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Ronal Infante Transdisciplinary Design Lead
Digital / Physical / Service

Master’s Thesis: Distress in Pediatric Optometry Exams

University of Houston
Hines College of Architecture & Design

University of Houston
College of Optometry

Individual project, Aug 2019 – Jun 2020

To perform cycloplegic refraction, dilation drops are delivered to both eyes for each medication. The drops sting, kids hate them, and restraint is often used, causing distress.

Guided by the findings of a year-long mixed methods case study into the anxiety of children during eye exams and subsequent collaborative design research methods, the proposed system allows optometrists to deliver dilation drops faster using syringes pre-loaded with a mixture of medications that twist-lock into the main device, uses visual targets to get kids to open their eyes naturally by looking up, and eliminates the need to restrain kids.



Mixed methods case study research

Repeated measures statistical data analysis

Theme analysis

Design ethnography

Survey design


Expert interviews

Focus groups


Journey mapping

Affinity mapping

Literature review

Academic writing


MS Excel



3D printing

This thesis has been published and is available for download.

Download Thesis Document

Please use this citation:

Infante, R. (2020). Designing for Distress in Pediatric Optometry Exams Using a Mixed Methods Case Study and Human-Centered Design. ProQuest Dissertations Publishing.

Descriptive Mixed Methods Case Study

Children can be difficult to examine because they may become noncompliant if their physical and emotional needs are not met. Yet, there is a lack of studies that describe and measure anxiety throughout the entire length of an eye exam, provide qualitative themes about the exam, and investigate if physical and emotional factors and factors related to the exam are correlated with distress. This thesis starts with a descriptive mixed methods case study using a survey, observations, and field notes.

The study was approved by the University of Houston’s IRB and took place at the University Eye Institute in collaboration with licensed optometry faculty who specialize in pediatrics and their student doctors and residents.

Statistical Data Analysis

Non-parametric statistical tests were chosen based on the distribution of the quantitative data and to support the research questions. The differences between the mYPAS scores of categorical factors and the associations of mYPAS scores with continuous factors were analyzed.

Exam totals, percentages, and descriptive means with standard deviations of mYPAS scores were calculated for 8 categorical factors. Due to fragmented repeated measures data and small sample size (COVID-19), differences in marginal mean mYPAS scores between categorical factors were analyzed separately using univariate tests from multiple repeated measure Linear Mixed Models (LMMs), using a maximum likelihood method, a heterogeneous first-order autoregressive covariance structure, and post hoc least significant difference pairwise comparisons. The rationale is discussed in the thesis document.

Associations between mYPAS scores and 7 continuous factors were analyzed using two-tailed Spearman correlations. A P value of <0.05 was considered statistically significant. Statistical analysis was done using IBM SPSS® Statistics software build (IBM Armonk, NY).


  1. Using patient history (procedure 1) as a baseline, tonometry (procedure 9) (p = 0.025), dilation (procedure 12) (p < 0.001), and ophthalmoscope test (procedure 14) (p = 0.040) had significantly higher anxiety than the baseline, F = 7.43, p < 0.001.
  2. Dilation showed significantly higher anxiety (p ≤ 0.001) than ophthalmoscope test and all other procedures with the exception of tonometry, which did not have a significant difference when compared to dilation (p = 0.052), F = 7.43, p < 0.001.


  1. For age group, the < 4 group had significantly higher anxiety than the 4 – 7 group and the > 7 group, F = 117, p < 0.001.


  1. Patients who were new to the clinic had significantly higher anxiety than patients receiving a yearly exam, F = 8.69, p = 0.005.


  1. Patients who received a morning exam had significantly higher anxiety than patients receiving an exam in the afternoon, F = 8.25, p = 0.006.


  1. For child’s mood, the 3-rating group had significantly higher anxiety than the 4-rating group and the 5-rating group, F = 9.12, p = 0.003.


  1. Patient age and mYPAS scores were strongly negatively correlated, rs(127) = 0.306, p < 0.001.
  2. Time since last nap and mYPAS scores were strongly negatively correlated, rs(127) = 0.395, p < 0.001.
  3. Number of eye exams and mYPAS scores were strongly negatively correlated, rs(127) = 0.448, p < 0.001.

Theme Analysis

Handwritten observations, notes, and anxiety measurements were all digitized, carefully read, and analyzed. The aforementioned research questions were reviewed to provide objectives. Parts of the observations were highlighted and assigned a code.

A total of 65 descriptive codes were developed by identifying tools used, behaviors that occurred during the observations, and the apparent effect of both on the mYPAS scores. Each code was given a number and a description. Of the 65 descriptive codes, 9 of them were deemed special findings. Special findings were identified by particularly relevant but uncommon events, notable things that were said, or extraordinary occurrences. A key was developed to keep track of existing codes during the analysis, provided in the thesis.

The 65 descriptive codes were used a total of 333 times. The codes that were most prevalent accross exams and most frequently used overall were used to determine 8 key themes. This process is outlined in detailed in the thesis.

