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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 122-1, 241-2, and 241-6.

FIGURE 122-1.

Anatomic diagram of the eye and the adnexa.

A visit to the ED is an opportunity to educate the patient and family about prevention of ocular injury and sun exposure. The annual incidence of eye trauma is 8 to 15.2 per 100,000 children, and most events are thought to be preventable.1 Protective eyewear and adequate supervision during recreational and competitive sports should be available and may prevent injuries.1

Discuss the use of sunscreen and sunglasses for children before going outdoors for any sustained period of time. Emphasize the importance of using sunglasses with both ultraviolet A and ultraviolet B protection. Sun exposure is cumulative, and there is some research that it has an effect on development of cataracts and macular degeneration.2 Ultraviolet B rays may also increase the risk of developing pterygia and pinguecula (yellowish-white vascular conjunctival lesions) later in life.


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 is the vital sign of the eye, and it should be the first objective measurement obtained after the history. Obtaining visual acuity 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, ...

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