Eye examination

Disclaimer

These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline. 

Read the full PCH Emergency Department disclaimer.

Aim

To guide staff in how to perform eye examinations in children.

Key points

  • Perform a full examination on all patients presenting with eye problems and document findings in the patients medical records
  • Discuss all abnormalities with ED Senior Doctor or the on-call Ophthalmologist.

Visual Acuity

  • Must be documented in all children presenting with eye problems
  • Use age appropriate testing method
  • Think significant pathology if:
    • Sudden visual loss or reduced visual acuity
    • Penetrating eye injuries
    • Chemical burns – do not delay irrigation by performing visual acuity testing.

Pupil Examination

  • Record size and direct and consensual response to light
  • Relative Afferent Pupillary Defect = “Swinging flashlight test” – optic nerve injury.

Eye Movement 

  • Check full range of movement and ask about diplopia
  • Look for nystagmus. 

Visual Fields

  • Detailed examination in patients with reduced visual acuity. 

Direct assessment

  • Look for foreign body, inflammation, oedema or discharge
  • Evert upper eyelid to exclude subtarsal foreign body. 

Fundoscopy

  • Perform in a dark room
  • Check red reflex – absence is an abnormal finding (intraocular haemorrhage, cataracts, severe corneal abrasions or scarring)
  • Look for retinal haemorrhages. 

Slit Lamp Examination

  • Allows detailed examination of conjunctiva, cornea and anterior chamber
  • Cannot be used in children under 3 years of age

Fluorescein

  • Shows corneal abnormalities when viewed under blue light
  • Consider herpetic dendrites if an ulcer is present without any history of trauma. 

Surrounding anatomy

  • Eyelid laceration
    • Exclude lacrimal duct trauma
  • Orbit injuries
    • Bruising – exclude globe injury, facial fractures and basal skull fractures
    • Orbit fractures – characterised by restriction of extra ocular movement
  • Periorbital Cellulitis – consider orbital cellulitis if:
    • Reduced visual acuity
    • Proptosis Ophthalmoplegia
    • Red eye.

Bibliography

1. Paediatric Practice Ophthalmology Gregg T Lueder 2011
2. Textbook of Paediatric Emergency Medicine 2nd Edition Cameron Elesevier 2012
3. Nelson Textbook of Pediatrics: 20th Edition Robert M. Kliegman, Bonita M.D. Stanton, Joseph St. Geme, Nina F Schor Publisher: Elsevier


Endorsed by:  Director, Emergency Department   Date:  Mar 2018


 Review date:   Feb 2021


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