Pediatric ophthalmologic problems are a common, yet challenging
issue for all emergency physicians. The history often comes from
the parents, particularly in preverbal children, and it may even
be difficult for older children to fully articulate their symptoms.
The child needs to be calmed and reassured sufficiently to allow
for a complete and thorough examination. It is important to comfort
parents as well as the child. This chapter includes a review of
eye examination techniques, and illnesses and injuries specific
to the care of children. Important emergency pediatric eye problems
are discussed. Because the care of pediatric and adult trauma to
the eye and its surrounding structures are similar, only those areas of
difference are discussed in this chapter. Further discussion of
eye emergencies is provided in Chapter 236, Eye Emergencies.
Eye anatomy is presented in Figures 115-1, 115-2, 115-3, and 115-4.
A and B. Orbital anatomy. (Reproduced
with permission from Shah BR, Lucchesi M: Atlas of Pediatric
Emergency Medicine. © 2006, McGraw-Hill, New York,
Extraocular muscles of the eye.
Anatomic diagram of the eye and the adnexa.
Horizontal cross-sectional diagram of the eye.
Perform a general survey of the child to note any obvious abnormalities—rash,
soft tissue changes, matter on the lashes, injection of the conjunctiva,
drainage from the eye, corneal or lens opacities, any misalignment
of the eyes, or ptosis. Newborns may appear cross-eyed during the
first month of life.
Visual acuity (VA) is the vital sign of the eye, and
it should be the first objective measurement obtained after the
history. The one exception to obtaining VA first is a chemical
exposure, which requires immediate copious irrigation with normal
saline. Obtaining VA in a child will depend on the child’s
age and level of development. The Snellen, Allen, and Rosenbaum
charts check distance VA. If the child knows letters of
the alphabet (typically 4 to 6 years of age), the standard Snellen
eye chart may be used; if the child knows numbers, the Snellen number
chart may be used. When using the Snellen charts, check acuity at
a distance of 20 ft. Document VA for the lowest line on
which four or more characters were correctly identified. One can
also chart “20/30 minus 3,” which indicates the
patient incorrectly identified three characters in the 20/30
line. For children 3 to 5 years of age, ...