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  • Normal visual acuity is 20/40 in a 3-year-old, 20/30 in a 4-year-old, and 20/20 in a 5- to 6-year-old child.

  • Steroids should not be used for patients with iritis or keratitis until herpes simplex is excluded.

  • Glaucoma should be suspected in patients who have eye pain and nausea and vomiting.

  • Neonates with suspected gonococcal conjunctivitis should undergo a complete sepsis workup, including a lumbar puncture. These patients should be admitted for intravenous antibiotics.

  • Chemical alkali burns to the eye can result in liquefactive necrosis and should be irrigated until the eye pH is between 6 and 8.

Children with eye disorders often come to the emergency department (ED) for evaluation and the emergency physician should make sure to perform a complete eye examination in order to avoid overlooking potentially debilitating ophthalmologic conditions. Visual development starts at birth and accelerates quickly during the first 2 years of life, reaching completion at 9 years of age, any disruption during that time due to ocular disease may result in permanent visual deficits.


A thorough and complete history can often help guide diagnosis and management of ophthalmic disorders. Relevant history includes:

  • Previous eye problems or surgeries?

  • Underlying health problems?

  • Review of eye symptoms including eye redness, eye discharge, vision changes, eye pain, periorbital pain, eye swelling.

  • A complete review of systems for other symptoms, especially headache, ear pain, fever, vomiting, dizziness, or rash.

  • Does the patient wear glasses or contact lenses?

  • What was done for the patient prior to arrival in the ED, including the use of any systemic or topical medications?

  • Exposure to others with similar conditions?


A thorough and systematic eye examination is divided into eight major categories: vision, extraocular movements, lids and orbit, conjunctiva and sclera, anterior chamber, pupils, posterior segment, and intraocular pressure. Information about the unaffected eye can help guide one in the assessment of the affected eye. The eye examination should be performed in a logical, methodical manner. Patients should be observed for any facial asymmetry. If indicated, dilation and palpation of the globe should only be done after a thorough systematic examination.

A complete physical exam is required in the evaluation of eye disorders, paying particular attention to the neurologic exam, including fontanelles in infants, which can often help in diagnosing acute eye disorders.


For very young children, the ability to focus on an object such as a toy may give a rough assessment of visual acuity. A newborn can fixate on an object 8 to 12 inches away and a 1-month-old infant should be able to follow a moving object. For older children, Snellen letters or Allen figures should be used to check visual acuity in both eyes. Normal visual acuity is 20/40 in a 3-year-old, 20/30 ...

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