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 and the parents need to be calmed and reassured sufficiently to allow for a complete and thorough examination. This chapter includes a review of eye examination techniques and illnesses specific to the care of children. Because the care of pediatric and adult trauma to the eye and its surrounding structures is similar, only those areas of difference are discussed in this chapter. Further discussion of eye emergencies is provided in chapter 241, "Eye Emergencies."
Eye anatomy is presented in Figures 119-1, 119-2, 119-3, and 119-4.
Anatomic diagram of the eye and the adnexa.
Horizontal cross-sectional diagram of the eye.
Orbital anatomy. [Reproduced with permission from Shah BR, Lucchesi M: Atlas of Pediatric Emergency Medicine. © 2006, McGraw-Hill, New York, Figure 8-13.]
Extraocular muscles of the eye.
EYE EXAMINATION IN A CHILD
If a history of chemical exposure is obtained, triage as highest priority, and immediately irrigate the eye with 1 to 2 L of saline.
A complete eye exam includes gross examination, assessment of visual acuity, extraocular movements, and ophthalmoscopic exam of the eye. A slit lamp exam of the eye should be performed whenever possible.
Begin by performing a general survey, adopting an outside-in approach, to note any obvious abnormalities such as rash, soft tissue changes, matter on the lashes, ptosis, misalignment of the eyes, injection of the conjunctiva, drainage from the eye, or corneal/lens opacities. Newborns may appear cross-eyed during the first 2 months of life as ocular fixation develops.
VISUAL ACUITY AND EXTRAOCULAR MOVEMENTS
Visual acuity (VA) is the vital sign of the eye, and it should be the first objective measurement obtained after the history. Obtaining VA in a child will depend on the child's age and level of development. A child 6 months to 3 years old should be able to fix and follow a face, toy, or light; a child 3 to 5 years old should have a VA of 20/40 or better with one line acuity difference between eyes; and a child >5 years old should have a VA of 20/25 or ...