Pediatric Ophthalmology Exam

Conduct a comprehensive eye and vision exam tailored for pediatric patients, focusing on visual function and early detection of serious pathology.

Visual Assessment

Evaluate the child's visual acuity using age-appropriate, child-friendly tools:

• Picture or symbol charts for pre-literate children.
• Snellen or similar letter charts for older children.
• Fixation and following behaviour in infants (does the child track a face or object?).

Visual acuity is often recorded as values such as 6/6 (or 20/20) if the child can see at a standard distance what is expected for normal vision. Use matching games, pointing, or picture naming for shy or non-verbal children.

External Eye Examination

Inspect the peri-ocular region and anterior eye structures:

• Redness, swelling or discharge (conjunctivitis, blepharitis).
• Eyelids: ptosis, entropion/ectropion, incomplete closure.
• Lid position and movement: facial nerve palsy, poor blink.
• Lumps or bumps: chalazion, stye, masses.
• Foreign bodies: on conjunctiva, under lids, on cornea.

Internal Eye Examination

Use an ophthalmoscope and torchlight to assess:

• Pupillary response: Size, symmetry, direct and consensual light reflexes.
• Cornea: Clarity, scars, abrasions (consider fluorescein staining if corneal injury suspected).
• Lens: Clarity (look for cataract, leukocoria).
• Red reflex: Equal and bright in both eyes; any asymmetry or white reflex is concerning.
• Fundus (if possible): Optic disc, vessels, macula and background retina.

Intraocular Pressure

Measure intraocular pressure (IOP) with child-friendly methods (e.g. handheld tonometer) when indicated – such as suspected glaucoma or trauma. Note:

• Raised IOP may present with enlarged cornea, photophobia, tearing, irritability in infants.
• Always correlate with optic disc appearance and corneal findings.

Types of Pediatric Eye Conditions

Type of Condition	Common Clinical Features
Amblyopia (Lazy Eye)	Reduced vision in one eye not fully correctable with glasses. Strabismus (misaligned eyes) may be present. Squinting, closing one eye, or head tilt to see better. Poor depth perception.
Conjunctivitis (Pink Eye)	Red, irritated eye(s). Watery or mucopurulent discharge. Crusty eyelids on waking. Itching or gritty discomfort.
Pre-septal Cellulitis	Swelling, redness and warmth of eyelids and surrounding tissue. Tenderness but no pain with eye movements. Vision and eye movements are normal. May have fever and systemic symptoms.
Orbital Cellulitis	Swelling and redness around the eye extending beyond the eyelids. Proptosis (bulging eye). Painful and/or restricted eye movements. Decreased or blurred vision, possible diplopia. Fever and systemic toxicity often present. An emergency – high risk of intracranial spread and vision loss.

Pediatric Eye Red Flags

Any of the following should prompt urgent ophthalmology/senior review and often admission:

Quick Pediatric Eye Algorithm for A&E

Use this mental flow to structure assessment in the Emergency Department:

1. Initial Impression
   • Is the child systemically unwell? (fever, toxic, septic picture)
   • Is there any concern for orbital cellulitis, trauma, or chemical injury?
2. Check Vision and Red Flags
   • Assess visual acuity in both eyes where possible.
   • Look quickly for leukocoria, proptosis, corneal opacity, or marked swelling.
3. Define the Main Problem
   • Red, sticky eye → conjunctivitis vs keratitis vs foreign body.
   • Swollen eyelids → pre-septal vs orbital cellulitis.
   • Painful, photophobic eye → consider keratitis, uveitis, acute glaucoma, corneal abrasion.
   • Sudden visual change → urgent ophthalmology review.
4. Look for Red Flags
   • If any red flag present → escalate for urgent imaging/ophthalmology input.
   • If no red flags, child well, and likely minor condition → treat in ED and provide safety net advice.
5. Disposition
   • Admit / urgent referral: orbital cellulitis, chemical injury, penetrating trauma, severe visual loss, suspected intra-ocular pathology.
   • Discharge: mild conjunctivitis, simple corneal abrasion, stable pre-septal cellulitis on oral therapy (with good follow-up).

Common Pediatric Eye Emergencies

Key ophthalmic emergencies you will often encounter in A&E:

1. Orbital Cellulitis

• Swollen, red eyelids with proptosis, painful/restricted eye movements, decreased vision, fever.
• Medical emergency – risk of cavernous sinus thrombosis and intracranial spread.
• Urgent IV antibiotics, imaging (CT or MRI), and ophthalmology/ENT referral.

2. Pre-septal Cellulitis

• Eyelid swelling and redness without proptosis or pain on eye movement, and normal vision.
• Often associated with local skin infection or insect bite.
• Oral or IV antibiotics depending on severity and age; close follow-up.

3. Corneal Abrasion / Foreign Body

• Pain, photophobia, lacrimation, foreign body sensation.
• Examine with fluorescein; evert eyelids to look for hidden foreign body.
• Topical antibiotics, analgesia; avoid contact lenses until healed.
• Urgent referral if large central defects, suspected penetrating injury, or non-healing.

4. Chemical Eye Injury

• True emergency – start immediate irrigation before full history/exam.
• Irrigate with copious normal saline or clean water for at least 15–30 minutes.
• Check pH and repeat irrigation until normal.
• Urgent ophthalmology review after initial resuscitation and irrigation.

5. Acute Visual Loss

• Sudden reduction in vision in one or both eyes.
• Check acuity, pupils (RAPD), visual fields and fundus if possible.
• Urgent ophthalmology and possibly neurology referral – time-critical.

6. Leukocoria (White Pupil)

• Abnormal white reflex noticed by caregiver or on photos.
• Causes include cataract, retinoblastoma, retinal detachment, Coats disease.
• Requires urgent specialist assessment – treat as high priority.

Always document visual acuity (or best possible assessment), red reflex, key findings, and safety net advice clearly in the notes.