FEBRUARY 2021 | VOLUME 18 | ISSUE 2 @Em_RockStars

PEDIATRIC

Emergency Medicine Practice Evidence-Based Education • Practical Application

LEARNING OBJECTIVES:

• What are the typical presenting

signs and symptoms for common
pediatric nontraumatic ocular
complaints?
• Which complaints are clinical
diagnoses and which require
diagnostic studies?
• Which diagnoses require consultation
with ophthalmology and should it be
emergent, urgent, or routine?

Authors
Ammarah Iqbal, MD, MPH

An Evidence-Based
Pediatric Emergency Medicine Fellow, Pediatric
Emergency Department, Yale New Haven Hospital,
New Haven, CT

Melissa L. Langhan, MD, MHS, FAAP

Associate Professor of Pediatrics and Emergency
Approach to Nontraumatic
Medicine; Fellowship Director, Director of Education,
Pediatric Emergency Medicine, Yale University
Ocular Complaints in
School of Medicine, New Haven, CT
Children
Jill Rotruck, MD
Assistant Professor of Ophthalmology and Visual
Science, Yale University School of Medicine, New
Haven, CT n Abstract
Gauthami Soma, MD Children commonly present to emergency departments with
Pediatric Emergency Medicine Fellow, Pediatric eye complaints in the absence of antecedent trauma. Signs
Emergency Department, Yale New Haven Hospital, and symptoms of ocular disease are often nonspecific. Red,
New Haven, CT swollen, or painful eyes may represent benign or vision-threat-
ening processes, making recognition and triage challenging
Peer Reviewers for the emergency clinician. This issue reviews the presenta-
tions of common nontraumatic ocular complaints and provides
Marni Kriegel, MD
Attending Physician, Pediatric Emergency evidence-based recommendations for management in the
Department, Hackensack University Medical Center; emergency department.
Assistant Professor, Department of Pediatrics,
Hackensack Meridian School of Medicine, Clifton, NJ

Jennifer E. Sanders, MD, FAAP, FACEP

Assistant Professor, Departments of Pediatrics,
Emergency Medicine, and Education, Icahn School
of Medicine at Mount Sinai, New York, NY

For online access, scan with your

smartphone camera or QR code reader app:

This issue is eligible for 4 CME credits. See page 23. EBMEDICINE.NET
 Case Presentations
A 6-year-old boy with autism is brought to the ED for swelling of his right eye…
• His mother tells you that he has had thick nasal discharge for the past week and has developed pro-
gressive redness and fullness of his right eye. He is cranky and holding his head in pain.
CASE 1

• The boy's vital signs are: temperature, 39°C (102.2°F); heart rate, 135 beats/min; respiratory rate, 25
breaths/min; blood pressure, 100/80 mm Hg; and oxygen saturation, 98% on room air. Your examina-
tion reveals a tired child with swelling and redness around the right eye. The patient refuses to open his
eyes, and you are unable to perform an ocular examination. The boy’s nasal turbinates are swollen.
• You consider both periorbital and orbital cellulitis in your differential diagnosis and wonder whether the
boy needs emergent imaging.

On a December afternoon, a 4-year-old girl is brought to the urgent care clinic by her mother for red,
matted eyes...
• The mother said she had wiped off the discharge and sent the girl to preschool that morning, but the
CASE 2

girl was sent home promptly. The mother tells you, “The school said she needs antibiotics to return.”
• On examination, the child's vital signs are: temperature, 36.5°C (97.9°F); heart rate, 130 beats/min;
respiratory rate, 24 breaths/min; and oxygen saturation, 98% on room air. The girl has bilateral conjunc-
tivitis with purulent exudate. Her pupils react normally, and she has full extraocular movements.
• You consider the preponderance of viral infections in this age group and wonder whether treatment
with topical antibiotics is appropriate.

A 17-year-old girl presents to the ED with acute left-sided vision loss...

• The girl reports reading on the couch 30 minutes ago when the vision in her left eye suddenly became
blurry. She denies associated pain, headache, fever, or trauma. She recently immigrated to the United
CASE 3

States and reports a distant history of a heart problem that was not corrected.
• On examination, visual acuity in her right eye is 20/20, and in her left eye she has only light perception.
There is a relative afferent pupillary defect in the left eye.
• Given her painless vision loss, you suspect central retinal artery occlusion, and you consider what you
should do first: consult ophthalmology, obtain imaging, or call a stroke code?

n Introduction tions, cataracts, chalazion, choroid, ciliary body,

The emergency department (ED) plays a significant
role in providing acute eye care to children.1,2 More
than 70% of patients presenting to EDs with eye
complaints have nontraumatic eye disease and, of
these, more than 90% are treated and released from
the ED.3 Studies suggest that emergency clinicians
often make inaccurate diagnoses of eye complaints,
especially in the setting of corneal, conjunctival, and
retinal pathologies. Because these processes may ulti-
mately threaten vision, it is important that emergency
clinicians have the skills to appropriately evaluate
and manage eye disease in children. This issue of
Pediatric Emergency Medicine Practice provides an
evidence-based assessment of nontraumatic pediatric
ocular complaints.
n Critical Appraisal of the Literature
A literature search was performed in PubMed using
the following search terms in combination: anterior
chamber, blepharitis, eye, eye diseases, eye infec-
conjunctivitis, cornea, fovea, glaucoma, hordeolum,
hyphema, iris, iritis, Kawasaki, Langerhans cell histio-
cytosis, macula, nasolacrimal, neuroblastoma, ocular,
ophthalmic, optic, pupil, optic nerve, optic neuri-
tis, orbital cellulitis, periorbital cellulitis, pink eye,
posterior chamber, retinal artery occlusion, retinal
detachment, retrobulbar hemorrhage, retinoblas-
toma, rhabdosarcoma, sclera, scleritis, stye, uvea,
uveitis, and vitreous. Studies not available in English/
English translation were excluded. The initial search
yielded 1983 articles; the titles/abstracts of these
articles were manually screened by the authors. Of
the 1983, 388 were ultimately assessed for quality,
and 80 were included. The date range for the articles
was 1970 to 2020. Bibliographies of relevant articles
were searched for additional references; 48 additional
sources were added in this manner.
The majority of results were review articles and
retrospective studies. The available literature also
included case series, case reports, and many interna-
tional studies. There were limited randomized con-

