How to examine patients with special needs

Excerpted from page 16 of the November/December edition of AOA Focus.

It's known that children with developmental or intellectual disabilities have a higher rate of vision disorders that often go undetected or untreated. That's why the AOA's Comprehensive Pediatric Eye and Vision Examination guideline recommends these special patients receive a comprehensive pediatric eye and vision examination. Although more clinically challenging, a visual assessment is possible with a bit of flexibility and preparation.

Sue Lowe, O.D., AOA Health Promotions Committee chair, and Dominick Maino, O.D., professor of pediatrics/binocular vision at Illinois College of Optometry, share helpful tips for examining these unique patients.

1. Do your due diligence.

"The most important thing I have found is to make sure when a patient calls that we find out why they were referred to us, or why they are coming, so that we can get a good telephone interview to begin with," Dr. Lowe says. This preparation is bolstered with a developmental questionnaire that includes patient history, concerns and the type of services currently received—be it occupational, speech or physical therapy—and development history. That initial groundwork is equally important for the doctor's self-education.

"The more you know, the better," Dr. Maino says. This is not only limited to a rudimentary understanding of the patient's condition, but also what the literature says may benefit that patient. For instance, patients with Down syndrome—no matter the age—often benefit from a bifocal lens, Dr. Maino says. So, too, these patients often have weak immune systems, which is why Dr. Maino chooses more aggressive treatment of a condition such as blepharitis. "I change my treatment to coincide with the patient's needs, backed up by that prior knowledge."

2. Consider patients' comfort.

New environments can be stressful, so do what you can to alleviate that anxiety even before the patient arrives at the practice. During scheduling, make sure staff inquire about appropriate examination times when the patient is at his or her best. Select a time of day when the patient is likely well rested and build in extra time for the examination, Dr. Lowe suggests. Also, consider allowing patients to visit the practice with their caregivers ahead of the examination, Dr. Maino says, to help alleviate that uncertainty the patient may be experiencing. And when the patient does arrive for his or her appointment, be willing to do the examination in a place other than the examination chair, Dr. Lowe says. Sometimes a patient may be more comfortable on a parent's lap or sitting on the floor, so be prepared with handheld instruments.

3. Be flexible in the exam.

If doctors have done their due diligence, they shouldn't be too concerned when approaching the actual examination. Start by checking assumptions at the door, Dr. Maino suggests, and let the patient prove what he or she can or cannot do. Although some patients may sit perfectly fine for a routine exam, others may need certain considerations. Children, especially, might not have the attention span for a full battery of tests. Therefore, it's important to come prepared with the necessary objective examination tools. Consider a light-up toy as a fixation device, or use LEA symbols for an uncommunicative patient. Importantly, do what you can and become comfortable dealing with "fuzzy clinical data," Dr. Maino says. Sometimes that involves using tools in different ways to get the desired data. "Some patients won't let you use an autorefractor, so I may use the direct ophthalmoscope to determine the spherical equivalent refractive error and start by using that as my first prescription."

4. Welcome collaboration.

It takes a village to raise children, they say. And that's certainly true when coordinating care for children with developmental disabilities or other challenges. Encourage patients or parents to bring along their care team—therapists, teachers—for the pediatric eye examination to improve their own education and bolster a collaborative environment, Dr. Lowe says. Make sure to offer explanations, not only to the patient, but also to the caregiver, and consider furnishing a written summary of the appointment.