Author: Melissa

It’s that time of year when we transition from summer sessions to fall. That also means it’s quite possibly time for evaluations.

First off, let me remind you that as part of your education, you are obligated to receive feedback on what is going well with your exams and your performance, and sometimes more importantly, what areas require improvement.

I cannot stress enough how important it is to not take this feedback personally! Having been on both the receiving and giving end, it is never a pleasant experience when one has to discuss less than stellar skills.

I’ll give a personal example – when I was a fourth year student, in my last rotation before graduation, I ended up working with an attending who left me feeling stupid each day I worked with him. I felt like he was pushing me harder and treating me differently than my peers, who were getting along with him just fine. He had critiques for every part of my exam, from refraction, to slit lamp, to BIO. I felt terrible.

At the same time, one of my other attendings at the same time happened to be a preceptor of mine during my summer of third year clinic. One day working together close to graduation, he made a comment to me that hit hard – he had seen me in third year, confident, engaged, happy to be in clinic and learning. Now this close to graduation, I seemed the exact opposite – the confidence was gone, I seemed to be questioning everything… “What happened?”

It wasn’t until years later when I was watching this video of a professor giving his last lecture that I understood the feedback wasn’t about me. The lecture has since served as a source of inspiration for me, and despite his having since died of pancreatic cancer, many of his tips still resonate with me. The one relevant here goes like this:

“When you’re screwing up and nobody says anything to you anymore, that means they’ve given up on you. You may not want to hear it but your critics are often the ones telling you they still love you and care about you and want to make you better.”

This is a classic way of how you get to decide how to look at the feedback you receive. Do you take it to heart and let it eat you up because you have failed, or do you take it as an opportunity to grow? Because your instructors are giving you feedback, they have noticed your effort and want to contribute to your growth. For those instructors who don’t offer any solid feedback and let you go on silently, well then, I might be more worried because that is a sign that they didn’t get to know you well enough to monitor your progression.

So take the feedback as what it is – a gauge on how you are doing as a student and clinician and how you can improve from there.

And if you have free time, I highly recommend watching Randy Pausch’s The Last Lecture or reading his book of the same name. I found both fun and easy to watch and read.

So let’s talk about those kids who are in that 3-5 year old range, where letters and numbers aren’t quite necessarily solid, left and right directions can be confused, and attention span is very, very limited.

What do you do?

I know back when I was an intern and doctor, the first thing I was told to do and followed ever since was take off my white coat before entering the room with them. For a lot of kids, a doctor’s office is really scary – who likes being poked, prodded, getting shots, and all that? It’s unpleasant enough for me now as an adult and to see it from a child’s eyes, well it can be pretty traumatizing too. So if there’s one less thing distinguishing me as a scary authority, then I’ll happily forego the white coat for these exams.

Next, I try to break the ice to see how open the kid is. That usually means asking if they have two eyes and their eyes are in their head. If I can get at least a smile, I know we’re going to be ok.

Depending on the child, I might have them sit in a parent’s lap or sit in a chair on their own – it might not necessarily be the exam chair at first! I want to get them comfortable and that has sometimes meant I bring out the color vision and stereo testing to do first wherever they are, just so they get comfortable. Then I have a handheld lea symbol guide and ask them to name each shape first when it’s super big so we all know what shapes they can grossly see under binocular conditions. Based off of those responses, then I can attempt a near VA with them either pointing to the guide or naming what they see so the child has options.

The patient’s confidence level can make or break this part of testing. I really try not to push an initial VA too hard because I know I still have other testing I need to do. I have them focus for a near cover test and some accommodation/convergence testing, and only after all that do I attempt a distance visual acuity, based off the child’s responses so far.

At this point, I have a couple options, I prefer free space retinoscopy with ret racks over autorefractor, although I will try to get both if I can, especially if I am concerned about any amount of cyl.

Biggest thing here is this though: do not spend more than 5 minutes total on refraction. The younger the child, the shorter refraction testing should be. Unless they are a very good, patient kid, they will lose interest and your results and their responses are just going to get worse and worse. Better to just get a rough idea and then move on to dilation.

When is a cycloplegic dilation warranted over just using normal tropicamide and phenyl? That will certainly depend on all the data that has come up so far, especially if this is the patient’s first eye exam ever – referral, chief complaint, visual acuity, retinoscopy, and refraction results. Generally, if there is some amount of plus, astigmatism, or eso tendencies, I will use cyclo for that first exam.

What if the kid has been great but then the idea of eyedrops freaks them out and they start screaming or crying before you can get near to them again? Well, there’s a few things. I can step outside and give the kid a moment to decompress and see if the parent can talk them into it after a bit (unlikely, but possible). I can try to force the kid to just take the drops and have the parent restrain their kid enough so that they hopefully don’t hit or kick you (also not ideal).

Personally, I’d rather build trust with the kid and try to not make the experience overly traumatic if possible. My goal is to make sure their eyes are healthy and they see well. If I can’t do everything at this first visit, then there will be a second visit to finish everything off. But I send the parent home with homework. I tell them to get a bottle of artificial tears and practice putting in an eyedrop in each eye every single day until they come back for their follow up. Hopefully, that few weeks’ worth of eyedrops is enough to desensitize them so that by the time they’re back, they’re okay with getting eyedrops in office and then I can perform the ocular health portion of the exam (I tell them I’m going to try to look inside their eyes so I can try to peek into their brains) and get more objective results for any needed glasses.

And that’s it. That’s my approach to a basic pediatric eye exam. I try to keep other questions light so they stay engaged – what grade they’re in, what’s their favorite subject, what’s their favorite food – and not as hyper focused on all the testing going on. And of course, giving them an end of exam sticker or two is always nice.

I hope you find this useful. Do you have any extra tips on how you deal with your peds exams?