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trolled trials, clinical guidelines, and pediatric-specific
studies. Articles that included only adults were
included if there were insufficient corresponding data
from the pediatric population.
n Eye Anatomy and Vision Development
Eye Anatomy
This review organizes ocular disease by eye anatomy,
progressing from anterior to posterior: extraocular
structures, the anterior segment, and the posterior seg-
ment. (See Figure 1.) The extraocular structures are
the eyelids, conjunctiva, and sclera. The conjunctiva is
a thin mucous membrane that covers the thick, fibrous,
white sclera. Tears are produced by the lacrimal gland
and move across the eye into small punctal openings
in the nasal lid margins to the nasolacrimal duct. The
anterior segment of the eye consists of the cornea, iris,
ciliary body, and lens. Within the anterior segment,
the anterior chamber is the space between the cornea
and the anterior iris, while the posterior chamber is the
space between the posterior iris and the vitreous. The
anterior and posterior chambers are filled with aque-
ous humor. Behind the anterior segment is the pos-
terior segment, which includes the vitreous, choroid,
retina, and optic nerve. The retina translates light into
electrical impulses, which are propagated by neurons
to the brain’s visual cortex for interpretation.4
Vision Development
Understanding the process of visual development is
a key aspect of pediatric eye care. At birth, the visual
acuity of a newborn is approximately 20/400. Over
the first months of life, the anatomic structures of the
eye and the neuro-ocular pathways develop rapidly.5
Figure 1. Anatomy of the Human Eye
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By 2 months, infants should be able to visually fixate
and follow. By 4 months, infants should track and
focus as well as fixate. Visual acuity is expected to be
20/50 by age 1 year and 20/20 around age 2 years.
Visual development is completed around age 9.6 Until
the visual system is mature, anything that decreases
vision (refractive error, strabismus, obstruction of the
visual axis) can cause amblyopia.
n Differential Diagnosis
Patients may present with ocular complaints that do
not stem from the eye. See Table 1, page 4 for a list of
the most common etiologies and associated present-
ing symptoms of nontraumatic eye complaints.
n Prehospital Care
Prehospital care for patients with ocular complaints
should include gross visual acuity and pupil evaluation,
which may facilitate subspecialty involvement on arrival
to the hospital. Patients with a history of trauma should
have an eye shield placed. Consideration should be
given as to whether the eye complaint originates in the
eye, or whether it is caused by systemic disease (eg,
toxidrome or neurologic disease). If an external pro-
cess (eg, toxidrome) is present, consider whether other
people on the scene were affected.
n Emergency Department Evaluation
History
A thorough history should be obtained, including
the onset, sequence, and duration of symptoms,
with a focus on the presence of monocular or bin-
ocular symptoms, ocular pain, discharge (eg, clear,
purulent, hemorrhagic), pruritus, photophobia,
and visual changes. Older children may be able to
describe photopsias such as flashes or floaters. At-
tention should then be given to associated systemic
symptoms including fever, headache, emesis, and
rash. Histories of sick contacts, recent trauma, previ-
ous similar episodes, previous evaluations by eye
specialists, need for corrective lenses (glasses or
contact lenses), and history of eye surgery should
be obtained. Medication history (including home
remedies) may also be helpful to understand risk fac-
tors as well as mitigating factors.11-13 Review of past
medical history, including history of prematurity,
presence of systemic illnesses or immunocompro-
mise, and vaccination status is important.
Physical Examination
Challenges and Suggestions for the Ocular
Examination of the Pediatric Patient
Children may be frightened by an eye examination.
Young patients are soothed by caregivers, who should
remain nearby. The examination should proceed
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from the least confrontational portions (observation,
corneal light reflex, visual acuity) to the most confron-
tational portions (Woods lamp, slit lamp). Much can
be assessed at a distance. Distraction, such as the use
of video, can be helpful.14 Transient complaints may
have been photographed or filmed by families on
personal smartphones and are a useful adjunct.
Neonatal vision is assessed by the presence of
blinking or eyelid squeezing in lighted settings. Eye
opening can be challenging to elicit in infants. Help-
ful techniques include dimming the lights, rocking,
gently lowering the head below the body, or having
the parent hold the patient upright over his/her shoul-
der.6 For children who are able to fixate and track,
the emergency clinician can use an object of interest,
such as a face, to aid in assessment. Emergency clini-
cians should strive to perform the examination but
limit harm to the patient. Occasionally, adjuncts and/
or sedation may be useful.
Topical Anesthetics
Topical anesthetic drops are useful to decrease eye
pain and facilitate cooperation with the examina-
tion.15 Studies have shown improved assessment of
visual acuity with their use. Proparacaine hydrochlo-
ride (0.5%) and tetracaine hydrochloride (0.5%) are
both effective topical anesthetics in the acute set-
ting.16,17 Topical anesthesia has diagnostic utility as
well. Relief of pain with topical anesthesia occurs in
conjunctival or corneal surface processes rather than
from deeper pathologies such as iritis.6
Initial Examination
The physical examination should proceed stepwise,
with assessment of ocular function and structure,
proceeding from external structures toward internal
structures. Table 2, page 5 provides an outline for
complete ocular examination. Much of the exami-
nation may be limited by patient cooperation and
developmental stage. Table 3, page 6 lists common
abbreviations that may be encountered in ophthal-

Table 1. Etiologies of Nontraumatic Eye Complaints7-10

Presenting Symptom Ocular Etiologies
Red eye • Keratitis
• Episcleritis/scleritis
• Conjunctivitis
• Subconjunctival hemorrhage
• Corneal abrasion (occasionally)
• Hyphema
• Anterior uveitis
Photophobia • Anterior uveitis
• Ocular surface irritation
Diplopia • Ocular motility disorders
(strabismus)
Eye swelling • Chalazia/hordeola
• Dacryocystocele
• Periorbital cellulitis
• Orbital cellulitis
Vision loss/changes • Cataracts
• Glaucoma
• Posterior uveitis
• Vitreous hemorrhage
• Retinal detachment
• Retinoblastoma
• Retinal artery occlusion
• Orbital hemorrhage
• Optic neuritis
Miosis • Anterior uveitis
• Postsurgical pupil
Mydriasis • Postsurgical pupil
Nonocular Etiologies
• Dermatologic diseases (eg, Stevens-Johnson syndrome, toxic epidermal
necrolysis, erythema multiforme, Mycoplasma pneumoniae-induced rash and
mucositis)
• Kawasaki disease
• Cat-scratch disease
• Ocular toxocariasis
• Toxoplasmosis
• COVID-19
• Zika virus disease
• Migraine
• Intracranial hypertension
• Primary cranial nerve pathologies
• Myasthenia gravis
• Phencyclidine (PCP) ingestion
• Neuroblastoma (opsoclonus-myoclonus)
• Cavernous sinus thrombosis
• Infantile hemangioma
• Dermoid cyst
• Thyroid orbitopathy
• Malignancy (eg, rhabdomyosarcoma, orbital neoplasm)
• Complex migraine
• Intracranial hypertension
• Cerebral vascular accident
• Methanol
• Homocystinuria
• Marfan disease
• Toxoplasmosis
• Multiple sclerosis
• Opioids
• Organophosphates
• Stimulants
• Anticholinergics
• Hyperthyroidism

Note: This list is not exhaustive.

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mologic documentation. In addition to the ocular
examination, a thorough neurologic examination and
palpation for sinus tenderness are warranted. Vital
signs should be obtained.
External Inspection
The presence of spontaneous eye opening should be
noted. Evaluate for extraocular erythema, edema, and
drainage. A baseline photo from the caregiver can
provide a comparison to clinical findings.
Ideally, the patient should be coaxed to open the
eyes voluntarily, if not spontaneously. Play improves
the chances of cooperation. If the child cannot open
their eyes spontaneously, the confrontational portion
of the examination should be deferred to the end. If
necessary, eyelid retractors or the fingers can be used
to spread the eyelids to assess the eye. Rarely, seda-
tion is necessary.
The emergency clinician should pay attention to
the presence and location of conjunctival injection.
The cornea should be examined for enlargement,
opacification, or aniridia.19 The eyelids should be
examined externally and internally for changes or
foreign bodies. Gentle retraction with avoidance of
direct eye pressure is appropriate. Eyelid retractors
or a cotton swab may be used. The cotton swab can
be placed on the external surface of the lid and the
lashes can be gently grasped to pull the lid over the
cotton swab. Alternatively, the swab can be rolled to
expose the palpebral conjunctiva.6
Pupillary Response
The pupillary response assesses the integrity of the
neurologic visual system. Identify pupillary asym-
metry and presence of and time to reactivity, noting
whether the patient has baseline anisocoria. A relative
afferent pupillary defect refers to an abnormal pupil-
lary response to light in an affected eye as compared
to a nonaffected eye. A “swinging flashlight” test may
be used. When light is shone on the affected eye, the
pupil may constrict appropriately but when the light
is shone on the unaffected eye, the affected eye may
pathologically dilate or fail to constrict appropriately.
This pathologic response can indicate abnormality of
the optic nerve or afferent pathways.20 An ophthal-
moscope can be useful to look through the aperture
during the examination to get a magnified view of the
surface structures.
Extraocular Movements
To assess extraocular eye motility for each eye, a finger
or interesting object should be moved in the shape of
the letter “H”. If the patient prefers to fixate on a face,
the emergency clinician or caregiver may move their
face in the specified directions. Alternatively, gently
hold the patient’s head and move it around.
Visual Fields
Visual field deficits should be assessed by presenting
an object of interest in all 4 directions (supratemporal,
infratemporal, supramedial, inframedial) for each eye.
A verbal child may be able to say when the object is
visible. Many nonverbal children will look toward a

