It occurred to me recently that I’ve probably tested more children (especially under 5s) than most pre-regs.  The first under 16 I tested was a three year old who was referred in for cycloplegic refraction from HES.  She had an accommodative esotropia and an overindulgent mother.  I got the drops in with a minimum of fuss (my supervisor told me to come and get her if I struggled with the second drop so I saw this as a challenge) and the girl and her mum went for a wander around the shops for 30 mins while the CYC kicked in.  I thought that was the worst bit, the administering of the drops – but I was wrong.  The worst part was when the girl returned and her mum decided to hand feed her pieces of Gregg’s sausage roll to keep her attention.  The girl was more interested in the food than staying still and my ret at that point was okay-ish in general but absolutely hopeless on a moving target.  It’s also really hard to do your job when a hand keeps gliding past your face to stuff some sausage roll in your patient’s mouth.  

This was at the start of my pre-reg, when I was still finding my rhythm, developing my routine.  I tried to cling to my routine as this was where I felt comfortable.  Testing that first 3 year old was challenging in a way I wasn’t ready to handle.  I wasn’t assertive enough to ask her mother to sit down or, even better, sit on the chair and hold her child still instead of hovering at my shoulder, blocking the ret reflex every time she moved forward.  I wasn’t ready to abandon my routine and just do the tests I needed to do as quickly as I could.  I wanted to do it all, in the right order and get nice, reliable results.  After 9 months, I have come to realise that flexibility of routine is the key to testing children.

I had a young boy (another 3 year old) come in for a test last week.  His mum and his gran came with him, although his mum seemed to be there reluctantly.  It was the grandmother (and her husband) who had pushed for the boy to have an eye test as they noticed him screwing up his eyes sometimes when he was watching TV.  When I saw him, he was very bouncy.  I tried to test vision but he was being very creative with DOG DUCK FISH FLOWER (we had elephants, giraffes and dinosaurs instead) and he was unreliable with the numbers.

Now, when I was talking to this child, he was turning his head away from me.  It seemed habitual.  Cover test was very difficult, even with my array of flashing (and now mooing and quacking) fixation targets.  He really didn’t like his right eye being covered.  I was sure I saw a left esotropia but his head turn and his lack of attention made it very difficult to be sure.  Retinoscopy was also pretty difficult as he was drawn more to the ret light than the spotlight on the wall.

Whenever I failed to get a solid result from a test, I just moved on.  I didn’t try to force my way through my routine.  I did everything I could but I didn’t spend too long on any part that wasn’t working.  His attention was fluid and it was slipping away with every passing second.  At the end, I had my suspicions but nothing solid. 

I told his mum that I wanted him to come back for eye drops and that this would let us know if he needed glasses.  She was unhappy about him needing specs and, again, seemed to be there to humour the grandmother.  I also told her that I suspected he was long sighted and that one of his eyes was turning in.  I wanted to make sure that she came back for that follow up appointment.

She brought him back a couple of days later and I cyclo-ed him.  He was R +6.00DS and L +7.00DS.  An accommodative esotropia made sense with that Rx.  As well as getting him a pair of specs to wear full time, I told his mum that I was referring him to an orthoptist (not just any orthoptist, though – I referred him to my favourite orthoptist) because of the suspected LSOT and the fact that his right eye was obviously his “good eye” and I wanted to make sure the left saw as well as the right in the future.

The mum’s partner was also there that day.  He asked if I’d taken a picture of the boy’s eyes and I said “yes”.  

“What shape is his eye?!” he asked.  

I was at a bit of a loss, I really wanted to say “eye-shaped”.  

“What shape is his eye?!” he repeated.  

“I don’t know what you mean,” I admitted.  

“My eye is a funny shape, is his a funny shape too?”

Oh, right, we’re talking about astigmatism.  “He doesn’t have funny shaped eyes, it’s just that his eyes are not as powerful as they should be.  This means that the part of his eye that allows him to focus on things is working really hard.  If he wears these glasses all the time, his eyes should become more powerful over time and he might need weaker glasses in the future or no glasses at all.”

I said to the mum that I knew that I’d given her a lot of information but the main thing was to get these glasses, that her son wears them all the time and that they go into the hospital to see the orthoptist so she could make sure that both eyes were straight and seeing as well as they could be.  Did she want to ask anything? No.

I told her to give me a call if she had any questions.  Our DO then dispensed the wee boy with some lovely frames that fitted him perfectly and they went on their way.

So, I got on with the rest of my clinic.  A few hours later (at around 8pm), I’m on the shop floor after sending one of my eye test patients out for a walk around the shop with some multifocal contact lenses in.  I see the wee boy from earlier running around the frame banks.  I look around and there’s his gran – she’s been waiting for a word with me.

Apparently the mum had not taken in anything I told her beyond her son needing to go to the hospital.  I had reassured her that I refer all children who have high Rxs and/or whom I suspect of having a turn in their eye.  She had gone home, upset, and told the wee boy’s gran that I’d seen something at the back of his eye and I needed him to go to the hospital.  Now, looking back, I had said “I think there’s a turn in his left eye” and she’s taken that to mean that there was something at the back of his eye.  The gran (her ex-partner’s mum) had come in to see me because she was worried.

As we watched the child run around the frame banks, being chased by his grandfather, I explained everything one more time.  I told her that it was great she’d spotted the problem before it even really became an issue.  At three, the visual system is still developing so, by catching his long-sightedness and the LSOT early on, she’s given him the best chance at having two eyes that work individually and together.  I was worried about his left eye becoming lazy, I told her, and that’s why I was referring him to the hospital.  The back of his eyes were fine.

She was visibly relieved and thanked me for taking the time to explain to her what was happening.

I wish there was a leaflet I could’ve given the mum about hypermetropia, accommodative esos and why we love orthoptists.  Something to take away and look at outside of the test room, something to reassure.  Does such a thing exist or do I have to write one?