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I’m definitely of the mind set that the more prepared you can make your child for doctor’s appointments, the better they turn out.  So, I thought I’d post about the details of what I do all day, in the hopes that maybe this will help calm the fears of our littlest patients.  I’ve had some parents tell me that they show their kids picture of my Honolulu magazine cover before the appointment and just that simple thing, makes my patients much more comfortable with me.

First up in an any eye exam is to check vision.  Vision should be checked with an actual eye chart for any kid over the age of 3.  Your pediatrician (or his/her nurse) should be doing this at the well child visit.  They may either use an old fashioned wall chart or any one of the number of new vision screeners out there that pediatricians are currently using. I’ve actually found that the Plus Optix screener that couple pediatricians use in the area is very accurate.  When your child comes into our office, we try to immediately escort them into our pediatric waiting room. IMG_6963This way they don’t have to feel antsy about sitting in a grown up chairs in an adult waiting room.  Here, they can play and read until they are called for their appointment.  Then, they are called into the exam room by one of technicians.  The child will sit in the chair (on a parent’s lap if necessary) and we will check vision. We have the children wear special glasses that have a hole on one side to check vision.  We have a pair which has the hole on the other side to check the other eye.Wong(Opt)Shoot42Older kids can check vision like adults, using the paddle.

Then we use a vision testing system which is a computer program.  It’s nice because we can isolate the chart to a single letter and can change the letters on any given line (for any of you guys who try to memorize the chart!).  It also has the advantage of having different types of tests to use based on the age of the kid.  This is why we can usually test any child older than 3 years of age.  Sometimes, we’ve even been able to do 2.5 year olds!

IMG_9161 And, if the kids are too young to know their letters, then we do these shapes or the HOTV letters.

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Some pediatricians still use the chart below to test kids who don’t know their letters.  They are called Allen symbols, but most pediatric ophthalmologists don’t like them because each picture is so unique in shape, that they’re easy to guess.

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Which kid now a days knows that that is a picture of a telephone? I had one patient call it a hot dog! I figured, close enough.

Then, we use special polarized glasses to do a test of 3D vision.

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“Grab the wings of the butterfly”

Then, if the child is older than 12 or 13 years old, I will refract them – that means checking to see if they need a glasses prescription.  That’s the whole “1 or 2 ” test.

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“What’s better – 1 or 2?”

If the kids are younger than 12 years old, then I don’t do this for them.  It’s tough enough for most adults to figure out which is clearer – 1 or 2.  For some reason, this simple question seems to provoke a lot of anxiety.  I check the glasses prescription for younger kids only after dilating their eyes.  Click here to read more about how I can figure out if babies need glasses.

If a child is old enough (at least 4 years old), I will try to examine the front part of the eye at the slit lamp biomicroscope. You’ve probably had this done if you’ve gone to the optometrist or ophthalmologist.  This basically gives me a closer look at the eyelids, conjunctiva, cornea, iris and lens.

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Then, on to the dilating drops.  This is probably what gives children the most anxiety.  I try to minimize this by combing all of the various drops into one spray bottle.  This way, the child doesn’t need to have 3 different drops (even though they may need 3 doses even of the spray).  And, the convenience of the spray is that I can apply it to the child’s eyelashes when their eyes are closed and if I really soak them, then whey they open their eyes, the drops get into their eyes.

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It’s actually quite rare for kids to scream and cry for the drops.  OK, maybe rare is an overstatement – my own oldest son cried when I put drops in his eyes to do his eye exam and that was me putting them in.  This is when the teachers at his preschool kept insisting that he needed glasses because he tilted his head to the side when watching TV or thinking.  And, they knew I was a pediatric ophthalmologist!  “Yeah, I’m pretty sure I’ve checked my son”, I condescendingly thought.  However, add 2 more kids to the crazy mix of our life and I will abashedly admit that I’ve never checked their eyes.  So I guess it wasn’t totally out of the range of possibility that I could miss my kid’s need for glasses.  But, that’s a tangent.

Once the eyes are dilated, I use this crazy thing on my head, called the indirect ophthalmoscope to examine the inside of the eye.  For young kids, I use toys to distract them so I can get a good view inside.  For older kids, I have movies playing to hold their attention (best money I have ever spent when setting up my practice!)

