Funduscopic Exam

The funduscopic exam is crucial in the evaluation of children with neuro-ophthalmic disorders, because most cases of visual loss or nystagmus are caused by an optic nerve or macular disorder that can usually be diagnosed with indirect ophthal-moscopy (Table 2-7). The test can be done by having the child cradled in the parent's lap, with the child's feet tucked under the parent's elbows, and the head supported by the parent's closed knees. If possible, to facilitate cooperation, keep the infant slightly hungry and feed the bottle during the fundus exam. If the child does provide some resistance, an assistant can be used to stabilize the head. The use of a lid speculum may be necessary, but every effort should be made to avoid it. Parents do not like the lid speculum and may become quite annoyed with the physician's "barbaric" techniques. Attempts at reassuring the parents that this is not uncomfortable, when the child is screaming loudly, usually are unsuccessful.

The older infant and young child can be persuaded into cooperating for the indirect ophthalmoscopy exam by making some

TABLE 2-7. Possible Etiology of Decreased Vision.





Optic nerve hypoplasia

Optic nerve hypoplasia

Optic glioma

Chiasmal glioma

Retinal dysplasia (Leber's congenital



Delayed visual maturation



Hereditary optic atrophy


Stargart's disease

Optic neuritis

Pseudotumor cerebri


Optic neuritis

Optic neuritis

Macular dystrophies

Leber's optic neuropathy

FIGURE 2-11. Indirect ophthalmoscopy in a child can be performed by using a 20 diopter lens. Control and stability can be obtained by resting the fingers on the child's forehead.

compromises in the quality of the exam. The first is to use as low illumination as possible. Although this does decrease the quality of the image, it is much better to get a "grade B" look of the fundus rather than a "grade A" view of the closed lids or inferior sclera. Second, avoid manipulating the lids as this usually causes the child to squeeze and results in the Bell's phenomena. By using a 20 diopter indirect lens and resting the fingers lightly on the child's forehead for support, the examiner can get an excellent view of optic nerve and macula (Fig. 2-11). Last, quick views should be obtained of each eye before prolonged retinal or optic nerve examination is attempted as all too often the child rapidly becomes uncooperative. A quick view of each eye is better than none at all. The peripheral fundus is rarely of neuro-ophthalmic significance but can be examined with a 28 diopter indirect lens if necessary.

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