Table 2. Ocular Examination18

Examination Assess/Findings Age

Initial Examination
External inspection • Spontaneous eye opening All ages
• Eyelids, eyelashes, lacrimal system, periorbital soft tissue, (evaluate for
erythema, edema, asymmetry), gross evaluation of the globe
• Conjunctival abnormalities
• Corneal and iris abnormalities
Pupillary examination • Irregular shape, asymmetric size, and reaction to light All ages

Ocular motility • Fix and follow >3 months

• Extraocular motion and associated discomfort
Visual fields • Peripheral vision >3 months
Visual acuity • Document type of vision chart used and associated results 3-4 years
Instrument-Based Examination

Ophthalmoscopy • Red reflex All ages

• Optic disc and vessels ≥3 years (pending cooperation)

Woods lamp • Fluorescein staining All ages

Slit lamp • Document additional examination findings of the external and internal structures ≥3 years (pending cooperation)
of the eye that are not visible on gross visualization; include any cells that are
visualized within the anterior chamber
Tonometry • Intraocular pressure measurement All ages

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moving object when it comes into view. Failure to do asking the patient to count fingers at a distance of 2
so in a quadrant suggests a visual-field defect. feet or recognize hand motion or light. Discrepancy
in visual acuity between the eyes is concerning and
Visual Acuity warrants formal ophthalmologic assessment. By age 2,
Visual acuity assessment is essential. The patient visual acuity should be close to 20/20.6
should wear prescribed corrective lenses unless contra-
indicated, given the suspected diagnosis. A letter chart Instrument-Based Examination
can be used for children who are literate. For children Ophthalmoscopy
who cannot read, the preferred charts are the LEA An ophthalmoscope is useful to assess posterior
Symbols test (see Figure 2) or the HOTV Matching chamber and posterior segment pathology through
Chart.18 Emergency clinicians should abide by speci- evaluation of the red reflex and optic fundoscopy.
fied light and distance recommendations.21 Each eye Ophthalmoscopy is optimized by pupillary dilation,
should be tested individually. To ensure this, options which is facilitated by dimming the room lights, using
include patching or covering by a hand-held cover. A a smaller disc of light, or dilating drops.22 Of note,
child’s objection to the covering of 1 eye may indicate pupillary dilation is contraindicated in patients with
asymmetric fixation preference and suggest an acuity closed-angle glaucoma or globe rupture.23,24 The
discrepancy. A more rudimentary assessment involves panoptic ophthalmoscope is used in many emer-
gency settings and may facilitate visualization of the
optic nerve.
The red reflex is an essential aspect of the physi-
Table 3. Common Abbreviations in
cal examination. The examiner should stand at arms
Ophthalmologic Documentation length from the patient and look through a direct
Abbreviation Definition ophthalmoscope while aiming directly at the pupils.
Past History  Visualization of both eyes simultaneously is necessary
POH Past ocular history
for comparison. The reflex will appear a symmetrical
shade of red as the result of reflection from the cho-
Eye Examination
roid pigment.22,24 In children who cannot cooperate
VA Visual acuity with the examination, the emergency clinician can ask
CC: With correction
the caregiver to take a picture of the patient with the
SC: Without correction
eyes open (the red-eye feature should be turned off,
T Tonometry
and the flash turned on).25
IOP Intraocular pressure An abnormal red reflex warrants further urgent
EOM Extraocular movement evaluation by a pediatric ophthalmologist. Asymmet-
ET Esotropia ric reflex, where one eye appears brighter than the
other, may indicate refractive error or strabismus. A
XT Exotropia
black reflex may suggest a corneal defect, hyphema,
OD Ocular dexter (right eye)
or vitreous hemorrhage. A white pupillary reflex
OS Ocular sinister (left eye)
OU Ocular uterque (both eyes)
APD Afferent pupillary defect
Figure 2. LEA Symbols
Slit-Lamp Examination
SLE Slit-lamp examination
WNL Within normal limits
W&Q White & quiet (normal)
D&Q Deep & quiet (normal)
C/F Cell/flare
Dilated Fundus Examination
DFE Dilated fundus examination
S/F/P Sharp/flat/pink (normal)
FR, FLR Foveal reflex, foveal light reflex (normal in pediatric
patients)
CWS Cotton wool spots
M1%, N.25% Typical dilating drops (tropicamide and
phenylephrine)

