An eye examination under anaesthesia: why, and what happens

There is a particular silence that follows the sentence. I explain that I would like to examine your baby's eyes while she is asleep, under a general anaesthetic, and the room goes quiet. Parents hear the word anaesthetic and stop hearing anything after it. That is a completely reasonable reaction, and it is why I try to say the rest of it slowly.

An examination under anaesthesia, which everybody in the eye clinic shortens to an EUA, is not surgery. It is a look. It is the same examination I do in clinic, done properly, on a child who is asleep instead of a child who is fighting.

Why does my child need a general anaesthetic just for an eye examination?

Because some of what I need to do cannot be done on a moving child. Certain tests mean touching the eye, holding the lids apart, measuring the pressure inside the eye, or photographing the retina right at the back, and a baby cannot hold still for that. A children's hospital eye department leaflet written for parents puts it in one sentence I have never improved on: it is sometimes kinder for children to be asleep while we examine them.

That is the whole argument. Not convenience, and certainly not that your child has been badly behaved. The measurement has to be exact, and exact measurements do not come from a struggle.

The other half of it is the memory. A child who is pinned down to have her eyes prised open at eighteen months does not forget the eye clinic, and if her condition needs watching for years, that first experience matters more than anyone admits. I would rather spend one anaesthetic than lose a child's trust for a decade.

Can they not just hold him still?

For a quick look, yes, and that is exactly what we do in clinic every week. A great deal can be learned from a torch, a lens and a well timed toy, and most of a young child's eye test needs no cooperation at all. The awake examination is tried first for most children, and for many of them it answers everything.

What it cannot always do is give the fine detail. If I need to know the exact curvature of a cornea, the precise pressure inside an eye, or what the far edge of the retina looks like, wrestling produces a number I would not act on. For a small number of conditions we skip straight to the examination under anaesthesia from the start, because the detail is the entire point of the visit and there is no version of the awake examination that gets there.

Whichever route is chosen, it is discussed with you first, and with your child if they are old enough to be part of the conversation.

What actually happens on the day?

Drops first, then sleep, then a careful look. In more detail, you arrive at the ward or day unit and the eye team put dilating drops in to widen the pupils, because a wide pupil is a window and a small pupil is a keyhole. The drops sting for a few seconds, and then they are done. If your child already uses eye drops or any other eye treatment, check with the eye department in advance whether to keep giving them up to and on the day, because that answer is not the same for every child. Parents who dread this part often find the trick to getting drops into a small human works just as well in hospital as at home.

The anaesthetist takes over from there. Your child goes to sleep, and many hospitals let a parent stay until that moment. Ask yours when the date is set, because the arrangement is not the same everywhere. Then the eye examination happens: each eye in turn, in detail, with the instruments that need a still eye. The back of the eye is often photographed as a permanent record, and those photographs belong to your child's file. You are allowed to ask to see them. Most parents do not realise that, and I think looking at the inside of your own child's eye is one of the stranger and better parts of the day.

Then she wakes up, in recovery, and you are brought to her.

Will they do treatment at the same time, or bring us back?

Sometimes at the same time, and this is the part I most want parents to hear before the day rather than during it. If the examination finds something that can be treated there and then, doing it while your child is already asleep spares her a second anaesthetic on another date. That is a real kindness and it is why you will be asked to stay contactable and stay nearby while she is in theatre.

Nothing is done without your consent. The conversation about what might be found and what might follow happens before your child goes to sleep, not afterwards, and it is a conversation you should push on. Ask what the possibilities are. Ask what would be done immediately and what would be planned for later. A parent who has already heard the list does not receive it as a shock in a corridor.

The same logic runs the other way too. If your child is already booked for an anaesthetic for anything else, dental treatment included, say so at the eye clinic. The two can sometimes be arranged together. One anaesthetic instead of two is worth a phone call.

Will it hurt, and how will she feel afterwards?

The examination itself is not painful. Some children have minor eye discomfort straight afterwards, and that is unusual rather than expected. What every parent should plan for is the light. The pupils stay large for roughly twenty four to forty eight hours because of the drops, so bright sunlight feels harsh and close-up vision is blurry in that window. Bring a hat or sunglasses, and if you can, plan a quiet afternoon rather than an errand.

Waking up from an anaesthetic has its own small aftermath. A headache, feeling sick, dizziness, a sore throat: these are the ordinary ones, and they usually settle over the same day or two. Ask the team what you can give at home if she is uncomfortable, and ask before you leave rather than at ten at night.

If anything worries you afterwards, and particularly if there is pain that is getting worse rather than better, or an eye that she will not open, ring the number you were given rather than waiting for the next appointment. Hospitals expect those calls and would far rather have them.

How many times will he have to have this?

It depends on the condition, and it is a fair question to ask outright when the booking is made. For some conditions a single examination answers everything and is never repeated. For others, this examination is how the condition is monitored, and it happens at planned intervals for a period. If your child is in the second group, it helps enormously to know it on day one, because a series of short, expected visits is a different thing in a family's life from a series of unpleasant surprises.

What does not change is the ordinary care around it. Clinic appointments carry on, sight is measured, glasses are adjusted, an eye is watched as it develops. The examination under anaesthesia is one detailed chapter, not the whole book. If the appointment is at a government hospital and you have not been through that system before, what actually happens at your first visit is worth reading beforehand, if only so that the day has fewer unknowns in it.

And the honest summary, the one I give in the doorway: I am not asking for an anaesthetic because something terrible is certain. I am asking because I would rather look properly, once, than guess repeatedly.

Common questions

References

1. Birmingham Women's and Children's NHS Foundation Trust · Examination Under Anaesthetic (EUA), information leaflet for parents and carers · bwc.nhs.uk
2. NHS · Childhood cataracts, treatment · www.nhs.uk
3. AAPOS · Cataract · aapos.org
4. American Academy of Ophthalmology · Procedures for the evaluation of the visual system by pediatric ophthalmologists · www.aao.org
5. AAPOS · Dilating eye drops · aapos.org

By Dr Chan Li Yen. General information only. It does not replace a consultation. If you are worried about your child's eyes or vision, please see an eye doctor.