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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 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.

Figure 115-1.

A and B. Orbital anatomy. (Reproduced with permission from Shah BR, Lucchesi M: Atlas of Pediatric Emergency Medicine. © 2006, McGraw-Hill, New York, Figure 8-13.)

Figure 115-3.

Anatomic diagram of the eye and the adnexa.

Figure 115-4.

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, an Allen picture chart or ...

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