Pediatric Eye Emergencies

Educational Objectives

The goal of this program is to improve management of pediatric eye emergencies. After hearing and assimilating this program, the clinician will be better able to:

1. Identify pediatric ocular emergencies.
2. Perform a thorough diagnostic evaluation of children presenting with a potential eye emergency.

Summary

Components of eye examination: examination of the eyelid is important because pathology within the orbit may cause the eyeball to protrude; eye motility examination allows evaluation of the muscles and nerves; fundus examination — pediatricians often lack sufficient training and experience; instruments to facilitate this examination are under development, including phone adapters that allow photographs to be transmitted to another clinician for interpretation; new ophthalmoscopes have improved optics and are smaller and more portable; evaluation of eye trauma — history provides ≈90% of the information (physical examination provides only ≈10%); IOP — advances in tonometry have greatly improved the tolerability of measurement in children

Urgency of referrals: history and vision determine whether the situation is emergent, urgent, or routine; in the pediatric population, the 2 major ophthalmic emergencies are chemical injury and ruptured globe; chemical injury can be identified from the history, but ruptured globe is more difficult to diagnose; urgent situations include hyphema (ie, bleeding within an intact eyeball), foreign body (not emergent unless the patient is experiencing intense pain), eye lacerations, and infections; ≈90% of cases are routine

Determination of urgency after eye trauma: vision examination is the most important component of evaluation; finger count test — if the patient can count the number of fingers being held up from a distance of 15 ft, vision is 20/50 to 20/60 and the case is nonemergent; if fingers cannot be counted, test for light perception (LP); no light perception (NLP) — inability to see light; suggests high risk for loss of the eye and constitutes an emergency; asymmetry — separately evaluate vision for each eye by patching the fellow eye; asymmetry is suggested when an infant cries when one eye is patched, but not with similar coverage of the other eye

Examples: subconjunctival hemorrhage — vision may be 20/20 despite a bloody appearance of the eyes; the eyeball remains intact; laceration of the cornea — may be difficult to visualize if the patient is uncooperative; if vision is limited to LP, emergent referral is indicated; when the eyeball is punctured, IOP drops from 10 to 20 mm Hg above atmospheric pressure to 0 mm Hg, causing the eyeball to collapse; because light can no longer follow a straight path, vision is compromised

Pupil examination: examine the pupil and ensure it is round; a pupil that is not round suggests presence of a laceration that has reduced IOP to 0 mm Hg, causing distortion of the pupil; a laceration in any portion of the globe may cause a drop in IOP that can occlude the iris; if facial swelling is preventing examination of the pupils, use a drop of proparacaine and an Alfonso speculum to open the eyelids (use of the fingers can place pressure on a potentially ruptured eye); if the pupil is not round, consider it a ruptured globe until proven otherwise

Imaging: computed tomography or magnetic resonance imaging may be appropriate to evaluate for foreign bodies (choice depends on the suspected foreign material)

External examination: the eyelid, which is composed of the thinnest skin in the body, is connected to the eyeball; therefore, swelling of the eyelid may indicate pathology within the eye; presence of other bodily injuries should raise concern for child abuse; lacerations at the eyelid margin — should be ruled out in cases of trauma; injury to the eyelid margin may sever the tear duct or nasolacrimal duct; without appropriate repair and optimal healing, the patient may suffer life-long epiphora; repair involves placement of a stent and closure of the laceration

Motility examination: evaluates function of the brainstem and the ocular muscles; after trauma, patients should be examined while looking in different directions; difficulty looking upward suggests that the orbital floor is encapsulating the inferior rectus muscle and preventing that eyeball from moving upward (eg, due to fracture of the orbit); not considered an emergency but needs to be repaired within 1 wk; double vision — consider infection; a protruding eyeball (due to, eg, subperiosteal abscess) can compromise muscle movement; as the volume of the orbit is limited, any space-occupying pathology can impair muscle movement and cause double vision; infection is treated with intravenous (IV) antibiotics; orbital cellulitis can be transmitted to the cavernous sinus, in which case the mortality rate may be ≤80%