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(leukocoria) can be seen in patients with cataracts,
congenital corneal opacity, or retinoblastoma.25 The
presence of a large red reflex may indicate the pres-
ence of iritis, aniridia, coloboma, or a systemic effect
(eg, drug use) causing asymmetric miosis.5
An ophthalmoscope also allows for visualization
of the optic vessels and disc. The examiner should
approach the patient from the same side as the eye
being examined. If possible, children should fixate on
a target. The emergency clinician should look through
the aperture of the ophthalmoscope, identify the red
reflex from 3 to 5 cm away, and then move closer to
the patient. A blood vessel within the location of the
red reflex should be identified first and then that ves-
sel traced centrally to the optic disc. For the patient
who cannot fixate on an object, the emergency clini-
cian can set up similarly and wait for the vessels to
come into view as the patient moves his/her eyes.13,24
Failure to visualize the optic disc is a common
reason for ophthalmologic consultation in the ED.26
As with other aspects of the ocular examination,
purposeful distraction can be helpful. Distraction
with a video has been shown to assist fundoscopy in
children as young as 2 years old.14 New technologies
such as ocular fundus or panoptic ophthalmoscopy
may be available for improved visualization.27,28
Slit Lamp
In a cooperative patient who is able to follow di-
rections, a slit lamp can be used for a focused and
magnified examination of the external and internal
structures of the eye. This aspect of the examination
should be performed by clinicians who are comfort-
able using a slit lamp.
Tonometry
A tonometer is useful to assess for the presence of
increased intraocular pressure (eg, glaucoma). Most
commercially available tonometers involve touching
the tip to the surface of the cornea and assessing for
changes in pressure. Normal intraocular pressure is 10
to 21 mm Hg. Given the limitations of the equipment,
multiple measures should be taken and averaged.
Topical anesthesia can decrease discomfort prior to ex-
amination. Sedation may be needed in select cases.29
n Diagnostic Studies
Fluorescein Dye
Application of fluorescein dye to the eye is useful to
assess for corneal surface defects. A saline or topi-
cal anesthetic drop can be applied to the fluorescein
strip, and that drop can be positioned to drain into
the eye. Combination preparations of dye and anes-
thetic also exist. Alternatively, the moistened fluores-
cein strip can be touched gently to the eye surface.
Blinking distributes the fluorescein. A Woods lamp or
cobalt blue filter causes areas of fluorescein uptake
to appear yellow to green.12 This can be used for
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diagnosis of corneal abrasions or ulcers, keratitis, and
occasionally foreign bodies.
Infection Testing
Ocular-surface Gram stain or culture is rarely help-
ful.30 Rare indications include suspected neonatal
conjunctivitis, hyperacute conjunctivitis, or herpes
simplex virus keratitis. Surface Gram stain and surface
culture may be considered after inadequate response
to empiric therapy for clinical diagnoses or for severe
or recurrent processes.6,30 Viral polymerase chain
reaction (PCR) nasopharyngeal testing may be helpful
in decreasing unnecessary antibiotic use in cases of
conjunctivitis.
Imaging Studies
Ultrasound
Ocular point-of-care ultrasound may be useful to
detect abnormalities in the lens, vitreous, retina,
and optic nerve.31-36 For papilledema, ultrasound
is highly sensitive (100%; 95% confidence interval
[CI], 84%-100%) and poorly specific (31.9%; 95% CI,
23%-41.7%), which are similar to test characteristics
of ophthalmoscopy.37 Papilledema can be diagnosed
by assessing for optic disc elevation and/or widened
optic nerve sheath diameter.38,39
To obtain ultrasound images, the patient is po-
sitioned supine in a position of comfort. A transpar-
ent dressing is applied over the closed eye. A large
amount of gel is placed on the dressing, over which
a high-frequency linear transducer is applied. This
allows for minimal pressure on the globe. Images
should be obtained in both transverse and longi-
tudinal orientations. The sonographer can use the
cheek or forehead of the patient to stabilize the
hand. The patient should be advised to close their
eyes and look ahead. The fluid-filled anterior cham-
ber and vitreous humor provide a good acoustic
window to view the structures of the eye. Ocular
ultrasound is contraindicated when globe rupture
or high intraocular pressure is suspected, as pres-
sure on the eye can cause further injury. See Figure
3, page 8 for a labeled description of a normal eye
ultrasound. Following the ALARA principle (as low
as reasonably achievable), color flow and Doppler
mode should be avoided in ocular point-of-care
ultrasound to minimize thermal and mechanical
indices and theoretical risk of tissue damage.36
Computed Tomography Scan
Computed tomography (CT) is a common imaging mo-
dality of choice in the emergent setting. For suspected
orbital cellulitis, a contrast-enhanced CT scan of the
orbits and sinuses assesses for the extent of disease
and complications. CT is otherwise rarely indicated for
nontraumatic ocular complaints without discussion with
an ophthalmologist.
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Magnetic Resonance Imaging
Magnetic resonance imaging (MRI) may be useful
when neurologic abnormalities are suspected, but the
cost, availability, and length of the procedure pose
challenges. MRI may be useful to assess for malig-
nancy, optic nerve inflammation, congenital lesions,
infection, or hypertensive encephalopathy.40,41 It
should be considered for patients with vision changes
that last >1 hour without complete resolution, espe-
cially if accompanied by pupil abnormalities or limited
eye movements.41 For patients with orbital cellulitis
and neurologic deficit when intracranial abscess or
cavernous sinus thrombosis is suspected, MRI/mag-
netic resonance venography/magnetic resonance
angiography is the gold standard.42
n Disease-Specific Management
Extraocular Diseases
Periorbital Cellulitis
Periorbital cellulitis is an infection of the skin and soft
tissues surrounding the orbit. Minor local trauma (eg,
insect bites, scratches) can serve as a nidus for infec-
tion. Responsible pathogens include Staphylococcus
aureus and Streptococcus pyogenes. Examination is
notable for periorbital erythema and edema, without
associated ocular manifestations or systemic signs (eg,
fever).6 Laboratory studies and imaging are not neces-
sary for this diagnosis. Treatment for periorbital cel-
lulitis is outpatient oral antibiotics that cover the likely
pathogens. Suggested antibiotic choices include oral
third-generation cephalosporins such as cefdinir.
Figure 3. Ultrasound of the Eye, With
Normal Anatomy Indicated
Image used with permission of Yale Department of Pediatrics, Section of
Pediatric Emergency Medicine.
FEBRUARY 2021 • www.ebmedicine.net 8
Orbital Cellulitis
Orbital cellulitis is a far more serious condition than
periorbital cellulitis.43 It results from direct extension
of sinus disease.6,44 Data available from case series
suggest that the most common pathogens include
the Streptococcus anginosus group, followed by S
aureus, S pyogenes, Streptococcus pneumoniae, and
Haemophilus influenzae.42,43,45,46 Case studies also
suggest that orbital cellulitis may result from contigu-
ous spread from an odontogenic focus.47 There are
no conclusive data that orbital cellulitis can result
from periorbital cellulitis. Mucormycosis may cause
orbital cellulitis in immunocompromised patients. Be-
cause the venous drainage system of the orbit tracks
intracranially and lacks valves, there is an increased
risk of intracranial sequelae after orbital cellulitis.11,43
In addition to soft-tissue edema, erythema, and
tenderness, examination findings in orbital cellulitis
may include conjunctival chemosis and injection,
pain on extraocular movement, limited mobility of
the eye, proptosis, decreased vision, and signs of
optic neuropathy. Up to two-thirds of patients have
fever.1 Complications of orbital cellulitis may be
vision- or life-threatening. They include—but are
not limited to—intraorbital abscess, subperiosteal
abscess, optic neuropathy, meningitis, and cavern-
ous sinus thrombosis. In one study, the likelihood of
abscess in patients with orbital cellulitis was 12%.48
Using retrospective data via a preliminary decision
rule, authors found that while painful or restricted eye
movements and proptosis may suggest the presence
of a subperiosteal orbital abscess on CT scan, these
signs are not sensitive and are absent in up to 50%
of pediatric patients with an abscess.48,49 Additional
risk factors for a subperiosteal abscess include age ≥3
years, previous antibiotic therapy, presence of edema
that extends beyond the eyelid, absence of infectious
conjunctivitis, and peripheral white blood cell count
>10,000/mcL.48
Contrast-enhanced CT scan of the orbits may
assist in the diagnosis of orbital cellulitis. However, it
is suggested that the primary role of CT is in iden-
tification of complications that may require surgical
drainage.48 Figure 4, page 9 shows orbital cellulitis
with associated subperiosteal abscess on CT.
There are no randomized trials evaluating anti-
biotic regimens for orbital cellulitis. Empiric therapy
should target typical skin and sinus pathogens. If
there is concern for intracranial extension, the an-
tibiotic should have adequate cerebrospinal fluid
penetration. While there are no published guidelines,
current practices include a single-agent regimen such
as intravenous (IV) ampicillin-sulbactam or third-gen-
eration cephalosporins. Metronidazole or clindamycin
may be added for anaerobic coverage.46 Vancomycin
may be added if methicillin-resistant S aureus is sus-
