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Volume 1 - Approaching and Examining the Very Young Child
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Lecture 20 of 24 NEXT»
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One of the supreme challenges for the strabismologist is approaching and examining a very young child - let's say under one year. This age group is not necessarily the toughest, the two year old can be more challenging, but the under 1 yr. old has special needs. The term approach is used intentionally. Don't accost! If you fail to approach the child properly, you may never be allowed to get to the essential part of the examination.
The initial approach:
1) Nonthreatening -
Talk to mom (family). Baby can be sitting on a parent's lap. The family wants to tell you why they are coming to see you. They would also like to be reassured that you are a "good guy/gal" before you start poking at their infant.
2) "Sneak a Peek"
While talking mainly to the "unencumbered" parent (the one not holding the child if both parents are present), observe the behavior of the child. This may be the best look you have of the infant during the entire examination.
3) Make a mental note of:
1. Alignment - Nystagmus?
2. Palpebral fissures for Epicanthus-Ptosis-size-slant
3. Head size - If you have a question, measure
4. Infant's Response to Surroundings
5. Head Posture - Tilt? Chin Up - Down? Etc.
6. Pupil Size - Response
7. Anything else?
All of the above may be done in subdued light which in most cases will encourage the infant to open his/her eyes fully.
After this initial encounter you will know a great deal about the infant even though you have not yet involved the infant in the process or started the actual "hands on" part of the examination. The examination continues with the infant now shifted to the parent's lap as the parent sits in the exam chair. You should:
* Look quickly and intently - recording thoughts and impressions without squandering valuable opportunity.
* Be quiet! Speak softly - be calm - be under control and in command - never "lose your cool!!"
Probably the biggest mistake examiners and assistants make is being overly noisy. There is a notion on the part of many that infants are attracted by loud noises, clapping hands, frequent repetitions of their name, etc. Not so!! Infants like mom and dad's face (and some other friendly faces), their bottle or pacifier, and soothing sounds accompanied by smooth motion carried out close to their face. Infants do not like a light as do 2 yr. olds who may be induced to "blow out" the light. Infants may follow a rattle, their bottle (although they would rather be drinking it in most cases) or sometimes they might like a rattle, or a little toy. We use a toy called  "Pecking Chickens" - this extremely useful gadget combines bright colors - smooth motion and nonthreatening sound which can be attractive to children from infancy to the older age groups of 5 and 6 years old. The toy is moved in front of the infant in such a way that lateral versions - and up and down gaze are observed in addition to the primary position alignment.
At this time you may carry out a nonthreatening cover test of the nondeviated or normal eye using your hand to check for amblyopia. If the infant becomes agitated, tries to push you hand away or fails to take up fixation with the uncovered eye, Amblyopia is suspected. Perform the Hirschberg corneal light reflex test or the Krimsky Test or even try the prism and cover test - good luck with the latter.
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Objection to occlusion OD means amblyopia OS |
Hirschberg - 40D ET OS |
Krimsky - 40D prism over the fixing eye centers light reflex in the deviated eye. |
During the interview with the family and observation of the infant with the aid of a toy (pecking chickens or your choice), check for fixation preference, and measure the alignment in the primary position. This takes only a few seconds. By now you will have most or perhaps all of the information you need about motility.
* However, things may not have gone well leaving you with a wailing baby or you may be unsure about whether the limited abduction you observed was Duane or VI N palsy or lack of cooperation.
* Doll's head test (oculocephalic response)
 A quick rotation of the infant's head to either side will elicit full lateroversions in the normal infant. Deficient abduction could indicate Duane or VI N palsy or some other cause of restricted movment. Be careful! Some congenital ET, called the Ciancia type is characterized by reluctant abduction because of combined convergence response and crossfixation.
- Don't do the doll's head test until after you have finished doing the "civil" part of the examination, because, at least on the infant's part, you will have betrayed trust, by forcibly rotating his/her head.
Refraction
You now can put in 1 or 2 drops, 0.5% Cyclogyl usually dropped on the cornea, for infants with average pigmentation (adjust to more potent cycloplegics appropriately-heavily pigmented irides usually require 1/2% to 1% atropine usually given over a period of three days - one drop in each eye each day. Homatropine 4% is a halfway measure which can be used in the clinic.) After 30 to 40 minutes carry out the refraction (retinoscopy) and the fundus examination including observation of the optic nerve and fovea (macula). The indirect ophthalmoscope is most useful. In cases of suspected optic nerve hypoplasia, use of the direct ophthalmoscope is recommended for a more accurate view.
The Strabismus Minute, Vol.1, No. 3 Copyright © 1999 Eugene M. Helveston All Rights Reserved
Editor-in-Chief: Eugene M. Helveston, M.D.
Associate Editor: Faruk H. Orge, M.D.
Editorial Board: Bradley C. Black, M.D.
Edward O'Malley, M.D.
David A. Plager, M.D.
Derek T. Sprunger, M.D.
Daniel E. Neely, M.D.
Naval Sondhi, M.D.
Senior Editorial Consultant: Gunter K. vonNoorden, M.D.
Graphics: Michelle L. Harmon
Technical Support: George J. Sheplock, M.D.
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