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can be more difficult to “trick.” Sometimes, by placing a drop of saline or topical
anesthetic in the eye while giving the child the suggestion that these “magic
drops” will cause a return of vision, the child then begins to see better. The
pinhole test (discussed above) can also be used in this manner. Ophthalmology
consultation is sometimes critical in discovering whether a child has truly
sustained visual loss.
Rarely, transient cortical visual impairment/blindness can result following
direct or contrecoup blunt occipital head trauma. Despite an otherwise normal eye
examination, centrally mediated vision loss may occur. Though the vision loss
may be transient, ophthalmology should be consulted. Traumatic cataract,
vitreous hemorrhage, commotio retinae (bruising and edema of the retina from
blunt injury), retinal detachment, and optic nerve injury may also cause acute
traumatic vision loss. For these injuries, ophthalmology consultation is also
required. The most effective screening tests for severe intraocular injury remain
visual acuity testing, evaluation of the pupils for direct, consensual responses as
well as relative afferent pupillary defects, inspection of the anterior segment, and
examination of the red reflex (with or without direct ophthalmoscopy).

Child Abuse
Virtually, any eye injury can be the result of child abuse. Perhaps the most
common ocular manifestation of child abuse is the finding of retinal hemorrhages
associated with the abusive head injury ( Fig. 114.11 ). Although these
hemorrhages can be seen with the direct ophthalmoscope, ophthalmology
consultation is required. Children who present to the ED before the age of 5 years
with significant intracranial hemorrhage, unexplained skeletal fractures, or
sudden, unexplained cardiorespiratory arrest should have a full dilated
examination conducted by an ophthalmologist to look for retinal hemorrhages
that may indicate that a nonaccidental injury has occurred.
Suggested Readings and Key References
General Approach to Ocular Trauma
Chapter 8: Pediatrics. In: Bagheri N, Wajda BN, eds. The Wills Eye Manual—

Office and Emergency Room Diagnosis of Eye Disorders. 7th ed. Philadelphia,
PA: Wolters Kluwer; 2017:177–203.
Levin AV. Eye emergencies: acute management in the pediatric ambulatory
setting. Pediatr Emerg Care 1991;7:367–377.