pected, based on risk factors and community preva-
lence. Some evidence supports the addition of corti-
©2021 EB MEDICINE
costeroids to decrease the duration of symptoms; this
decision should be made with ophthalmology.50,51
While <15% of patients will ultimately require
surgical intervention, it is important to identify those
who may benefit. As such, an ophthalmologist should
be involved in the care of all patients with concern for
orbital cellulitis.52,53 In cases with suspected sinus in-
volvement, otolaryngology involvement is indicated.
When there is suspected central nervous system ex-
tension, the patient should be transferred to a tertiary
care center urgently, where pediatric ophthalmology,
otolaryngology, and neurosurgery are available.
Blepharitis
Blepharitis refers to the inflammation of the eyelid
margin, frequently secondary to bacterial colonization.
The diagnosis of blepharitis is based on examination
findings such as the presence of flaking and crusting
at the lash base (anterior blepharitis) and Meibomian
gland clogging and irritation (posterior blepharitis).
There may be associated corneal irritation, reactive
conjunctivitis, or chalazion. Treatment includes use of
warm compresses and daily washing of the area.12
Hordeola and Chalazia
A hordeolum (stye) is an acute infection of an oil
gland, either the glands of Zeis within the hair follicle
(external hordeolum) or a Meibomian gland posterior
to the eyelashes (internal hordeolum). Staphylococcal
Figure 4. Right-sided Subperiosteal
Abscess in the Setting of Orbital Cellulitis
on Computed Tomography
Reprinted from Saudi Journal of Ophthalmology, Volume 25, Issue 1.
Seongmu Lee, Michael T. Yen. Management of preseptal and orbital
cellulitis, Pages 21-29. Copyright 2011 King Saud University, with
permission from Elsevier.
GROUP SUBSCRIPTIONS: groups@ebmedicine.net
species are the most common cause. A chalazion is
due to a blockage of a Meibomian gland, inciting an
inflammatory response. The inflammation can be-
come chronic and granulomatous. A chalazion is not
itself an infection; however, it often begins as a hor-
deolum. They may become irritated or superinfected.
Hordeola and chalazia are both characterized
by localized nodular swelling adjacent to the eyelid
margin. Hordeola tend to be more erythematous and
painful (Figure 5), whereas chalazia are typically less
painful (Figure 6).
While they are typically self-limited, recommended
treatment for both hordeola and chalazia includes
warm compresses and massage to help relieve ob-
struction of the gland and encourage the contents
to drain. Limiting the use of eye makeup and contact
lenses is advised. Given the infectious nature of horde-
ola, it is necessary to note that, while trials are lacking,
oral antibiotics are typically not indicated. Additionally,
data regarding the efficacy of topical antibiotics is in-
conclusive.54,55 For both conditions, failure to improve
warrants referral for possible incision and drainage.13
Figure 5. Hordeolum
Figure 6. Chalazion
9 © 2021 EB MEDICINE. ALL RIGHTS RESERVED.
Lacrimal System Diseases
Nasolacrimal duct obstruction is most often con-
genital (dacryostenosis) and results from incomplete
development of the nasolacrimal duct system. It is
present in up to 6% of newborns. In patients with
this condition, the distal portion of the duct is incom-
pletely canalized at birth, prompting the symptoms.
(See Figure 7.) Obstruction of the draining nasolac-
rimal duct and the canaliculi can prompt formation
of a dacryocystocele. Patients with dacryocystoceles
should be referred to an ophthalmologist, due to the
significant risk of infection, dacryocystitis, and nasal
obstruction leading to respiratory compromise.56
Dacryostenosis often presents with unilateral
tearing and discharge. Because tear production may
not develop fully until 2 months of life, the onset of
symptoms may occur later after birth. The diagnosis
is based on the history and examination.57 Dacryo-
cystocele is seen as a bluish swelling in the area of
the nasolacrimal duct. (See Figure 8.) Imaging or
additional studies are not routinely indicated for
the diagnosis of dacryostenosis or dacryocystocele.
However, when dacryocystocele is suspected, a
Figure 7. Nasolacrimal Duct Anatomy
Reprinted from Zitelli and Davis' Atlas of Pediatric Physical Diagnosis,
7th Edition. Basil J. Zitelli, Sara C McIntire, Andrew J Nowalk, eds.
Copyright 2018, with permission from Elsevier.
FEBRUARY 2021 • www.ebmedicine.net 10
nonemergent CT scan may be recommended by the
consulting surgeon, to better define anatomy and to
assist with surgical planning.58 It is estimated that up
to 67% of cases of dacryostenosis resolve spontane-
ously by 6 months and 90% by 12 months. Conserva-
tive management is recommended for all patients,
which includes massage of the nasolacrimal fold and
warm compresses. Probing of the lacrimal system may
be considered as early as 6 months or delayed to 1
year of age, depending on the severity of symptoms.
A dacryocystocele should be managed urgently by
an ophthalmologist and may involve probing of the
nasolacrimal system.
Dacryocystitis refers to infection within the
lacrimal system. It is a rare complication of nasolac-
rimal duct obstruction; it is also a rare complication
of periorbital cellulitis after facial trauma. Typical
pathogens include skin flora, such as Staphylococ-
cus epidermidis, and S aureus, as well as additional
pathogens such as S pneumoniae, H influenzae,
and Pseudomonas aeruginosa.59,60 Complications
include orbital cellulitis and subsequent sequelae.58
Dacryocystitis should be considered if redness,
swelling, tenderness of the lacrimal sac, or purulent
discharge from the eye are present on examina-
tion.61 When dacryocystitis is suspected, it is rec-
ommended that the discharge be expressed and a
culture sent.61 Ophthalmology should be consulted
emergently, and systemic antibiotics are indicated.61
Dacryoadenitis is an inflammation or infection
of the lacrimal gland itself, and it can be acute or
chronic in nature. Acute cases stem from inflamma-
tory diseases and a variety of pathogens, including
viruses, bacteria, and fungi. In children and young
adults, the majority of dacryoadenitis cases are viral in
origin, but other causes must be considered.
Figure 8. Dacryocystocele
Dacryostocele: Bluish-colored, firm, nonmobile cyst seen below the
medial canthal tendon.
Reprinted from Fanaroff and Martin's Neonatal-Perinatal Medicine,
11th edition. Faruk H. Örge. Examination and common problems in the
neonatal eye. Pages 1934-1969. Copyright 2020, with permission from
Elsevier.
©2021 EB MEDICINE
Conjunctivitis
Conjunctivitis refers to inflammation of the conjuncti-
va and is characterized by dilation of the conjunctival
blood vessels, prompting hyperemia and, occasional-
ly, discharge. The presentation of conjunctivitis varies
by age, season, and method of transmission.
Neonatal Conjunctivitis
Neonatal conjunctivitis is often secondary to infection,
with etiologies including Chlamydia trachomatis, Neis-
seria gonorrhoeae, and herpes simplex virus.62 These
are usually acquired by exposure during passage
through the mother's genital tract at birth. Chlamydia
is the most common infectious agent that causes
conjunctivitis. Chlamydial conjunctivitis typically pres-
ents at 5 to 14 days of life. Gonococcal conjunctivitis
represents <1% of cases of neonatal conjunctivitis and
presents at 2 to 5 days of life. Neonatal herpetic eye
disease is rare and typically presents between 6 and
14 days of life. Other causes of neonatal conjunctivitis
are typical bacterial organisms such as Staphylococcus
and Streptococcus species.
Infants with chlamydial conjunctivitis often have
a mild conjunctivitis with associated white, stringy
discharge. It may be associated with pneumonia, but
this typically occurs after the conjunctivitis by weeks
to months. Gonococcal conjunctivitis typically causes
copious mucopurulent discharge and severe injection;
it may lead to rapid corneal ulceration and perfora-
tion. Herpes simplex virus typically presents as a mild
conjunctivitis and possible keratitis, and there may be
vesicular lesions on the skin.
Superficial cultures are recommended for all
cases of neonatal conjunctivitis. In cases of suspected
chlamydial conjunctivitis, nasopharyngeal cultures
should be obtained to evaluate for associated chla-
mydial pneumonitis,63 in addition to cultures from the
palpebral conjunctiva for confirmation of the diag-
nosis. Imaging is not routinely indicated. The Ameri-
can Academy of Pediatrics Committee on Infectious
Diseases recommends that all infants with suspected
gonococcal disease be evaluated for disseminated
infection, as it may involve the blood, cerebrospinal
fluid, and joint fluid.62 Thus, a full septic workup,
including blood tests and a lumbar puncture, is
strongly recommended. In cases of suspected herpes
simplex virus conjunctivitis, evaluation for dissemi-
nated herpes simplex virus is imperative, including
superficial swabs of the eye and skin, and blood and
cerebrospinal fluid herpes simplex virus PCR tests.
In the neonate, chlamydial conjunctivitis is treated
with oral erythromycin. Gonococcal conjunctivitis is
treated with copious saline irrigation and IV ceftriax-
one. Ceftriaxone administration in neonates requires
caution and monitoring. It is the medication of choice
in gonococcal disease, but otherwise avoided in the
neonatal period due to the possibility of ceftriaxone-
associated hyperbilirubinemia in this age group.
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Monitor the patient's clinical status and serum biliru-
bin levels during therapy. The duration of ceftriaxone
treatment is determined by the extent of systemic
involvement. Treatment for neonatal herpes simplex
virus is IV acyclovir; duration depends on the extent
of systemic involvement.64 Topical corticosteroids are
not indicated.64,65 Suspected gonococcal or herpes
