Ophthalmic conditions can present to the pediatric hospitalist in several settings. Usually, it is an incidental complaint or secondary finding during the evaluation of another presenting issue; for example, a red eye in a patient being treated for bronchiolitis. Occasionally, it is the reason for admission as in orbital cellulitis. Other times, ophthalmology consultation is required for supplemental information for a complicated systemic issue as in the need for a dilated fundus exam in a setting of presumed child abuse.
This chapter will review basic ophthalmic history taking and examination skills for the pediatric hospitalist. It will also provide information about the common ophthalmic conditions encountered by the pediatric hospitalist.
As in most fields in medicine, the most important part of ophthalmologic assessment is the chief complaint and history. Many common ophthalmic diseases can be diagnosed from the history alone. Children present with eye conditions for three general reasons: “I can’t see,” “My eye(s) hurt(s),” “My kid’s eye looks funny,” or some combination of the three. Eliminating one or more of these categories helps narrow the differential diagnosis.
If the child is old enough, it is important to ask if he or she has noticed a change or loss in vision. Most children will not differentiate one eye from the other and will simply say, “Things are blurry” or “I can’t see.” In pre-verbal children, the caregiver often notes vision loss, and history taking will elicit information such as “He is sitting closer to the TV than he used to” or “She keeps tripping or bumping into things.”
It is imperative to ask about trauma to the eye. For example, children may not volunteer the history that their friend shot them in the eye with a pellet gun.
In addition to a good history, a focused and simple eye exam can help differentiate a minor issue from a vision- or life-threatening condition. If a near card is available, and the child can read numbers, the vision in each eye individually should be recorded. The vision with both eyes open is not useful. If this card is not available or if the child cannot use it, documenting if the child can count fingers or blinks to light is necessary. If a vision cannot be obtained, it is necessary to obtain an accurate history regarding any change or loss in vision. Examination of the eyelids and skin around the eyes is helpful in settings of trauma and a red eye. The pediatric hospitalist should take note of any lacerations, foreign bodies, vesicles associated with herpes simplex or zoster, or presence for a preauricular node. The conjunctiva, sclera, cornea, anterior chamber, iris, and lens compose the anterior segment of the eye. Evaluation with a penlight is useful for noting gross defects. When mild trauma is suspected, fluorescein dye can be ...