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For the young kids, this is when I check the refraction.  I do this both with an automatic machine (pictured below) and then I double check everything by using a retinoscope as well.

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And, that’s about it.  Of course, they get to choose a toy from our treasure chest on their way out.  I have a lot of kids who don’t want to leave our office.  We have the nicest techs and they are just wonderful with children.  We try to make the experience as pleasant as possible!

FullSizeRenderAnd, no I don’t usually have a professional photographer following me around the clinic.  Almost all of these pictures were taken a freshman in college, right before he graduated from college.  His pics are amazing, for any local moms who want to use him when he comes home for summers and breaks.

 

 

 
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I just did a recent article for Midweek about pink eye.  Feel free to check it out – I just talk about prevention and treatment of conjunctivitis.  But, that’s not the topic of this post.  The Midweek writer’s first question to me was “What got you interested in pediatric ophthalmology?”.   I’m lucky enough that this question is such a non-brainer.  Is there anything better than restoring sight to a child? Complex surgery or a simple pair of glasses – both are so important in the developing vision of children.  That question made me think about one of our my first patients here in Hawaii.  I worked for a year after my fellowship as an attending at Boston Children’s Hospital. but there I was surrounded by senior physicians.  If I needed help on a case, or advice, they were there to assist.  When I moved out here with my husband 6 years ago, it was, honestly a bit terrifying.  I had lost my safety net and I had to build a practice from the ground up, somehow convincing parents that despite looking young and inexperienced, that I actually was a capable surgeon.

Niko was just a 6 year old boy when he came into see me my first month practicing at Honolulu Eye Clinic.

He had previously been living in California and had recently moved to Hawaii.  His mom had noted that he squinted a lot.   Niko was a smart little boy, but he had real trouble with the eye chart.  When I dilated his eyes, I discovered cataractsin both eyes.  A lot of people are often surprised that children and even babies can get cataracts.  It’s obviously much more rare than in adults, but it does occur.   I met with Niko and his sweet mom, Louise and told them that we should schedule surgery for Niko.

Marking Niko's eye for surgery in the pre-op area

This is what Niko’s mom wrote about her experience:

We first found out about a vision problem when Nikolas and I were reunited in Hawaii after a year of separation due to an illness of mine. He spent kindergarten year in San Jose California with my parents and siblings while I received treatment.While in San Jose he complained about not being able to see the board at school towards the end of the school year. When I picked him up and brought him back to Hawaii I decided to take him for a complete physical and suggested to the clinic physician for an eye exam as well.  They tested his eyes and we discovered that he couldn’t read most of the letters. The optometrist doing the exam referred us to Dr. Wong. He said that Niko may have cataracts. I was shocked and worried because he had just turned 6 yrs old.
 
Dr. Wong and her staff were so warm and welcoming. Even before we stepped into the clinic, I had already spoken to her on the phone several times. She told me about herself and her experience that gave me such relief to have found someone that can help my sons condition.  She performed surgery first on the right eye about 4 wks later and the left eye another 4 wks after that. The surgeries went well and Niko mentioned that everything so much brighter than before on the way to school a few days after. I was moved to tears of joy.
He now wears bifocal glasses that he loves and thrives in school. He is always excited to see Dr. Wong and her loving staff for regular check ups. He even mentioned to me several times that when he grows up he wants to become an eye doctor just like Dr. Wong so he can also help others see better.
 

Niko gave me this card.  Six years later, I still keep this card at my house.

After surgery, Niko’s first words to me were “I  can finally see the clock in school!”  His vision improved to 20/20 in each eye.

Each time he came for his post-operative visit, Niko would show off his latest dance moves for my staff.  I mean, seriously, is there anything better than getting that letter from a Mom or this card from a six year old?  He got cute bifocal glasses which he proudly wore all the time.

And, now 6 years later, Niko is an aspiring actor and model!

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I know pediatric ophthalmology is not one of the “sexy” subspecialties of ophthalmology.  Everyone wants to do Cornea or Cataract with all the fun laser cataract machines or Retina with the cool new macular degeneration drugs that are coming out.  But, peds/strabismus has its HUGE rewards and I for one, cannot think of anything else I’d rather do.

 

 

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