conjunctivitis warrants admission for IV antimicrobials.
Childhood Conjunctivitis
Childhood conjunctivitis can be divided into infec-
tious or noninfectious processes. In the pediatric
population, infectious conjunctivitis is most commonly
bacterial (50% to 75% of cases); however, the pre-
dominance of viral infections increases with age.66-68
Though childhood conjunctivitis is a clinical diagnosis
based on the history and physical examination, clini-
cians are poor at distinguishing between etiologies.
Meltzer at al created a clinical decision rule to risk
stratify those more likely to have a nonbacterial source
or a negative bacterial culture; these patients include
those who: (1) are aged ≥6 years; (2) present in April
to November; (3) have absence of watery discharge;
and/or (4) absence of “glued” eye in the morning. The
probability of a negative bacterial culture in patients
with all 4 predictors is 92.3% (95% CI, 66.1%-98.2%).67
Pruritus and prior conjunctivitis also make bacte-
rial conjunctivitis less likely.69 Gonococcal or chla-
mydial conjunctivitis should be suspected in cases in
adolescents in whom symptoms last >7 days or those
who do not respond to typical therapy. Hyperacute
conjunctivitis should be suspected in cases of sud-
den, severe mucopurulent discharge. In all cases of
conjunctivitis, corneal involvement should be suspect-
ed if there is severe itching or redness, conjunctival
chemosis, or photophobia.30 In the case of allergic
conjunctivitis, erythema and pruritus are typical.
For suspected childhood conjunctivitis, cultures
of the eye are not recommended routinely. Addi-
tional testing or imaging is also not recommended
routinely. For suspected hyperacute conjunctivitis in
older adolescents, conjunctival scrapings for Gram
stain and/or PCR can be used to diagnose gonococ-
cal conjunctivitis.70
Occasionally, topical corticosteroids may be
indicated, but this decision should always be made
in consultation with an ophthalmologist.30 In cases
of suspected corneal involvement with conjunctivitis,
ophthalmology should be consulted.30
Bacterial Etiologies
Associated bacterial pathogens include H influenzae,
S pneumoniae, S aureus, and Moraxella catarrhalis.
H influenzae has been implicated in otitis-conjuncti-
vitis syndrome, causing simultaneous conjunctivitis
and acute otitis media.71 Hyperacute conjunctivitis
with severe mucopurulent discharge should raise
suspicion for gonococcal or chlamydial conjunctivi-
11 © 2021 EB MEDICINE. ALL RIGHTS RESERVED.
tis, which is increasingly common among sexually
active young people.66,70 Complications include
keratitis or ocular perforation.
Although childhood conjunctivitis is typically
self-limited, antibiotic eye drops can decrease the
duration of symptoms in bacterial conjunctivitis.72
There are many appropriate topical agents. In otitis-
conjunctivitis syndrome, oral antibiotic therapy is
recommended (eg, amoxicillin-clavulanate). In cases
of hyperacute conjunctivitis, treatment should be
specific to the suspected pathogen. Suspected gono-
coccal conjunctivitis in adolescents should be treated
systemically with azithromycin and ceftriaxone, and it
requires emergent ophthalmology evaluation.73
Viral Etiologies
Viral pathogens are implicated in 30% to 50% of
pediatric conjunctivitis cases.66-68 Adenovirus is the
most common and is the cause of pharyngoconjunc-
tival fever, a phenomenon in which viral conjunctivitis
occurs together with fever and pharyngitis. Adenovirus
is also implicated in epidemic keratoconjunctivitis, a
highly contagious keratoconjunctivitis that causes out-
breaks. Of note, rhinovirus, enterovirus, and influenza
virus may also cause viral conjunctivitis.74 In cases of
suspected viral conjunctivitis, treatment is supportive
care.68 In suspected outbreaks of epidemic kerato-
conjunctivitis, aggressive cleaning and disinfection
protocols should be put in place. Personal protective
equipment should be used by the clinician.74
Noninfectious Etiologies
Allergic conjunctivitis is the most common noninfec-
tious etiology of conjunctivitis. It often results from ex-
posure to environmental antigens (eg, animal dander)
or, more commonly, seasonal antigens (eg, pollen). For
cases of suspected allergic conjunctivitis, treatment
should include avoidance of the offending agent, if
possible. Topical antihistamines and mast cell stabiliz-
ers have been shown to be effective.75 Chilled artifi-
cial tears can facilitate manual dilution and removal of
the antigen and bring symptomatic relief.
Subconjunctival Hemorrhage
Subconjunctival hemorrhage refers to bleeding in the
subconjunctival space after rupture of a conjunctival
capillary. While most cases are a result of trauma, it
also can occur as a result of increased pressure from
coughing or Valsalva, and as a complication of infec-
tious conjunctivitis. In cases without trauma, it is im-
portant to consider an underlying bleeding disorder.
Cases may be idiopathic in nature.76 Alternatively,
nonaccidental trauma should also be considered.77
Patients with subconjunctival hemorrhage typi-
cally present with findings of 1 or more focal red
areas notable on the ocular surface. These patients
are often asymptomatic but may present with a “for-
eign body” sensation. Examination findings consist of
FEBRUARY 2021 • www.ebmedicine.net 12
localized blood in the subconjunctival space without
vision changes or pain.
Management is expectant, as isolated subcon-
junctival hemorrhages typically heal without compli-
cations. Ophthalmology may be consulted electively
in the case of recurrent subconjunctival hemorrhage.
Episcleritis and Scleritis
Episcleritis is inflammation of the episclera (the layer
between the sclera and the conjunctiva) and is usually
idiopathic. Scleritis is inflammation of the sclera and
is uncommon in children. Limited pediatric literature
exists, but in adults, up to one-third of patients with
scleritis may have an associated autoimmune or con-
nective tissue disease.78 Scleritis may also be associ-
ated with infection, atopy, rosacea, and neoplastic
masquerade syndromes. While the risk of vision loss
in episcleritis is minimal, scleritis carries a significant
risk of vision loss if untreated.79
Children with episcleritis complain of eye water-
ing with diffuse erythema. While difficult to distin-
guish from conjunctivitis, episcleritis is often more
painful (rather than “irritated”), and patients may
have tenderness to ocular palpation.12 Pain tends to
be milder in episcleritis compared to scleritis. Scleritis
often presents with significant, often boring pain and
redness of the eye. These patients also often have
significant tenderness to palpation and may have a
bluish discoloration to the eye.12 In both cases, exam-
ination is notable for redness of the eye and pain, and
examination may reveal changes in visual acuity.
Episcleritis may resolve spontaneously but may
require topical corticosteroids.79 Treatment of scleritis
should always be performed in conjunction with oph-
thalmology and will depend on the underlying etiology
and often includes nonsteroidal anti-inflammatory drugs
(NSAIDs), corticosteroids, or immunomodulators.78
Diseases of the Anterior Segment
Anterior Chamber
Corneal Abrasion
Corneal abrasions are epithelial surface defects that
result from minor trauma, often unnoticed. Symptoms
include abrupt onset of pain, photophobia, and tearing
after events such as eye rubbing or contact with debris.
In preverbal children, corneal abrasions are in the dif-
ferential diagnosis of the inconsolable infant.80 Recent
data suggest that corneal abrasions may be common
in infants, with behaviors such as crying and fussing.
These abrasions have unclear clinical significance.81
Patients with corneal abrasions often present
with eye pain and tearing. They may have limited eye
opening secondary to pain. Gross examination of the
eye may not reveal significant abnormalities. A full,
everted eyelid examination should be performed to
ensure no foreign body is present. When suspected,
corneal abrasions are evaluated with a Woods lamp
and fluorescein staining. (See the “Fluorescein Dye”
©2021 EB MEDICINE
section, page 7.) Any epithelial defect, including
those from corneal abrasions, appears fixed, persis-
tent, and yellow or green.
If a corneal abrasion is identified, prophylactic
topical antibiotics (eg, trimethoprim/polymyxin or
erythromycin) are given to prevent secondary corneal
infection. Consider topical fluoroquinolones for Pseu-
domonas coverage in contact lens wearers.82 Contact
lens wearers should refrain from wearing contact lenses
until the abrasion is fully healed. For patients with
discomfort, topical NSAIDs for 1 to 2 days may be
considered.83 Cycloplegics are not recommended.84
Patching is no longer recommended, as it does not
speed recovery and may have associated harms.85 Cor-
ticosteroids can delay epithelial healing and should be
avoided. While topical anesthetic use may relieve pain
in the first 24 hours, prolonged use is not recommend-
ed.86,87 Most corneal abrasions heal within 24 to 48
hours. Complications include progression to infectious
keratitis and recurrent erosion syndrome.88
patient should be evaluated for associated systemic
diseases (eg, bleeding diathesis, leukemia, and sickle
cell disease or trait).
A hyphema appears as an inferior sanguineous
fluid level overlying the iris. (See Figure 10.) The size
of the hyphema has prognostic and management im-
plications. Ophthalmologists use a grading system to
describe this, but emergency clinicians should know
that when measuring from the inferior aspect of the
cornea, hyphemas that occupy >50% of the anterior
chamber are more likely to have associated increased
intraocular pressure and risk of rebleeding.92 Sickle
cell disease can cause elevated intraocular pressure
with minimal blood in the anterior chamber.
Figure 9. Herpes Simplex Virus Keratitis
With Dendritic Pattern on Fluorescein
Staining

