The College of Optometrists

I find it very hard to test children sometimes, especially when they are milingring. I had a child today she was 7 she was difficut to test because she was pretendint that she can't see letters on the chart even 6/120 she say that she can't see the ret was not possible because her eyes were all over the place. she refuse the cyclo. I didn't know what to do, the mother was telling me that she can very well, when I asked her to read the near chart she was saying that she can't see N48. please help me to understand this. Thank you

PS: her sister had new glasses and she was very keen to get a glasses as well

Good Morning

This is all to do with the relationship with the patient. You are unable to get the information you need - you feel confused.

There are few little tips to settle the kid down, after all seven is a very young age.

Always have the mother or father present. And before you start say Hi to the child and ask if they want glasses. If they are angling for specs - they will say they want them. This will help you relate to the kid.

Malingerers usually presents their symptoms in a vague but with drama. So you may need to find out for yourself using your tests. You can do a 'history' during the whole test by asking the parent and then reflecting the answers back to the child. For example, the mother says 'he gets terrible headaches at school' - so you ask the kid ' is it every day? Do you have one now?' etc

The test has to be presented as fun and must not be presented as a test. Many young children are shy to say letters and prefer pictograms. Alternatively, you can get them to draw out the letters they see, with their finger pointing in the air.

Try not to do too much -if the results are not understandable - then say so to the parent and rebook the child a new test later. You can be frank to the parent - I personally call it 'childhood blurring' and I say that I am still not able to understand given my findings, so lets book in again for a new eye test. Rushing or getting stressed never works.

If the results are contradictory, then refer to the GP and ask the GP to take it further. It may well be childhood blurring (due to nerves or a sense of drama or what ever) - but it could also be due to child abuse, or even some pathology. So a second opinion is best.

-All the best - best to try and enjoy these eye tests. There are little tests worth trying - prisms base in is one, walking the kid upto the testing chart is another, using very low powered letters is another. I like the Titmus Fly - which is fun and scary.

I hope what I have said gives you some ideas - steve It is also covered in Pickwells Bino book.

Just to add to that a little - I will say some patients of any age are good at pushing optoms buttons and worrying them.

This causes the eye test to go off track.

you know:

"Near vision only N48"

"My eyes are full of floaters and flashes - but only on a Sunday."

"Its all hazy and sometimes it hurts"

When this happens -just slow down and try to get the info you need in small packets. Some people go in for drama - and can cause anxiety in the eye-tester.

Just chill out and assimulate one fact at a time. It isn't unusual - it does not mean that much. Its more to do with communication as anything else. Thats why I don't like the word malingerer!

Interestingly enough I knew a family all of whom had phantom conditions. The dad wore an arm sling for a "broken arm" for years. The daughter never ever admitted to seeing better than 6/12; the mum used a stick for her 'back' and the son had terrible migraines. All this came out after I refered the girl as a routine because of the bad vision. I think there were social problems as the root cause.

thank you very much for your guidance that really help.

Just to add what Steve said, I always try the add +0.50 then -0.50DS trial lens over the top as you find the VA often comes up. You are fooling the child into thinking they are accepting more powerful lenses when essentially you are giving them plano.

Changing the distance is helpful too as if a child sticks at the 6/60 letter at 6m and 1m they are "malingering". Stereopsis and suppression tests can be useful if it is only one eye they claim they are unable to see from.

However be wary some children will have a genuine problem. Some of the congenital retinal dystrophys are very hard to identify on retinal examination at an early stage but cause significant visual reduction and children can be branded as malingerers who have pathology! Also don't forget a child may not just be after glasses but may be asking indirectly for help with a social problem. Worst case abuse from friends or family.