EMERGENCY EVALUATION OF IMPORTANT OCULAR SYMPTOMS
EVALUATION OF THE RED OR PAINFUL EYE
Historical factors are important to determine the cause of ocular complaints in the pediatric patient. History, when correlated with characteristic ocular findings on focused physical examination, often makes the diagnosis. History includes a child’s activity and behavior, and the usual historical items, including previous episodes, onset of symptoms, contact lens use, concurrent illnesses or complaints, and associated symptoms (Table 32–1) (Figures 32–1, 32–2).
Table 32–1.Causes of unilateral red or painful eye. |Favorite Table|Download (.pdf) Table 32–1. Causes of unilateral red or painful eye.
|History and Clinical Findings ||Conjunctivitis ||Iritis ||Acute Glaucoma ||Corneal Infection (bacterial ulcer) ||Corneal Erosion |
|Incidence ||Extremely common ||Common ||Uncommon ||Uncommon ||Rare |
|Onset ||Insidious ||Insidious ||Sudden ||Slow ||Sudden |
|Vision ||Normal to slightly blurred ||Slightly blurred ||Markedly blurred ||Usually blurred ||Blurred |
|Pain ||None to moderate ||Moderate ||Severe ||Moderate to severe ||Severe |
|Photophobia ||None to mild ||Severe ||Minimal ||Variable ||Moderate |
|Nausea and vomiting ||None ||None ||Occasional ||None ||None |
|Discharge ||Moderate to copious ||None ||None ||Watery ||Watery |
|Ciliary injection ||Absent ||Present—perilimbal ||Present ||Present ||Present |
|Conjunctival injection ||Severe diffuse in fornices ||Minimal ||Minimal, diffuse ||Moderate, diffuse ||Mild to moderate |
|Cornea ||Clear ||Usually clear ||Steamy ||Locally hazy ||Hazy |
|Stain with fluorescein ||Absent ||Absent ||Absent ||Present ||Present |
|Hypopyon ||Absent ||Occasional ||Absent ||Occasional ||Absent |
|Pupil size ||Normal ||Constricted ||Mid-dilated, fixed, and Irregular ||Normal ||Normal or constricted |
|Intraocular pressure (IOP) ||Normal ||Normal ||Elevated ||Normal ||Normal |
|Gram-stained smear ||Variable; depending on cause ||No organisms ||No organisms ||Organisms in scrapings from ulcers ||No organisms |
|Pupilary light response ||Normal ||Poor ||None ||Normal ||Poor to normal |
Red or painful eye. Reproduced, with permission, from Stone CK, Humphries RL: Current Diagnosis & Treatment Emergency Medicine, 7th ed. New York: McGraw-Hill, 2011. Copyright © McGraw-Hill Education LLC.
Differential diagnosis for the painless red eye with discharge.
Complete eye examination includes the following components, which need to be tailored to the age and capabilities of each patient
Visual acuity testing of the neonate, infant, or toddler is performed by testing the pupillary reaction to light. The ability of the child to track and fixate on a light source 1-3 feet away determines adequate visual acuity. Steady fixation roughly indicates 20/40, unsteady fixation 20/100, and inability to fixate 20/400. Formal visual acuity testing of a child 2-3 years of age is performed by means of a Snellen chart, Allen chart, or rotating “E” ...