Keratitis
Keratitis (corneal inflammation) is often the result of
infection. Bacterial etiologies are the most common,
followed by viral, fungal, or parasitic disease. Typical
pathogens include coagulase-negative Staphylococ-
cus, S aureus, and Streptococcus species.89 Contact
lens wear is a significant risk factor for the develop-
ment of bacterial keratitis from P aeruginosa.90 Kera-
titis may progress to corneal ulcers, corneal perfora-
tions, hypopyons, and vision loss. Herpes simplex
virus is a common viral cause of keratitis.
Symptoms of keratitis include eye pain and a
foreign body sensation.91 In microbial keratitis, a
round white spot may be seen on the cornea. Corneal
inflammation promotes dye uptake. Herpes simplex
virus keratitis presents with unilateral pain and con- Image used with permission of Jessica Chen, MD.

junctival injection with associated vesicles, typically

in the V1 distribution. With fluorescein staining and a Figure 10. Hyphema
Woods lamp, herpes simplex virus keratitis may show
a classic dendritic pattern. (See Figure 9.)
Topical antibiotics are indicated, pending local
susceptibility patterns to cover typical pathogens.
One textbook recommends topical fluoroquino-
lones.89 For herpes simplex virus keratitis, topical
or oral antiviral agents may be used to decrease
the duration of symptoms and prevent recurrence;
options include topical ganciclovir or trifluridine for
10 to 14 days or oral acyclovir for 10 days.64 Repeat
episodes of herpes simplex virus keratitis may ben-
efit from chronic suppressive antiviral therapy.64 The
decision to add topical corticosteroids should be
made with an ophthalmologist.

Hyphema
A hyphema is the presence of blood in the anterior
chamber. It often results from trauma, but in rare
cases occurs spontaneously. In atraumatic cases, the Image courtesy of Jill Rotruck, MD.

GROUP SUBSCRIPTIONS: groups@ebmedicine.net 13 © 2021 EB MEDICINE. ALL RIGHTS RESERVED.

