The general examination of the eye has been considered already, but in the case of the child, certain aspects require special consideration. Before the age of three or four years, it might not be possible to obtain an accurate measure of the visual acuity, but certain other methods that attempt to measure fixation are available. The rolling ball test measures the ability of the child to follow the movement of a series of white balls graded into different sizes. Another test makes use of optokinetic nystagmus, which can be induced by making the child face moving vertical stripes on a rotating drum. The size of the stripes is then reduced until no movement of the eyes is observed. In practice, a careful examination of the child's ability to fix a light, and especially the speed of fixation, is helpful. The behaviour of the child can also be a helpful guide, for example the response to a smile or the recognition of a face. Sometimes grossly impaired vision in infancy is overlooked or interpreted as a psychiatric problem, but such an error can usually be avoided by careful ophthalmological examination. The reaction of the pupils is an essential part of any visual assessment. One of the difficulties in examining children is that they are rarely still for more than a few seconds at a time, and any attempts at restraint usually make matters worse. Before starting the examination, it is useful to gain the child's confidence by talking about things that might interest him or her, not directly but in conversation with the parent. In fact, it is sometimes better to ignore the anxious child deliberately during the first few minutes of the interview. Once the young patient has summed you up, hopefully in a favourable light, then a gentle approach in a quiet room is essential for best co-operation. The cover test can only be performed well under such conditions and once this has been done the pupils and anterior part of the eye can be examined, first with a hand lens but if possible with the slit-lamp microscope. Fundus examination and measurement of any refractive error demand dilatation of the pupils and paralysis of accommodation. Cyclopentolate 1% or tropicamide 1% are both used in drop form for this purpose. The indirect ophthalmoscope is a useful tool when examining the neonatal fundus, the wide field of view being an advantage in these circumstances. If the infant is asleep in the mother's arms, this can be beneficial because it is a simple matter to raise one eyelid and peer in without waking the patient. In the case of children between the ages of three and six years, fundus examination can be more easily achieved by sitting down and asking the standing patient to look at some spot or crack on the wall while the optic disc is located. On some occasions the child has become too excited or anxious to allow a proper examination and here one might have to decide whether it is reasonable to postpone the examination for a week or whether the matter seems urgent enough to warrant proceeding with an examination under anaesthesia. A casualty situation, which occurs from time to time, is when a child is brought in distressed with a suspected corneal foreign body or perhaps a perforating injury. Here, it is simplest to wrap the patient in a blanket so as to restrain both arms and legs and then examine the cornea by retracting the lids with retractors. Particular care must be taken when examining an eye with a suspected perforating injury in view of the risk of causing prolapse of the contents of the globe. Any ophthalmological examination demands placing one's head close to that of the patient and this can alarm a child unless it is done sufficiently slowly and with tact. It is sometimes helpful to make the child listen to a small noise made with the tongue or ophthalmoscope to ensure at least temporary stillness.
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