Funduscopic examination (FE): may lead to diagnosis of, eg, hydrocephalus secondary to a brain tumor, pseudotumor cerebri; an increase in cerebrospinal fluid pressure causes the optic nerve to protrude; however, most brain tumors cause atrophy and a pale appearance of the optic nerve; red reflex testing — may be performed if FE is not possible; red reflex should be symmetric; the reflected color varies with ethnicity and complexion (red reflex is seen in patients with light skin, but the color is whitish in darker-skinned patients because there is more pigmentation at the back of the eye); as the probability of having an infection, papilledema, or retinoblastoma bilaterally is low, a symmetric reflex is reassuring; asymmetry raises suspicion for abuse (blood at the back of the eye blocks reflection; unlikely to be symmetric); testing can be completed in ≈5 min

Dealing with emergencies: call for ophthalmologic consultation; relay findings from the vision, pupil, external, motility, and fundus examinations; when appropriate, treat with IV antibiotics, vaccinate against tetanus, and provide pain control

Foreign bodies: should be left in place because they may be providing tamponade (ie, removal may result in collapse of the eyeball); prevent rubbing of the eye by placing a shield over it (arm restraints may be needed)

Chemical injuries: irrigation with saline is ideal, but tap water is acceptable; household cleaning agents, a common source of chemical injury, are typically basic, so it is necessary to lower the pH; basic materials directly penetrate into the eye through saponification; even if the pH is 7, continue to irrigate for ≥30 min because basic material may have entered the nasolacrimal duct system

Questions and answers: vernal keratoconjunctivitis — may be confused with viral keratoconjunctivitis (secondary to, eg, herpetic infection), which may be worsened by steroids; therefore, it is best to refer to an ophthalmologist before initiating treatment; motility examination in young children — have the child sit on the guardian’s lap; the guardian holds the child’s head so that only the eyes follow a brightly colored object

Readings

Bhagat N, Turbin R, Langer P, et al. Approach to management of eyes with no light perception after open globe injury. J Ophthalmic Vis Res. 2016;11(3):313. doi:10.4103/2008-322X.188388; Cariello AJ, Moraes NS, Mitne S, et al. Epidemiological findings of ocular trauma in childhood. Arq Bras Oftalmol. 2007;70:271-5. doi:10.1590/s0004-27492007000200015; Dua HS, Ting DSJ, Al Saadi A, et al. Chemical eye injury: pathophysiology, assessment and management. Eye (Lond). 2020;34(11):2001-2019. doi:10.1038/s41433-020-1026-6; Juang PS, Rosen P. Ocular examination techniques for the emergency department. J Emerg Med. 1997;15(6):793-810; Li X, Zarbin MA, Bhagat N. Pediatric open globe injury: A review of the literature. J Emerg Trauma Shock. 2015;8(4):216-223. doi:10.4103/0974-2700.166663; Morad Y, Barkana Y, Avni I, et al. Fundus anomalies: what the pediatrician’s eye cannot see. Int J Qual Health Care. 2004;16(5):363-5. doi:10.1093/intqhc/mzh065; Pokhrel PK, Loftus SA. Ocular emergencies. Am Fam Physician. 2007;76(6):829-36; Toli A, Perente A, Labiris G. Evaluation of the red reflex: An overview for the pediatrician. World J Methodol. 2021;11(5):263-277. doi:10.5662/wjm.v11.i5.263; Wladis EJ, Aakalu VK, Tao JP, et al. Monocanalicular stents in eyelid lacerations: a report by the American Academy of Ophthalmology. Ophthalmology. 2019;126(9):1324-1329. doi:10.1016/j.ophtha.2019.03.045.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Suh was recorded at the 43rd Annual Las Vegas Seminars: Pediatric Update, held November 17-20, 2022, in Las Vegas, NV, and presented by the American Academy of Pediatrics, California Chapters 1, 3, and 4. For information about upcoming CME meetings from this presenter, please visit https://aap-ca.org. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.75 CE contact hours.

Lecture ID:

OP612001

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.