How we examine the eyes

The first two years of life
The eyes of the newborn are usually closed and the doctor may need to
open the eyelids gently by hand in order to examine them. However,
often enough, lowering the light in the surrounding area leads to
opening the eyes («eye popping reflex»). This alone indicates some
visual function and its absence may indicate an existing problem.

A very important thing that we must be aware of about children up to
two years old (in which the collaboration with the doctor is expected
to be small) is to compare the vision of both eyes. A safe way to do
this is to first cover one eye and then the other (manually or for
example with a card) and observe the child’s reactions. If the
child keeps its interest to an object with both eyes, this is
positive about its eyesight. But if the child loses its attachment to
the object or cries and resents or attempts to remove the hand or
card that covers the eye, then that is a strong indication of a
problem in the eye that is currently open.

From two to four years old
After the age of two, children are usually more cooperative with the doctor
who examines them.
However, it is important in each case to let them understand that we won’t
hurt or harm them. Perhaps the best tactic for children of this age
is to convince them that the clinic is part of a playground and the
entire review process is a fun activity. Perhaps the best tactic for
children of this age is to convince them that the doctor’s office
is part of a playground and the entire review process is a fun
activity.

A good start is to welcome the child with a "high five", by
moving our palm to strike gently but vigorously the palm of the
child. From there on we must continue the examination pleasantly and
as quickly as possible, since children of this age do not hold their
interest for a long time.

The most useful tool in an ophthalmological examination of a child is the
flashlight- pen. This small flashlight can easily check the anterior
of the eye and pupil of the child for any abnormalities, and serves
as a stimulus to maintain the attention of the child. Although most
tools are kept in a short distance from the child, it is useful to
have some remote controlled machine dolls in the office, moving and
producing sounds or a TV at the end of the examination rooms to
maintain the focus of the child. It is also good to convince the
child that it "controls" the movement of toys by touching
for example their nose, because children seem to have a higher
interest for items that they think they control.

The paedophthalmological clinic should ideally look like a playground, so
the child sees the examination as a fun activity. (Photo of the
examination room in the Athens Eye Hospital).

Mydriasis (pupil dilation) in children
The pharmaceutical mydriasis is required for the ophthalmic test in
children. It can not only reveal abnormalities in the depths of the
eye, which would not be perceived without it, but the drops that are
used, additionally cause cycloplegia, which relaxes the muscles that
control the curvature of the lens, which is essential for the proper
prescription of eyeglasses for children .
The ability of the eye’s lens to change its radius of curvature under
the influence of muscle fibers of the ciliary body and to focus at
different distances is called adaptation.

Our eyes are normally arranged to see far away and the influence of the
ciliary muscle that surrounds the lens, focuses to a closer distance.
This 'adaptive force' of our eyes deteriorates with age, finally resulting
in presbyopia, where we cannot focus closely without glasses.
However, during childhood, the 'adaptive force' is so big that it can
overpower an underlying refractive error (hyperopia), making
mandatory the use of eye drops that would "paralyze"
temporarily the adjustment to properly assess the child's vision.

The mydriatic / cycloplegic eyedrops
The pupil dilation (mydriasis) and paralysis of adjustment (cycloplegia)
are caused for diagnostic or therapeutic purposes by using eye drops.
Despite its frequent use in daily ophthalmological practice, eyedrops
have side effects and the recommended dosage, especially in children,
should be strictly observed.

The main drugs used are anticholinergics: atropine, cyclopentolate and
tropicamide, which cause paralysis of the pupillary sphincter and
ciliary muscle which are innervated by the parasympathetic system.

The sympathomimetic phenylephrine causes mydriasis without
cycloplegia through direct activity on the dilator muscle of the
pupil, but without any effect on the ciliary muscle.

Atropine is the strongest and longest-lasting cycloplegic activity used in
clinical practice. Paralysis of adjustment (cycloplegia) appears
slowly and lasts about 7 days, while mydriasis may last up to 12
days. In children, diluted solutions are used with a density of 0.25%
for the first year of their life, and 0.5% for ages 1-3 years old.

In systemic absorption, atropine can cause side effects such as fever
and rash, and displays the highest frequency and allergic reactions
in relation to the rest of the mydriatics.

The effect of Cyclopentolate is immediate but does not last long. The
maximum cycloplegia result is observed in 25-75 minutes after
instillation and recovery of adaptation after 6-24 hours. The dosage
for controlling refractive abnormalities in children is one drop of
0.5%, and recurrence after 5-10 minutes. Adverse effects of
Cycloplegia include hyperemia and facial stimulation.
Tropicamide (Tropixal) has the same basic properties with cyclopentolate. The
maximum cycloplegia result appears 20-35 minutes after instillation
of 1% solution and recovery of adjustment after 2-6 hours.

Phenylephrine enhances the mydriatic effect of anticholinergics, which allows the
combination between them at lower densities to avoid or reduce side
effects. However, its administration to children needs special
attention and its contraindicated in children with Down syndrome.

The frightened child
It is essential to rapidly build a relationship of trust between doctor
and his young patient. Occasionally, though, the child cannot
overcome its fear and possibly might cry during the examination. In
such cases when it is impossible to reassure the child, we must focus
on the progress and completion of the examination. If the examination
is left unfinished, important findings may be lost and serious
diseases may not be identified leading to being much more difficult
to treat when older.

Parents play an important role in supporting the child who is afraid of the
examination.

All these happen, of course, to make the child feel as comfortable as
possible.

Throughout the course of the examination, particularly in scared children an
important role is played by the parents, not only for the child's
psychological well but in general. In most tests the child's head
should remain completely still even for a moment. Parents can help by
holding the child with their hands, steady in the proper position.

Fortunately, with the evolution of technology, measurements taken in a eye test,
are done very quickly and with minimal discomfort