Introduction

Few ophthalmological emergencies relate exclusively to children. Although the pathology may be the same, the general approach, examination and compliance with treatment is very different depending on the age and development of the child. Also, the long-term sequelae of serious eye injury or disease are much greater.

History

As with other paediatric encounters, it is important to gain the child’s confidence in you whilst obtaining the history from the parents or carers. A detailed history should be obtained from an adult witness. If this is unavailable, injury will be the likely cause of a painful red eye. Other conditions presenting with a red eye are listed in Table 13.1.1. Always enquire about the use of contact lenses or glasses.

Table 13.1.1 Differential diagnosis of the red eye

Normal visual acuity   Conjunctivitis (bacterial, viral, allergic, chemical) Gritty, itchy, injected conjunctiva, discharge Foreign body Pain, grittiness, epiphoria, photophobia Episcleritis Mild pain, localised conjunctival injection Scleritis Severe pain, diffuse conjunctival injection Subconjunctival haemorrhage Consider trauma or pertussis Reduced visual acuity   Corneal abrasion Pain, grittiness, epiphoria, photophobia. Corneal defect seen with fluorescein staining Keratitis Photophobia, epiphoria, ciliary injection, flare in anterior chamber, corneal infiltrate Corneal ulcer Photophobia, epiphoria, corneal injection, flare in anterior chamber, defect on fluorescein staining. History of contact lens use? Anterior uveitis Photophobia, epiphoria, ciliary injection flare in anterior chamber, miosis, posterior synechia

Examination

The approach to the examination of a paediatric eye may differ from that of an adult in that an opportunistic strategy should be taken. Leave touching the child until last, particularly if it will result in fear, pain or discomfort.

Some form of assessment of acuity must be made. In pre-verbal children, assess their ability to fix and follow interesting objects and then reach for them. In older children, monocular testing should be carried out using picture cards, single letter matching or a standard Snellen chart. Use of the slit lamp is not essential for a detailed examination, but even small children may co-operate if they remain seated on their parent’s knees.

If the child is compliant, a logical sequence of examination would be from outside to inside thus:

All drops will sting, except for fluorescein. However, once the pain has subsided, the effects of local anaesthetic may allow for a much more meaningful examination than would otherwise have been possible. If, however, this remains impossible, consideration should be given to examination under anaesthetic.

Eyelid disorders

Disorders of the lacrimal apparatus