The Affordable Care Act (ACA) potentially will cover millions of previously uninsured families and guarantee eye care to their children. This means that many of these children—some of whom have special needs—could find their way into your practices for routine eye exams.

An inefficient visual system can significantly interfere with any child’s ability to learn, but is especially debilitating for the approximately 10.2 million children in the US with language delays, autism and other developmental disorders. Visual disorders can be devastating to a child with special needs when the primary care optometrist entrusted with their care lacks the tools to diagnose and treat their visual problems.

With the help of some basic pearls, we can perform an exceptional, comprehensive examination on these young individuals. Also, this opportunity can provide a great deal of professional satisfaction in ensuring the visual capabilities necessary for the child to flourish.

This article reviews how you can more effectively provide vision care to children with special needs. Additionally, it offers several short case reports that underscore the fundamental importance of thorough pediatric examinations.

Setting the Stage

Preparing your office for a special needs child requires some due diligence from your staff. Many of these kids have complicated histories and are on multiple medications. In addition, they may have transportation issues that slow them down on the day of their appointment. Here are a few tips that can make the first visit easier:

• Have the “Welcome to the Office” form filled out before the visit.
• Encourage the child to bring a favorite toy or stuffed animal to have its eyes checked.
• Create a questionnaire to determine which problems may exist. Consider having the staff ask the child’s parents these questions over the phone before the exam.
• Make sure the caregivers know how to get to your office.
• Invite the patient to meet the staff and get acquainted.
• When appropriate, have the staff confirm the appointment and talk with the patient to convey how much they are looking forward to having him or her come in to the office.
• Make sure to note special interests, and make light conversation about those topics to keep the child engaged and attentive.

The Examination

Kids can sense your anxiety level, so it is imperative that you enter the room relaxed and with a clear mind. Never enter the room feeling rushed or burdened.

There are many ways to examine a child with special needs. The first thing to consider is that time is of the essence. Too many preliminary tests can fatigue the patient. Your one-on-one time is invaluable; so, it may be wise to limit tech time and elicit the most pertinent information while the patient is receptive. Also, make an effort to document the most significant parts of  developmental history, including ApGar scores, language skills and reading levels prior to the visit.

Keep in mind that if you walk into the room and try to be someone you’re not, it could turn around to bite you. Think about going into a room with your brother or sister and trying to be Dr. Nice Guy if you aren’t. It would seem out of character to them, and it won’t go far with these kids either.

• Visual acuity testing, if attainable, is an invaluable part of the examination. It’s not as important for you as it is for the parents. They often want to know what the child sees––even if it’s an approximation.

LEA grating paddles can be used in a variety of ways to estimate visual acuities. It is possible to obtain an accurate acuity assessment on an uncommunicative individual by changing the distance and rotation of the gratings. An off-label variation of this product is similar to the preferential looking test. Using matching symbols tests can also be very effective. Most of the available computer-generated charts allow you to isolate symbols for accurate distance visual acuities.

• Binocular vision assessment can be performed easily, quickly and accurately with a Worth 4-dot test. One simple and effective modification is to have the child touch the dots. The examiner can tilt the red-green glasses and see which dots the patient touches. Using the reflection in the glasses can prove invaluable not only for evaluating suppression, but also when testing for concomitance in trophic cases.

• Motilities can be evaluated rapidly using the Heidi fixation targets. The smiling face on the paddle is a natural pull for any visual system. A Brock string with a fixation target, such as a sparkly bead found at most craft stores, also will attract the child’s attention and can allow you to quickly assess convergence skills. The LEA Face Disposable Occluder (Good-Lite Co.) can be used to accomplish this, and also may be given to the child to keep, as a form of motivation and positive reinforcement.

Additionally, FixiStix produces Wiggle Pictures fixation targets that can be very mesmerizing for any child. Many times, the best targets are found in your giveaway toy box. Using targets with sound or lights often triggers fixation.

• Cover testing is usually best performed with a transilluminator. Fixation typically is reliable with a point source of light, especially if it hasn’t been used until this point in the examination. The key is using monocular light fixation and the angle kappa as objective means of determining eye deviations, combined with prism neutralization.

Using a 6- to 8-power prism and watching the angle kappa can provide insight to binocularity and fixation. Instead of employing individual prisms, use a horizontal and a vertical prism bar to significantly reduce the time needed to determine the angle of deviation. Prism bars also can be extremely helpful when trying to neutralize diplopia.

• Refraction typically needs to be performed without the phoropter for children with special needs. Take note that standard of care dictates a cycloplegic refraction, as well.

The Smart System PC Plus (M&S Technologies) offers an excellent short video with red and green balloons. This provides a good target for distance fixation and also works as a quick screening for color when the child is able to respond.

Near retinoscopy is an invaluable tool in prescription determinations. A very effective near target is the press-on Flashing Fixation Stars (Good-Lite Co.). These provide a colorful stimulus with a center bright spot that allows for detailed near fixation.

Another technique for determining accommodative lag is to have the child perform natural Harmon distance tasks. In this instance, ask the child to play at their natural near working distance while performing near retinoscopy.

