Pediatric emergency medicine trisk 1009

Assessment of Ocular Positioning and Movement
It is often useful to start with assessment of the extraocular muscle movements.
This procedure is discussed in Chapter 28 Eye: Strabismus . By using a toy or
another interesting hand-held object, the clinician can entice the child to look in
the direction in which the object is placed. Both eyes should move equally in all
directions. The examiner should test upward and downward gaze as well as eye
movements to the left and right.
The examiner can use the direct ophthalmoscope as a tool to accomplish
several tasks without touching the child. The ophthalmoscope light may be useful
as a fixation target in testing eye movements, to assess whether the eyes are
aligned (Hirschberg light reflex test, see Chapter 28 Eye: Strabismus ), to test for
a red reflex (see Chapter 114 Ocular Trauma ), and as a simple hand-held
magnifier. While viewing through the ophthalmoscope, the focusing wheel can be
dialed in the direction of the black or green numbers to allow the eyeball to come
into focus regardless of the distance between the examiner and the patient.

Visual Acuity Testing
Visual acuity testing is usually performed at a standardized distance. Most
standard wall charts are calibrated to be read at 20 ft, however there are eye charts
calibrated to be read at 10 ft. A patient can be placed 10 ft from an eye chart
calibrated to be read at 20 ft and the results interpreted with an adjustment for this
distance. For example, the line marked 20/60 on the chart (a line that a person
with normal sight can see at 60 ft but a person with that visual acuity would need
to stand at 20 ft to see) becomes a 10/30 line when tested at a distance of 10 ft. In
some centers or with some vision charts, the metric system is used with 20 ft
being equivalent to 6 m. As examples, vision of 20/20 is written as 6/6, 20/30 as
6/9, and 20/200 as 6/60. Visual acuity should be tested and recorded in each eye
separately (i.e., with other eye occluded) and then with both eyes open.


FIGURE 123.1 A: HOTV visual acuity chart. B: Picture visual acuity chart.

Chart selection is important when trying to obtain an accurate visual acuity.
Letter charts should be used only for patients who can clearly recognize the
alphabet. If there is any question by parental report, a number or picture chart
should be used. In general, the HOTV or picture visual acuity charts should be
used for children 3 to 5 years ( Fig. 123.1 ), and the Snellen number or letter chart
for children 6 years and older. Vision assessment in infants and children less than
3 years of age involves evaluating whether each eye can fix and follow objects.
A useful option for children who are not “in the mood” to verbalize their
responses or are very shy is the use of matching acuity chart systems. The two
most common are the Sheridan Gardiner (Keeler Instruments, Inc., Broomall, PA)
and HOTV (Precision Vision, La Salle, IL). In both situations, the child is holding
a card that has all of the letters that are on the posted or hand-held chart 10 or 20
ft away. The child need not know letters but can identify them as shapes. For
example, the H can be called a little ladder and the O a circle. Instead of verbally
responding, the child points to the matching shape (letter) on the card he/she or
his/her parent is holding. When using any visual acuity chart, it is not necessary
to start with the largest symbol and have the patient read every symbol on every
line thereafter. Doing so risks losing the child’s attention. Rather, one can start


with the 20/20 line and then go to larger lines if the child is having trouble. The
child needs to recognize only a few letters on each line. Minor errors such as the
substitution of the letter F for the letter P, or the letter C for the letter O, may be
tolerated.
It is almost an instinct for young children to use their better eye and suppress
the vision in their lesser eye. The examiner should ensure that it is not possible to
peek with the nontested covered eye. Therefore, children should not be allowed to
cover their eye with their own hand (small cracks between the fingers can
actually allow vision out of the “covered” eye). Children may also look around

commercially available occluders for the same reasons. Perhaps the best way to
obstruct the vision in the eye not being tested is to use a broad piece of tape,
ensuring the tape also covers the depression at the bridge of the nose ( Fig. 123.2
). To help ensure the patient is not “cheating,” the examiner should look back
directly at the child while standing by the chart indicating the letters or pictures.
If the child has glasses they should be worn during visual acuity testing. Any
child who can read a chart but shows reduced visual acuity should be tested using
a pinhole. If vision improves with a pinhole then the patient only needs glasses
and there is no organic abnormality causing the blurred vision.
After external examination and visual acuity are completed, the examiner can
then proceed with other procedures as indicated, such as upper lid eversion and
dilating the pupil. These techniques, along with the proper methods of examining
the retina and optic nerve using the direct ophthalmoscope, are discussed in
Chapter 114 Ocular Trauma .

FIGURE 123.2 A broad piece of tape can be used to obstruct the vision of the eye not being
tested. If the tape is not adherent to the bridge of the nose, the child can peek out by turning the
face to the side (right frame) .

Examining the Swollen Eye


When the eyelids or periorbital tissue is edematous or the patient refuses to
voluntarily open the eyelids, proper examination can be difficult. The techniques
described in Chapter 114 Ocular Trauma for opening the traumatized eye may be
useful. Warm compress can be used to gently loosen crust or discharge if present.
When there is mild to moderate swelling, the examiner can place his/her thumbs
on the supraorbital and infraorbital ridges and gently apply pressure against the
underlying bone while pulling fingers (and thus the eyelids) away from each
other. A Desmarres retractor can be helpful to control the upper eyelid and can

also be applied simultaneously to the lower eyelids ( Fig. 123.3A ).
Commercially available speculums, when used in association with a topical
anesthetic, are another painless and efficient way of opening the eyelids ( Fig.
123.3B ). Importantly, when refusal to open an eye is secondary to pain (as with a
corneal abrasion) instillation of topical anesthetic prior to examination will often
lead to spontaneous eye opening.
In infants, the eyelids may be separated using cotton swabs. The swabs should
be placed at the midbody of the upper and lower eyelids. As they are separated,
pressure should be applied down against the eyelid and the swab should be
rotated inward toward the eyelashes. This will keep the eyelids in place so they
do not spontaneously evert and further obstruct the examiner’s view. The cotton
swab technique should not be used in patients being evaluated for eye trauma
because pressure on the eyeball from this technique could cause further injury
(see Chapter 114 Ocular Trauma ).

Instillation of Eye Drops
It may be necessary to instill certain eye drops to complete the eye examination
(e.g., topical anesthetics, dilating drops). Instillation of eye drops can sometimes
be difficult because of swollen eyelids or patient noncompliance. Ophthalmic
solutions are designed for a one-drop dose. Drops are most efficiently delivered
by pulling down the lower eyelid and placing the drop in the inferior fornix. In
patients who are extremely resistant, forced eyelid opening is needed to expose
just a small strip of palpebral conjunctiva. The eyeball itself does not need to be
visualized. An alternative technique involves placing the eye drop in the sulcus
between the medial canthus and the side of the bridge of the nose while the
patient is in the supine position. Every child must eventually open his or her eyes
and when this happens the eye drop will naturally flow onto the conjunctiva.
Topical anesthetics may be necessary to complete some parts of the examination,
especially in the patient with significant pain. Topical anesthetics should never be
prescribed for outpatient use. These are strictly diagnostic agents. Prolonged use

of topical anesthetics may result in corneal ulceration.