Pediatric emergency medicine trisk 917

HISTORY
The emergency provider should quickly assess the child’s relevant past history in
order to assess the expected baseline visual acuity. The mechanism of injury
should also be ascertained in order to understand the risk of serious ocular
pathology and predict injury patterns. Finally, the patient should be asked about
current symptoms including pain, decrease in vision, foreign body sensation,
photophobia, or tearing.

Assessment of Prior Eye Pathology and Relevant Medical
History
It is important to establish the child’s prior ocular history in order to assess the
anticipated baseline visual acuity. A history of poor vision including use of
contact lenses or glasses, amblyopia, or strabismus surgery should be queried. If
the child is wearing contact lenses, they should be removed if this can be done
safely. A history of systemic disorders may predispose some children to specific
injuries or worse outcomes. For example, patients with collagen disorders are
more prone to open-globe injuries or intraocular hemorrhage, and patients with
sickle cell anemia have a higher incidence of complications from hyphema.

Assessment of Injury Mechanism
Clinicians should assess the exact mechanism of injury as the type of trauma and
the nature of the force inflicted may predict injury patterns and prognosis. For
example, significant blunt impact directly to the globe (e.g., baseballs),
projectiles, and sharp objects (e.g., sticks or pencils) have high risk of intraocular
damage. Severe blunt trauma may cause orbital fractures and can also rupture the
globe. Projectiles pose great risk to the globe, and globe rupture sustained
following gun injury often leads to poor visual outcome. Hammering, drilling,
filing, and nailing are particularly high-risk behaviors for intraocular foreign
bodies, especially if safety eyewear use is suboptimal.

PHYSICAL EXAMINATION

Every attempt should be made to examine the eye with the child in a position of
comfort in order to minimize agitation, particularly if the history or gross
appearance of the eye suggests the possibility of an open-globe injury. If the
examination is concerning for an open-globe injury, the physician should stop the
examination, shield the eye, and consult an ophthalmologist emergently. Pain
medications and antiemetics can help reduce common causes of elevated
intraocular pressure that can lead to further prolapse of intraocular contents.


Assess Visual Acuity
The first step is to assess the visual acuity of both the injured and the unaffected
eye. The presence of bilaterally poor vision in a patient with unilateral eye trauma
suggests that the cause of the poor vision may be unrelated to the trauma.
Some patients may be unable to perform this task because of eye pain,
noncompliance, inability to open swollen lids, or obtundation from accompanying
head trauma. Even if the eyelids remain closed, the physician should test for light
perception. By shining a bright light in the direction of the globe through the
closed eyelid, the physician can ask the patient whether he or she perceives the
additional light on that side. A verbal acknowledgment or a reflex contraction of
the lids indicates light perception.
TABLE 114.1
TRAUMA INDICATIONS FOR EMERGENT CONSULTATION WITH
AN OPHTHALMOLOGIST
1. Definitive or suspected open-globe injury
2. Inability to open the eyelids to inspect the eye due to severe ocular trauma or
periocular injury
3. Visual disturbance related to ocular trauma
4. Hyphema
5. Extraocular movement disturbance
6. Foreign body not able to be removed

7. Absent red reflex
8. Papilledema
9. Retinal hemorrhages
If the patient is able to exhibit a greater degree of compliance, the examiner
may ask the patient to count fingers that are held at varying distances. The
maximum distance at which this task is completed should be noted on the chart
(e.g., counting fingers at 4 ft). If the patient is able to comply, the examiner
should obtain a visual acuity using a distance chart (see Chapter 123 Ophthalmic
Emergencies ). If the patient cannot stand but can identify letters or numbers, a
commercially available near visual acuity card, a smart-phone eye chart
application, or any other reading material may be used to assess near vision. This
testing has to be done at the appropriate distance from the patient’s eye; all near
vision cards will denote the testing distance for the calibrated visual acuity


measures. Normal near vision usually indicates that the patient has not sustained a
significant ocular injury.
If a patient demonstrates poor acuity in the traumatized eye, the clinician
should suspect that the deficit is injury-related. However, one can readily
establish whether this deficit is related to the trauma or uncorrected refractive
error using the pinhole test. When a person looks through a pinhole and
experiences improvement in performance on visual acuity testing, he or she may
have uncorrected refractive error as the cause of the initially tested poor vision. If
the visual deficit does not improve through a pinhole and therefore is likely
related to the trauma, an ophthalmologist should be consulted. The urgency of
evaluation will depend on the mechanism of injury and other physical
examination findings.

Inspect the Periorbital Tissues and Eyelids Thoroughly
The periorbital tissues and eyelids should be carefully examined for ecchymosis,

laceration, deformity, swelling, tenderness, and ptosis. Palpation of the orbital
bones should be performed to assess for tenderness, deformity, or step-off that
may suggest orbital fracture. If crepitus is present, it may be indicative of a
fracture communicating with a sinus. Laceration in the periorbital tissue should
be assessed for fat prolapse, which suggests communication with the orbital
compartment and need for ophthalmology consultation. It should also be assessed
for occult foreign bodies that may embed innocuously into the orbital
compartment. Examine sensation to evaluate for infraorbital or supraorbital nerve
injury secondary to laceration, blunt trauma, or orbital fracture. For eyelid
lacerations, careful attention should be paid to the location of the laceration and
the depth of the wound. The eyelid should be everted to evaluate for
subconjunctival and globe involvement, indicating that the laceration may be a
full-thickness, complete perforation. Lacerations in close proximity to the medial
canthus should prompt ophthalmology consultation for evaluation of the integrity
of the lacrimal duct system.

Open the Eyelids
If the patient is unable to open the eyelids voluntarily, the examiner should assist
the patient. A warm compress may be applied gently to the eyelashes to loosen
any crust, blood, or discharge that may be holding the eyelashes together. When
opening the eyelids, avoid pressure on the globe, which might lead to extrusion of
intraocular contents via an underlying open-globe injury. The examiner’s thumbs
can be placed on the supraorbital and infraorbital ridges while exerting pressure
against the underlying bone, and then pulled away from each other such that the


eyelids are separated ( Fig. 114.1 ). If the globe cannot be readily viewed using
these techniques, it is safer to refer the patient for an ophthalmology consultation.
Risking the use of a speculum or retractor may upset the patient, raise intraocular
pressure, and contribute to disruption of intraocular contents if an open-globe

injury is present. Even the ophthalmologist may choose to avoid such attempts
and proceed directly to an examination under anesthesia.

Check the Red Reflex
Absence or asymmetry of the red reflex indicates an abnormality to the path of
light into the eye. This abnormality may be at the level of the cornea (e.g., a
contusion or laceration causing edema and clouding) or anterior chamber or
posterior chambers of the eye (e.g., vitreous hemorrhage or inflammation). An
abnormal red reflex requires emergent ophthalmology consultation.

FIGURE 114.1 Opening swollen eyelids manually from the superior and inferior orbital rims.