If you determine that a distance or near prescription is needed, trial frames and lens flippers can demonstrate the effectiveness of the prescription to both the patient and the parent. Loading one side with a “dummy” prescription and the other with the actual prescription allows the patient to react favorably to their new vision.

Facial expressions, recognition of details in objects of interest and vocalization are all cues to success. The child’s responses to “real” and “dummy” prescriptions also can alleviate anxiety for the parents regarding whether the glasses will make a difference. Remember––to the parents––it is a bit magical that you have come up with the correct prescription without actually asking, “Which is better, one or two?”

It’s important to prescribe with respect to anisomoptropic demands to allow for equal accommodative demands between the right and left eyes. It’s also helpful to prescribe full plus for esotropia and high esophoria, and minimum plus for exotropia and high exophoria.

High plus prescriptions do not tend to go towards plano, and most of those prescriptions level off when the patient reaches 18 months of age._¹

• Visual fields, while necessary, can be difficult or even impossible to perform. Remember that fields must be taken monocularly. Standard visual field testing for special needs patients requires more time and attention than routine screening fields. Frequency doubling technology (FDT) has become a standard in many practices for rapid, reliable fields measurements. However, FDT is not reliable on most kids under the age of eight––much less on those with special needs.

One effective approach is the monocular fixation in a binocular field (MFBF) test. Red and green glow stick flashlights can be purchased at many grocery and hardware stores.

For the MFBF technique, first place red-green glasses on the patient. Activate the green flashlight directly in front of the patient to use as a fixation target, while the red flashlight is deactivated in the patient’s lower right visual quadrant. Then, once you activate the red light, the patient will respond. Set the red flashlight to flash, which will cause the patient to respond again.

The response can be a nod, noise or any other indication that there has been a change. Repeat this in the other three quadrants of the patient’s visual field. Once the process is completed, repeat the test using the red flashlight as the fixation target and the green flashlight as the visual field stimulus.

Another way to assess visual field integrity and acuity is via optokinetic nystagmus testing.

It is important to note that the nystagmus reflex does not usually develop until the patient has reached six months of age in infants with normal development. Also, this technique should only be applied as an adjunctive screening tool in addition to acuity or visual field testing.

Correction Prescribing Tips

We know that children at the highest risk for amblyopia development are those with high aniosometropia and/or esotropia. It’s also important not to interfere with the child’s natural emmatropization process when prescribing corrective lenses.
For a variety of reasons, special needs children have an increased risk of amblyopia. They experience less visual stimulation from reading and computer work, and their underdeveloped neurological systems exhibit a predilection for esotropias and amblyopias. So, it’s essential to avoid amblyogenic risks whenever possible.

Additionally, new research is investigating the relationship between pediatric near visual demands and how much time is spent outside.

Emmetropic children with two myopic parents who spent five hours or less per week outside had about a 60% chance of becoming myopic. However, the probability was reduced to 20% for emmetropic children with two myopic parents who spent 14 hours per week or more outside. Children with one or even no myopic parents also benefitted from more time outdoors.

This research suggests that outdoor activity might be protective against both amblyogenesis and myopia development._²
General prescribing guidelines include correcting hyperopia greater than 5.00D, myopia greater than 8.00D and astigmatism greater than 2.50D. It is also important to minimize amblyogenic anisometropia by prescribing for hyperopia greater than 1.00D, myopia greater than 3.00D or for astigmatism greater than 1.50D.

Also, be certain to remember that children with Down syndrome and cerebral palsy frequently do not accommodate well.
A general rule: When in doubt, prescribe if kids are behind or developmentally delayed. It’s important to give them an advantage, especially when they have a hyperopic correction. A 2008 study published in Archives of Ophthalmology indicated that baseline visual motor integration scores are significantly more reduced in children with hyperopia than those with myopia._³

In simple terms––it’s important to get what you can get when you can get it. You may need to have the patient return on another day to accurately assess the visual system, provide an accurate diagnosis and create a realistic treatment plan. Sometimes, it’s helpful to intentionally avoid referring to refractive data from a previous encounter as a way to confirm your suspicions.

Most of these kids are familiar with going to the doctor, which can work to your advantage; however, they may be unfamiliar with the fancy equipment in your exam room. It may be helpful to meet them first or just say “hello” when they are playing with toys in the waiting room.

One final suggestion: Have fun with these truly special kids. You will learn as much from them as they will from you.

Dr. Wilson is in private practice in Colorado Springs, Colo. He has worked with special needs children for the last 27 years. He also is the coauthor of “SportsVision: Training for Better Performance.”

1. Mutti DO. To emmetropize or not to emmetropize? The question for hyperopic development. Optom Vis Sci. 2007 Feb;84(2):97-102.
2. Jones LA, Sinnott LT, Mutti DO, et al. Parental history of myopia, sports and outdoor activities, and future myopia. Invest Ophthalmol Vis Sci. 2007 Aug;48(8):3524-32.
3. Roch-Levecq AC, Brody BL, Thomas RG, Brown SI. Ametropia, preschoolers’ cognitive abilities, and effects of spectacle correction. Arch Ophthalmol. 2008 Feb;126(2):252-8; quiz 161.