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High-Yield Facts

  • 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 work-up, 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). It is imperative that the emergency physician performs a complete eye examination in order to avoid overlooking potentially debilitating ophthalmologic conditions. The physician must remember certain important guidelines when facing patients with ocular disease.

A thorough and complete history must be taken. Have there been previous eye problems or surgeries? Are there underlying health problems? Does the patient wear glasses or contact lenses? What was done for the patient prior to arrival in the ED? In the absence of trauma, is eye pain present? Has there been eye discharge or exposure to others with similar conditions? Has there been use of systemic or topical medications?

The visual acuity in both eyes must always be checked. 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. Toys or other objects that hold the interest of the child and allow proper evaluation of the visual fields should be used. The eye should be touched and dilated only after a thorough systemic examination, and only if indicated.

Physical Examination of the Eye and Differential Considerations

A thorough and systematic eye examination is divided into six major categories: vision, lids and orbit, anterior segment, pupils and extraocular movements, posterior segment, and intraocular pressure.


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 a close object and a 1-month-old infant should be able to follow a moving object. For older children, Snellen letters or Allen figures are useful to check visual acuity in both eyes. 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. Vision can be impaired from any obstruction of the visual pathway.

Lids and Orbit

The lids must be examined by testing the ability to raise and lower the eyes and noting any erythema, edema, lacerations, or ecchymosis. Children with periorbital cellulitis will often have ...

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