Ophthalmic imaging has in recent years become an integral part of the diagnosis and monitoring of patients. There is now a wide range of instruments available for imaging children and assisting in the provision of detailed clinical information for the team providing ophthalmic care.
These include traditional digital fundus photography (often via a handheld device), Optos widefield digital imaging, optical coherence tomography (OCT) imaging of the posterior and anterior segment, handheld OCT imaging, B-scan ultrasound imaging, and ultrasound biomicroscopy (UBM) anterior segment imaging. Much as in adult patients, imaging children brings its own challenges and rewards.
The imaging of children can be challenging due to young patients level of comprehension of what is happening, their compliance and in many instances, their unwillingness to sit still. To this end, one has to be creative to capture good clinical images successfully and consistently. Here, I will outline how at Great Ormond Street Hospital (GOSH) we carry out ophthalmic imaging with our ‘Always’ values in mind. These values are always Welcoming, Helpful, Expert and One Team.
Prior to bringing a patient into the imaging room, ensure their details are entered into the machine beforehand, and thus you are ready for prompt image capture. Not having this done in advance results in the technician spending time typing in patient details and getting the equipment set up. In that time the child may become bored, disengaged or nervous. Also, the noise of an Optos machine powering up can seem to a young child as dramatic as the starting of a jet engine!
Greeting
Always greet the patient yourself. That initial meeting gives you the opportunity to take note of any obvious disabilities, which in turn will influence the choice of imaging modality. For example, if the patient is in a motorised wheelchair, then they will probably struggle with standing, kneeling or sitting high enough on a chair to access a table-mounted OCT scan. You may then consider a handheld device as an alternative.
While interacting with the patient you can determine how they are feeling. You may be able to make them laugh on the way to the imaging room. If the child is upset from having received dilating drops, you may joke “Oh (insert patient name), I didn’t want to come here today either, but we will make the most of it.” In this greeting, the patient and parents get to know you both as a technician and a healthcare professional and you can immediately start allaying fears, listen to how the parents and child feel, and build your strategy for getting good clinical images.
Giving instructions
The first thing any technician should do before operating an imaging device on patients is to go through the process themselves. That technician will then know and understand the colour / shape of the fixation target, where it’s situated at any given time, and if there are any other distracting light sources that may cause loss in fixation. To know what each device does and how it behaves helps hugely in giving instructions to a patient.
“I hope that in the future, ophthalmic technicians, particularly those working with children, will collaborate and share ideas on best practice and on improving what we do and how we do it”
When guiding a paediatric patient, ensure instructions are kept simple and as positively put as possible. Saying, “Don’t look at the red light, look at the blue light,” confuses a child being imaged by OCT. You have given them two instructions instead of one. Simply say, “Just look at the blue light.” Likening the lights to characters, fruit or other objects can bring about brief but invaluable periods of fixation. This is how I realised that the traffic light system, which indicates when the patient is the correct distance from the camera on Optos devices, is not only visible on the operator screen, but also to the patient as they look through the testing aperture. To this end, we give patients the button to “take” the images themselves. Telling them to “press the button when that blue light turns green.” It has enabled us to concentrate on head holding and managing explosive blinking!
Speed
The ophthalmology outpatients clinics at GOSH are very busy and the bulk of patients attending are sent for imaging. Empathy for patients and parents / guardians, who may have been in the department for long periods of time, is needed and we thus try our best to see everybody in a timely fashion. Since imaging is often a bottleneck of the service, the waiting area can become overloaded quite quickly. We see many patients with complex medical needs and the longer they spend in a busy waiting area, the less compliant they will be. So, being expert in the imaging processes and modalities is a very important factor in ensuring that the more compliant patients are seen very quickly and those requiring extra time are afforded it.
Absolute candour
Due to the nature of the role of an ophthalmic practitioner / vision scientist in imaging, I enjoy being able to keep things reasonably light. When there is an order for both Optos and OCT imaging, I often tell patients, “We have two cameras to use, a fun one and a boring one; which one do you want to do first?” This offers a bit of levity to a nervous patient, the parents may chuckle as well, which in turn puts everybody more at ease. The statement also gives the patient a feeling of more agency in their care, due to the choice being offered. This in turn may increase compliance.
Working as a team
Obtaining ophthalmic images in challenging circumstances, from patients who are not overly keen on being imaged, is always a team effort. Acquiring Optos images on such patients can really assist diagnosis and management particularly in children who have not been imaged previously because the challenge was too great. In the past, working in isolation, it was often too great for me, too. However, working within a team, I learned that if one tech explains the situation to the parent / carer and holds the patients head in a gentle but secure manner (with additional hugging holds from the parent), another tech can move the table up and down with any patient movements and take the decisive image.
This teamwork has led to a reduction in the need for examinations under anaesthetic (EUAs) and a greater cohort of patients being examined objectively and in more in depth. Making this difference is very rewarding and is why I do this job.
The future
I hope that in the future, ophthalmic technicians, particularly those working with children, will collaborate and share ideas on best practice and on improving what we do and how we do it. Development of recognised standards, which enable imaging technicians to effectively use a range of tools in the management of challenging patients, can only further enhance diagnosis and treatment of our young patients in the 21st century.
Declaration of competing interests: None declared.
