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32: Eye Emergencies

Robert D. Greenberg; Cassandra Zhuang

EMERGENCY EVALUATION OF IMPORTANT OCULAR SYMPTOMS

EVALUATION OF THE RED OR PAINFUL EYE

HISTORY & EXAMINATION

Historical factors are important to determine the cause of ocular complaints in the pediatric patient. History, when correlated with characteristic ocular findings on focused physical examination, often makes the diagnosis. History includes a child’s activity and behavior, and the usual historical items, including previous episodes, onset of symptoms, contact lens use, concurrent illnesses or complaints, and associated symptoms (Table 32–1) (Figures 32–1, 32–2).

Table 32–1.Causes of unilateral red or painful eye.
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Table 32–1. Causes of unilateral red or painful eye.
History and Clinical Findings Conjunctivitis Iritis Acute Glaucoma Corneal Infection (bacterial ulcer) Corneal Erosion
Incidence Extremely common Common Uncommon Uncommon Rare
Onset Insidious Insidious Sudden Slow Sudden
Vision Normal to slightly blurred Slightly blurred Markedly blurred Usually blurred Blurred
Pain None to moderate Moderate Severe Moderate to severe Severe
Photophobia None to mild Severe Minimal Variable Moderate
Nausea and vomiting None None Occasional None None
Discharge Moderate to copious None None Watery Watery
Ciliary injection Absent Present—perilimbal Present Present Present
Conjunctival injection Severe diffuse in fornices Minimal Minimal, diffuse Moderate, diffuse Mild to moderate
Cornea Clear Usually clear Steamy Locally hazy Hazy
Stain with fluorescein Absent Absent Absent Present Present
Hypopyon Absent Occasional Absent Occasional Absent
Pupil size Normal Constricted Mid-dilated, fixed, and Irregular Normal Normal or constricted
Intraocular pressure (IOP) Normal Normal Elevated Normal Normal
Gram-stained smear Variable; depending on cause No organisms No organisms Organisms in scrapings from ulcers No organisms
Pupilary light response Normal Poor None Normal Poor to normal

Reproduced, with permission, from Stone CK, Humphries RL: Current Diagnosis & Treatment Emergency Medicine, 7th ed. New York: McGraw-Hill, 2011. Copyright © McGraw-Hill Education LLC.

Figure 32–1.

Red or painful eye. Reproduced, with permission, from Stone CK, Humphries RL: Current Diagnosis & Treatment Emergency Medicine, 7th ed. New York: McGraw-Hill, 2011. Copyright © McGraw-Hill Education LLC.

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Figure 32–2.

Differential diagnosis for the painless red eye with discharge.

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Complete eye examination includes the following components, which need to be tailored to the age and capabilities of each patient

Visual Acuity

Visual acuity testing of the neonate, infant, or toddler is performed by testing the pupillary reaction to light. The ability of the child to track and fixate on a light source 1-3 feet away determines adequate visual acuity. Steady fixation roughly indicates 20/40, unsteady fixation 20/100, and inability to fixate 20/400. Formal visual acuity testing of a child 2-3 years of age is performed by means of a Snellen chart, Allen chart, or rotating “E” chart at 20 feet. ...

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