follow directions and speak directly to the child. Ask the child if they have any questions. Stay positive and make it as much fun as possible while at the same time moving through the exam as quickly as possible.

It is important to take a moment to engage a child rather than jumping right into an exam. However, this does not need to take up a significant amount of time. Just a minute or two. Each child is different. Some will be calm and more cooperative than most adult patients and others may be timid and afraid. I used to ask them if they had ever had their eyes checked and would tell them that we will be playing some games and it that it will be fun. I explained how important it is to follow the rules of the games like looking where I tell them to and sitting still. I would have them start with something quick and easy like telling me how many fingers I’m holding up and then ask them if they thought that was easy. That usually puts them at ease. Asking them to hold something for me while I got the history from mom or dad seemed to go over well. I started with easy preliminary testing like motility and the cover test. When I checked pupils, I explained what I would be doing and assured them that nothing would touch them and prepared them to see a bright light. I performed a quick retinoscopy and biomicroscopy before drops were administered. I found that children are much less apprehensive if they can have a relaxed experience for the first few minutes.

Provide a simple quick explanation before each procedure so the child knows what to expect. Most of their fear is not knowing what you are going to do to them. It is not uncommon that a child may be anxious because they think you will be giving them a “shot.” Letting them know at the beginning that you will not be giving them a shot or doing anything that hurts can have a significant impact on their anxiety and cooperation.

Engaging Children in Exam Room: Sample Script

For a young child I may start with something like: “Hi Sally! Your dress is so pretty! Is that your favorite dress? Have you ever had your eyes checked before?”

If Sally answers “yes,” you could say,”Oh, good, so you know how much fun it is! Did you play games the last time you had your eyes checked?”

If Sally answers “no,” you might say, “Oh, well, we are going to have so much fun! I check your eyes by playing games! The games we play are very easy and fun! All you need to do is look where I tell you and tell me what you see. Do you know your colors? [if Sally answers “yes”] Good! It’s really important that you sit up straight and keep very still and only move your eyes when I ask you to. Don’t move your head, OK? Alright, this first game is really easy. All you have to do is keep your head still and only move your eyes to follow my finger, OK?”
Explain What is Happening When Administering Eye Drops
For children who are afraid, drops are typically the most challenging part of the examination. I had the most success by explaining to the child that I need to put a few eye drops on their eye, but that it’s just like water when they swim in the pool. I prepared them for the proparacaine by telling them the first drop tickles and the rest they wouldn’t feel. It is also helpful to ask them if they want to sing a song or tell you the alphabet. I also instructed them to close their eyes gently and not squeeze their eye lids. When I instilled the proparacaine I reminded them to close their eyes gently and gently covered their eyes with my hand, very slightly moving my hand back and forth a little and I continued to talk to them if they were not singing. I waited until the eyes didn’t “tickle” any more, and before instilling in the remaining drops, I reminded them that the rest of the drops would feel like water.

I then put them back in the slit lamp and performed Goldmann tonometry telling them I want to look with a blue light, but it is important that they don’t move and look where I ask them to. I would tell them that I am going to move their eyelashes so nothing touches them, which allowed me to hold their lids easily. I also would tell the child what a great job they did and explain that they could take a break and that all I had to do when I called them back was look at a light and we would be all done.

Indirect ophthalmoscopy should be done with both eyes open providing the child with a colored light as a fixation point to make it as easy as possible. The parent or a technician can assist holding and moving the fixation point to the different areas of gaze. For children who are more sensitive to the white light, I would typically use the green filter which is much more soothing and easier on the child and would just use the white light toward the end as quickly as possible to look at any area that needed closer examination and the posterior pole.

If Treatment Requires Eye Drop Regimen, Take Time to Explain to Both Parent and Child

I always explained treatment regimens to the parent and the child at the same time. I spoke more directly to the parent but also told the child how important it is that they help their parents. An example may be an antibiotic drop that needs to be taken four times per day. I would explain to the parent and child:

“It is very important to put a drop in the left eye four times per day in order to treat this infection. That would be about every four hours. You can write down the time you used the drop and plan the next one four hours later. Another easy way to remember is to instill a drop in the morning upon waking. The next drop can be taken at lunch time, the next drop at dinner time and the last drop before bedtime.

I am writing this down for you to help you remember once you get home. Do you think this will be easy for you to do? Do you anticipate any difficulty in following this schedule on a school day? I will write a note for the school so they will allow the drops to be administered during school hours.”

You can put in the first drop when you wake up in the morning, Johnny, and can you please help your Mommy by letting her put the drop in when she needs to? Do you have any questions?”

Parents Not Always a Good Idea in Exam Room

Every child is different. Some do better with their parents in the room and some without. The parents would typically accompany their child at first. If this works well they would be welcome to stay. If the child was uncooperative, or the parent was over protective, I would ask the parent to wait outside after briefly explaining what I would be doing and explaining that I would be certain to call them in at the end of the exam to explain all my findings to them.

Manage Parental Expectations

Managing the parents is as important as managing the child. Parents can be a big help in assuring and encouraging the child to follow directions during the exam. However, an anxious parent will have a negative impact on the child. Reassure the parent that you want their child to feel as comfortable as possible and will do everything necessary to provide them with the best care while making them feel as comfortable as possible. Make sure the parent understands that you like children and have experience with them. Keep the parent informed and ask them to leave the exam room if necessary.

If the parent is to remain in the room during the examination, only allow one parent to stay, and it is usually better to have siblings wait outside the exam room if possible.

Accommodate Parents’ and Children’s Schedules

Having extended hours at least one day a week makes it much more convenient and easier for parents and children. I found that most parents prefer to come right after school, so I would have one day during the week when I started and ended later. Another option is having Saturday morning hours. Even offering these time slots every other week can make a big difference. How many days you require extended or Saturday hours can depend on how many children you see.

Beware of Scheduling Challenges

Scheduling children with siblings and/or parents on the same day can be very convenient, but also carries a risk if they book a block of your schedule and don’t show up or cancel at the last minute. What I found to be most effective for new patients or existing patients who had been unreliable in the past is to explain to the parent that there will be a slightly longer wait because two exams back-to-back are not available and there is another patient scheduled in between, however, you will do everything possible to minimize their wait. I would also double book one time slot every hour with a non-family member.

On the day of the exam I would always accommodate them which would make them extra happy. But this way if they don’t show up you don’t end up with a huge gap in your schedule, especially if it is a family of four.

When a parent and child came in for examinations on the same day I would also call them both back in for DFE at the same time and examine them back-to-back. This is very efficient and does not take much more time than seeing one patient.

On occasion you may run into a situation where the child is completely uncooperative. Try to sooth the child and reassure them for a moment. If that is not sufficient ask the parent to please try to sooth their child outside the examination room while you see the next patient and you will call them back. Having a technician who is good with kids can be very helpful in these circumstances. If unsuccessful, I never forced the child if it was a routine examination. I would ask that the parent reschedule and take the time to talk to their child every day to reassure them and explain what they can expect before the next visit. I would also recommend they instill an unpreserved artificial tear every day so the child would become comfortable with drops and working with their eyes. There is also a children’s storybook about getting an eye exam available that helps some children if they have it read to them at home a couple of times before returning. Usually by the time they return the child is much more comfortable and cooperative.

Related ROB Articles

InfantSEE: Bring the Whole Family Into Your Practice

Incorporating Vision Therapy Into Your Practice

Children Patients: Engage the Child in the Exam and Build a Family Practice

JeanMarie Davis, OD, is global head, technical, Global Performance Development for Alcon. To contact her: drdavis2020@yahoo.com.

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