Pediatric Annals

PEDIATRIC OPHTHALMOLOGY 

Resident's Column

Beata A Puri, MD

Abstract

My first encounter with pediatric ophthalmology came during my third year of medical school. As part of the 8-week core pediatric rotation, 1 week was spent in the outpatient clinic. One morning I was asked to see an established patient for her routine 6month well-child visit. I felt comfortable going in on my own to begin the history and physical examination, because my attending physician stated that he would be in to "check up on me" in a few minutes. This was a busy, inner-dty hospital clinic, with a waiting room overflowing with parents and children who spanned the cultural spectrum. I knew that I would have enough time to explore my patient's "life's story" before being checked up on.

I called the child's name. An African American father and his adorable, energetic daughter greeted me. The history was taken without a problem. The father had no difficulty giving accurate information and seemed comfortable with the care of his daughter.

I advanced to the physical examination, confident that I had covered all of the basic questions and key points on which I would later be quizzed by my attending physician. As I had been taught, I examined the child starting from the center of the body and moving outward, leaving invasive techniques, especially otoscopie and ophthalmoscopic evaluation, for last.

Recalling my physical diagnosis class, I began what I thought would be a standard eye examination using a trick I had learned only the day before, which was to have the child sit on the parent's lap when examining the face. Her eyes were normal (based on what I knew as normal and abnormal at that time), but something bothered me about the way light was reflecting in her pupils. I shined the ophthalmoscope at her eyes and, sure enough, she had an unequal pupillary reflection in the left eye. I performed the red reflex examination and for the first time in my short medical career, I had diagnosed leukocoria. There was clearly a white reflex in the left eye.

My attending physician was impressed. Much discussion followed, including an extensive differential diagnosis that included cataracts, coloboma, incontinentia pigmenti, retinal detachment, retinoblastoma, uveitis, and vitreous hemorrhage. We proceeded to reveal the finding to the father, who, much to my surprise, thanked me for being so diligent and discovering this. The rest of my day was spent making sure I performed red reflex examinations on all of my patients. I remember that experience to this day and always include it when teaching residents and medical students how important it is to "look."

I believe that pediatricians feel uncomfortable evaluating the eye, partly because it is usually difficult to do so well when a child is not particularly cooperative and partly because there seems to be a disproportionate lack of attention paid to this specialized organ in residency training. We frequently call on our ophthalmology colleagues at the first hint of an abnormality. It is our responsibility as pediatricians to completely examine the eyes and associated structures and to deterrnine the course of action.

It is imperative that we gain confidence in using an ophthalmoscope. This must stem from early medical training. Just as the skill of putting in intravenous lines develops with repetition and practice, so should the ability to conduct a precise eye examination that includes, at minimum, visual acuity, cover testing, and ophthalmoscopic evaluation. We have to leam to trust what our eyes are showing us. It is also our obligation to train our students and residents in proper ophthalmologic techniques and to continuously use those techniques. We must continue…

My first encounter with pediatric ophthalmology came during my third year of medical school. As part of the 8-week core pediatric rotation, 1 week was spent in the outpatient clinic. One morning I was asked to see an established patient for her routine 6month well-child visit. I felt comfortable going in on my own to begin the history and physical examination, because my attending physician stated that he would be in to "check up on me" in a few minutes. This was a busy, inner-dty hospital clinic, with a waiting room overflowing with parents and children who spanned the cultural spectrum. I knew that I would have enough time to explore my patient's "life's story" before being checked up on.

I called the child's name. An African American father and his adorable, energetic daughter greeted me. The history was taken without a problem. The father had no difficulty giving accurate information and seemed comfortable with the care of his daughter.

I advanced to the physical examination, confident that I had covered all of the basic questions and key points on which I would later be quizzed by my attending physician. As I had been taught, I examined the child starting from the center of the body and moving outward, leaving invasive techniques, especially otoscopie and ophthalmoscopic evaluation, for last.

Recalling my physical diagnosis class, I began what I thought would be a standard eye examination using a trick I had learned only the day before, which was to have the child sit on the parent's lap when examining the face. Her eyes were normal (based on what I knew as normal and abnormal at that time), but something bothered me about the way light was reflecting in her pupils. I shined the ophthalmoscope at her eyes and, sure enough, she had an unequal pupillary reflection in the left eye. I performed the red reflex examination and for the first time in my short medical career, I had diagnosed leukocoria. There was clearly a white reflex in the left eye.

My attending physician was impressed. Much discussion followed, including an extensive differential diagnosis that included cataracts, coloboma, incontinentia pigmenti, retinal detachment, retinoblastoma, uveitis, and vitreous hemorrhage. We proceeded to reveal the finding to the father, who, much to my surprise, thanked me for being so diligent and discovering this. The rest of my day was spent making sure I performed red reflex examinations on all of my patients. I remember that experience to this day and always include it when teaching residents and medical students how important it is to "look."

I believe that pediatricians feel uncomfortable evaluating the eye, partly because it is usually difficult to do so well when a child is not particularly cooperative and partly because there seems to be a disproportionate lack of attention paid to this specialized organ in residency training. We frequently call on our ophthalmology colleagues at the first hint of an abnormality. It is our responsibility as pediatricians to completely examine the eyes and associated structures and to deterrnine the course of action.

It is imperative that we gain confidence in using an ophthalmoscope. This must stem from early medical training. Just as the skill of putting in intravenous lines develops with repetition and practice, so should the ability to conduct a precise eye examination that includes, at minimum, visual acuity, cover testing, and ophthalmoscopic evaluation. We have to leam to trust what our eyes are showing us. It is also our obligation to train our students and residents in proper ophthalmologic techniques and to continuously use those techniques. We must continue to educate ourselves. In this age of highly powerful and precise technology, we are bringing micro-preemies into the world, weighing a mere 450 to 500 g. They have many complications, one of which is retinopathy prematurity. We need to be attentive to this condition, how it is managed, and what the future holds for these children as they come to our offices well-child visits.

I learned a valuable lesson that morning. I pediatric residents and tricians to continue to pay attention to their patients' and to always rely on the basic skills of physical examination that they first learned in medical school.

10.3928/0090-4481-20010801-12

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