I’m taking part in a child vision screening clinic in the next few weeks. How can I be more efficient with my retinoscopy?

I like to take things slow. I’m patient. I can wait. But sometimes even I recognise that speed is necessary. I used to work in clinics where children who had failed school screening (aged 5-6 years old) were referred. Reasons for failure where reduced vision in one or both eyes, strabismus or reduced stereoacuity. Reduced stereoacuity can be caused by reduced vision in one or both eyes, or strabismus or a combination of all of these.

The way the clinics were set up was that an orthoptist would log the child’s attendance, carry out monocular vision tests, distance and near cover test and stereoacuity and then instil cyclopentolate in order for me to conduct retinoscopy refraction and retinal and optic disc examination 40 minutes after drug instillation.

For a 2 hour clinic around 30 children were sent appointments but because the failure to attend rate was usually around 50%. Parents were given the encouraged to phone to rearrange if they couldn’t make it. For most clinics only around 15 or so children attended. I say for most clinics because occasionally 25-30 children attended. The failure to attend rate bothered me as these children had failed screening and were very likely to have a treatable eye abnormality. But you can’t treat patients who don’t come to the clinic.

For those clinics with 15 or so attendees, time allowed me to use handheld trial lenses to determine the presence of any refractive error by conducting traditional cycloplegic refraction. However, with a very busy clinic, I used my lens bar-sometimes called a lens rack (see figure). Moving the lens bar up and down close to the eye I was working on allowed me to quickly determine spherical and sphero-cylindrical refractive corrections without having to reach for and put back trial lenses. The lens bar allowed me to be quick and accurate at the same time.

When I worked in direct service clinics in Ghana and Vietnam people travelled from far away to have their eyes examined by ‘Westerners’. The view was that the ‘Westerner’ eye specialists must be better than the local ones. It was a view I couldn’t accept which is why I didn’t do more direct service clinics. However, of our clinic spread fast and 300-500 people would show up for an 8-hour clinic. Even though we were in a team of 12 it was still hard. Many people were disadvantaged financially, visually or both and we didn’t want to leave before everyone had been examined. In order to be quick and accurate at the same time, we used lens bars during retinoscopy and then refined what we had found using traditional subjective refraction techniques.

If you are likely to be involved in very busy clinics and find retinoscopy useful, then have a lens rack as part of your equipment.

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