Collaborative Design

The second phase of this thesis uses collaborative design methods, the design thinking framework, and a human-centered design mindset to translate the research findings into design principles used in the development process of a product to help reduce distress in children during eye exams. The design principles led to specifications which, in turn, guided ideation and refinement.

This mixed method, data-driven, and transdisciplinary approach aims to continue ongoing conversations about the merging of scientific research and applied design research strategies as a way to better design for diverse perspectives in healthcare during a time when disparities and costs are on the rise.


Data-driven Brainstorming Session

Led a brainstorming session with graduate design students. User personas were presented and key insights from the study were discussed. This discussion resulted in a list of “How Might We” (HMW) questions that described potential directions using a uniform format.

HMW questions are structured to include a user, a problem, and context for the problem. They aim to postulate solutions that focus on emotions, aim to create value, and question assumptions.

Focus Groups with Doctors

Led focus groups with student doctors and faculty to gague perceived impact and desirability of directions.

The directions that emerged through the creation of HMWs were summarized and placed on sticky notes. Poster board and tape was used to create a large matrix with four quadrants. One axis represented the potential positive impact that a direction could have on patients and the field of optometry. The other axis represented the doctor’s desire to apply the direction to their practice. Directions that were placed in the top right quadrant were seen as both desirable and impactful.

Scored Affinity Diagram & Design Briefs

Due to their advanced knowledge and experience, faculty members assigned two points while student doctors assigned one point. A total of 4 student doctors and 2 faculty were tasked with placing directions on the matrix. Thus, the minimum score that a direction could receive was 0 and the max score was 8.

Scores for each of the directions were calculated. Directions that scored a 4 or higher were given priority. These directions were organized into groups based on their relationships to each other. Each of the affinity groups implied a unique design brief and a total of 3 design briefs were created as a result: Redefining Experiences, Agile Eye Drops, and Comfortable Exams. Handouts were produced that describe each of the design briefs, provide background, and pose key questions.

Workshops & Group Ideation

Led 2 workshops with undergraduate students to share how I translated research to design principles and to further capture and discuss divergent thinking.

After giving a presentation on the research findings with a few reenactments of how children are often restrained, participants were split into three groups and tasked with sketching solutions that meet each of the design briefs. Each group of participants was given various handouts, 10 minutes for each brief, and then asked to switch.

A total of 15 undergraduate design students participated in the 2 workshop sessions. They produced a total of 47 sketches which were evaluated using feasibility, viability, and desirability as criteria in order to choose the most impactful of the 3 briefs.


The second brief, Agile Eye Drops, was determined to be most successful based on the quantity and quality of the ideas produced from the sketches. These ideas, along with ideas of my own, fueled the development of heuristic principles.

In addition to selecting a design brief, a target user persona was also selected. It was determined that the toddler persona would receive the most benefit from the brief. Toddlers are young enough that they are unlikely to have had many eye exams and are unlikely to remember the exams they had as infants. They are old enough to have conditioned fears, yet they are generally not emotionally mature enough to control fickle emotions. Moreover, they have developed enough motor skills and are large enough to need restraint when distressed.

Heuristic Principles & Specifications

The Agile Eye Drops brief presents a challenge to create a solution that delivers eye drops to both eyes at the same time while the child remains unaware of the procedure. The solution must allow the optometrist to ensure that the drops were successfully administered and must speed up and simplify the procedure.

Proposed Solution

The proposed system allows optometrists to deliver dilation drops faster using syringes pre-loaded with a mixture of medications that twist-lock into the body, uses visual targets to get kids to open their eyes naturally by looking up, and eliminates the need to restrain kids.

Opening Eyes Without Restraint

Inspired by sensory bottles, which are containers filled with various materials that encourage sensory play for children, these visual targets capture a child’s attention by leveraging the use of color, movement, and light. The idea to use color, movement, and light came directly from the study’s observations of tools used as visual targets during exam procedures. The visual targets take the form of a hollow container shaped like a large lens. The container is filled with common sensory bottle materials, such as glitter or colorful oil suspensions, and is sealed after being filled. The container’s material is transparent to allow patients and optometrists to see through the visual target.

The visual targets are removable. They snap onto the body of the device above the line of sight, forcing a child to look up. Looking up naturally opens the eyelids and distracts from the nozzles of the device by applying the concepts of focal distance and depth of field.


Certainly, children have unique needs that ought to be designed for in healthcare. In optometry, children can be difficult to examine if they are distressed. This thesis tackled the need for a more holistic understanding of anxiety throughout the entire length of an eye exam, the need for qualitative themes about the exam, and the need to examine factors that had not yet been covered by other studies.

Furthermore, this thesis serves as an example of how to maximize empathy and include diverse perspectives by merging both traditional scientific research and applied design research methods when designing for healthcare. The underlying call to action is that there needs to be more work like this in order to include diverse perspectives when designing for healthcare. The experiences of children, as well as those of other groups, deserve to be taken into account in healthcare designs to improve clinical outcomes. As disparities and costs in healthcare rise, it is now more important than ever to be critical of the way we design tools, equipment, and services to best meet the needs of their users. By sharing new knowledge and hybrid methodology, this thesis aims to create positive impact and make the world happier and healthier.

– Ronal Infante

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