Refracting the young child!

Optom
In Optometric clinical services refraction is amongs the most relevant clinical procedure carried out. Here in Nigeria, Optometry practice revolve around refraction, management of chronic eye conditions like Glaucoma and/or co-managing co-morbid conditions with other healthcare providers etc one cannot fail to agree that refraction becomes a routine tool in the hand of the Optometrist to identify early ocular manifestation of some systemic diseases like Diabetes; to manage ametropia; to treat refractive errors, anisometropias, some kind of squints, especially those that are not beyond 22 prism dioptres etc; to break suppression; to manage low vision; to check the prognosis of a cataract extraction surgery... Refraction can help treat binocular difficulties associated with accommodation anomalies. Refraction should be as routine as, say, routine blood pressure check in adults!
Refraction procedure carried out in adults is pretty straight forward, except in individuals with very poor cognitive background or in adults with poorly managed Diabetes, Glaucoma, Cataract, hypertension etc. It involves-
a) Checking visual Acuity (VA) in Right eye then left the left eye.
b) Using retinoscopy in a dark room to determine refractive error of the eyes.
c) Doing subjective refraction to get the final prescription of the individual.

Its a very simple procedure in adults but somehow in children we always wary ourselves by the prospect of hyper-active accomodative facility. Attentional span is another matter while compliance with refractionist's instruction is one of the major challenge in refracting a child. The younger the child, the less likely to comply in refraction and vice versa. What do I do?
After eliciting visual acuity information from the child, case history from the child and parent, I do a dark room objective refraction on the child looking out for induced accomodation by the light of my retinoscope. I start with the right eye and end up with the left eye. I almost always follow it up with a wet refraction and my drug of choice is Gutt: Mydracyl 1% ii ou for like 10 minutes. After my wet refraction, I compare my dry & wet refraction under the spectrum of the child's chief complaint and make my final "Doctor's" judgement.
I do not normally give oblique angles for children with such manifest refractions except in situations where there are obvious reasons to prescribe it. I approximate to the nearest 180 degree or 90 degree cylinders! I find it very skeptical fully correcting a child, but I do devout lots of interest in doing followup refractions every 3-6 months to monitor obvious refractive changes! I can even give a child of nine months glasses but I never forget that the vision in a child's eye is dynamic... it changes with time.
Thanks,
Dr Ezebuiroh Victor Okwudiri


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