 Hyphemas warrant emergent ophthalmology
referral. Conservative management in the ED includes
an eye shield, 45° head elevation, and activity restric-
tion. Topical corticosteroids and/or cycloplegics may
be necessary and should be used in conjunction with
ophthalmology.12 NSAIDs should be avoided. Coun-
sel patients about the risk of recurrent hemorrhage
within the first 5 days of the initial episode.
Glaucoma
Childhood glaucoma is intraocular pressure-related
damage to the eye, which may include optic neu-
ropathy, corneal clouding, and ocular enlargement.
Untreated glaucoma risks vision loss.
Children with glaucoma may present with tear-
ing, corneal edema, and eye redness.13 There may
be associated corneal enlargement as the result of
elevated pressure in the anterior chamber; this is clas-
sically diagnosed in the infant who has “big, beauti-
ful eyes.”19,25 Tonometry is important to assess for
elevated pressure.
Therapeutic options range from topical and oral in-
traocular pressure-lowering agents to surgery. Timolol
ophthalmic 0.1% is among the first-line therapeutic op-
tions, and oral acetazolamide is rarely necessary prior
to procedures. Both should be initiated in conjunction
with ophthalmology and with due consideration of side
effects, such as respiratory distress and hypoglycemia
in the former and failure to thrive in the latter. Surgery
is the first-line treatment for congenital glaucoma.
Uveitis
Uveitis refers to inflammation of any of the structures
within the uveal tract such as the iris, ciliary body, or
choroid. Anterior uveitis is more common in pediat-
ric patients. Patients may present with involvement
of the intermediate or posterior structures or diffuse
uveitis (panuveitis). While it may be idiopathic, >25%
of patients with uveitis have underlying systemic dis-
ease (eg, rheumatologic diagnoses or infections).93-95
Anterior uveitis most often presents with an
acutely painful, red eye. The examination is notable
for conjunctival injection, most prominent near the
cornea, with associated photophobia and vision
changes. White blood cells can be seen in the anteri-
or chamber on slit-lamp examination and occasionally
accumulate in the inferior anterior chamber, forming
a hypopyon. If the iris is involved, the pupil may be
small, may dilate poorly, and may have an irregular
shape due to posterior synechiae.13 When posterior
structures are involved, the patient may not have
pain, and instead may describe floaters or scotomas
in their vision.96
While a definitive diagnosis is difficult to make in
the ED, suspicion for uveitis should prompt urgent oph-
thalmology involvement. Treatment may include topical
or systemic corticosteroids, cycloplegia, immunomodu-
lators, and addressing the underlying disease.12
FEBRUARY 2021 • www.ebmedicine.net 14
Posterior Chamber
Cataracts
A cataract is an eye lens opacity. In the pediatric
population, cataracts are often congenital. They may
be hereditary, associated with systemic disease, or id-
iopathic in nature. Unilateral cataracts may be related
to dysgenesis of the eye or lens and are not typically
associated with systemic disease. There is high risk
for development of amblyopia in young patients, and
timely consultation is appropriate.6
On examination, patients with cataracts have
initial clouding of the lens that progresses to lens
opacification. Subtle findings can include an abnor-
mal red reflex. For infants with progressive cataracts,
the examination can be notable for signs of vision im-
pairment such as strabismus, squinting, or nystagmus.
Urgent ophthalmology evaluation is appropriate to
assess vision development and to plan likely surgical
intervention.
Diseases of the Posterior Segment
Many patients with posterior segment pathology
present with decreased or absent vision, and the
specific diagnosis may be difficult for the emergency
clinician to determine. Posterior segment pathology
can be vision- or life-threatening.7 Emergent ophthal-
mology consultation is necessary.
Vitreous Hemorrhage
The vitreous is a clear, gelatinous substance that fills
the globe and gives it its spherical structure. Bleeding
into this space occurs usually as the result of trauma,
but it may occur spontaneously in patients with reti-
nopathy of prematurity, sickle cell retinopathy, diabetic
retinopathy, retinoblastoma, or retinal detachment.
Patients with vitreous hemorrhage may present
with a history of trauma or bleeding disorder. They
may present with leukocoria or vision loss, with the
degree of hemorrhage correlating to the extent of vi-
sion loss.97 In younger children, however, the present-
ing symptom may be nystagmus or strabismus.98
In the case of leukocoria, ultrasound can be used
to distinguish between etiologies of vitreous hemor-
rhage or retinoblastoma. On ultrasound, vitreous
hemorrhage lacks a hyperechoic mass characteristic of
retinoblastoma. A CT scan can be used to further diag-
nose, but this decision should be made in conjunction
with ophthalmology. If vitreous hemorrhage is suspect-
ed, ophthalmology referral is indicated emergently to
discuss possible operative management.99
Retinoblastoma
Retinoblastoma is the most common intraocular tu-
mor of childhood.100 It may occur in one or both eyes.
Emergency clinicians must maintain a high degree of
suspicion for this diagnosis, as it is increasingly diag-
nosed in EDs.101 Early diagnosis is important. In the
United States, 5-year survival is >90%.102
©2021 EB MEDICINE
 Children with retinoblastoma typically present
with leukocoria as toddlers, but more rare presenta-
tions include strabismus, fixed and dilated pupil(s),
vision changes, and proptosis. On examination, an
asymmetric red reflex is seen.
When assessing for retinoblastoma, ultrasound
may be a useful adjunct for the emergency clini-
cian. On ultrasound, there may appear to be a solid
hyperechoic mass with focal calcifications.103 For
determination of the extent of disease, the use of CT
has been replaced by MRI. However, ultrasound may
be sensitive and an important tool for diagnosis in the
ED setting.104
When retinoblastoma is suspected, management
is urgent oncology and ophthalmology referrals to
avoid tumor spread to the contralateral eye and vi-
sion loss.
Retinal Detachment
Retinal detachment should be considered in patients
with trauma, myopia, congenital eye anomalies, or
previous eye surgery.105-107 Children with retinal de-
tachment complain of painless vision deficits or loss.
Verbal children may also describe floaters, flashes
of light, or a “dark curtain,” although the specific
symptoms may be difficult to articulate. Accordingly,
early diagnosis can be missed. Retinal detachment is
extremely difficult to diagnose on nondilated fundo-
scopic examination.
Ocular ultrasound is recommended as an aid
for the diagnosis of retinal detachment. In a meta-
analysis by Gottlieb et al in 2019, point-of-care
ultrasound was found to have a sensitivity of 94.2%
(95% CI, 78.4%-98.6%) and specificity of 96.3% (95%
CI, 89.2%-98.8%) for the diagnosis of retinal detach-
ment.108 It is thought that ultrasound may serve as a
helpful tool when the ocular examination is limited
or ophthalmology involvement is not available.108,109
Retinal detachment may present as a thin, hyperecho-
ic membrane.31-34 (See Figure 11.) When suspected,
emergent ophthalmologic evaluation is appropriate.
Retinal Artery Occlusion
Retinal artery occlusion is a true emergency. It is
rare in children. Case reports suggest an association
with migraines, hypercoagulable states, and cardiac
disease.110,111 Patients with retinal artery occlusion
report sudden, painless vision loss. MRI and possibly
vascular imaging should be considered to evaluate
for concomitant cerebrovascular accidents. Manage-
ment should occur at a stroke center in consultation
with ophthalmology, neurology, and stroke interven-
tionalists. Early revascularization is associated with
improved outcomes.112,113
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Orbital Hemorrhage
Orbital hemorrhages are rare but do occur in young
patients.114 An orbital hemorrhage is bleeding within
the orbit. Orbital hemorrhages occur as the result of
trauma, vascular abnormalities, or bleeding diathesis,
and they are associated with sickle cell disease. Chil-
dren with orbital hemorrhage present with subcon-
junctival hemorrhage, elevated intraocular pressure,
and painful proptosis. MRI with possible angiography
should be considered to identify vascular abnormali-
ties. If signs of optic neuropathy are present, lateral
canthotomy and cantholysis should be performed
emergently. Emergent ophthalmology intervention is
recommended.
Optic Neuritis
Although optic neuritis is a disease of the central ner-
vous system, it will be discussed briefly. Optic neuritis
is an inflammatory demyelinating disease of the optic
nerve, often associated with multiple sclerosis. Optic
neuritis presents with acute or subacute painful mon-
ocular and, rarely, binocular vision loss.
n Consulting Ophthalmology
Treatment for many of the etiologies discussed in this
review can and should be initiated by the emergency
clinician at the time of diagnosis. Certain diagnoses
may benefit from the consultation of ophthalmology,
emergently, urgently, or on a routine basis. If subspe-
cialists are not available, local practice patterns will
dictate whether they should be consulted by tele-
medicine or through interfacility transfer. See Table 4,
page 16, for indications for ophthalmology consulta-
tion by chief complaint, diagnosis, and acuity.
Figure 11. Retinal Detachment on
Ultrasound
Image used with permission of Yale Department of Pediatrics, Section of
Pediatric Emergency Medicine.
15 © 2021 EB MEDICINE. ALL RIGHTS RESERVED.
n Special Populations and Circumstances
Neonates
Given the development early in life of visual axis struc-
tures, interruption of this process can cause dense de-
privational amblyopia. Infants aged 0 to 3 months are
the highest-risk group. Accordingly, neonatal ocular
disease requires urgent ophthalmology evaluation.25
Solar Retinopathy
Direct visualization of the sun is dangerous. Lasting,
painless damage to retinal areas through photochem-
ical mechanisms may occur. Urgent ophthalmology
involvement is recommended. Indirect solar view-
ing through filtered gasses is the safest way to view
eclipse events.116
Nutritional and Metabolic Disease
The leading cause of preventable blindness in the world
is vitamin A deficiency. The typical manifestation is
nyctalopia, which can progress to corneal ulceration and
then to corneal melting. In developed countries, vitamin
A deficiency should be considered in patients with food
aversion or with certain malabsorptive diseases. Beta
carotene usually reverses the process.117 Dosing options
include: 6 to 15 mg of beta carotene (the equivalent of
10,000 to 25,000 units of vitamin A activity) per day for
adults and teenagers, and 3 to 6 mg of beta carotene
(the equivalent of 5000 to 10,000 units of vitamin A
activity) per day for children.
Eye Complaints Related to Infectious Etiologies
Globally, the most common infectious etiology of ac-
quired blindness is trachoma. This disease (caused by
C trachomatis) causes recurrent episodes of conjunc-
tivitis causing scarring and trichiasis (inward turning
of the eyelashes). It is predominant in the dry regions
Table 4. Recommendations for Ophthalmology Consultation6,64,66,88,115
Acuity Chief Complaint
Emergent (0-24 hours) • Severe eye pain
• Photophobia
• Loss of vision
• Abnormal pupil size
Urgent (24-72 hours) • Asymmetric red reflex
• Leukocoria
• Excessive eye tearing
• Severe purulent discharge
• Refractory symptoms
Routine (within 3-6 weeks) • Dry eye
• Watery eye
• Squinting
• Eye swelling
Not Indicated •  Eye swelling
FEBRUARY 2021 • www.ebmedicine.net 16
of Africa, the Middle East, and South East Asia. The
traditional treatment is azithromycin. Mass administra-
tion programs have been effective.118
COVID-19 and Zika virus disease also have as-
sociated eye involvement. The most common ocular
manifestation of COVID-19 is viral conjunctivitis,
which may be present in as many as 30% of patients
with COVID-19.119 Existing reports suggest that con-
junctivitis occurs more commonly with severe system-
ic disease. There are no reports of sight-threatening
manifestations. Of note, the Kawasaki-like syndrome
that has been described in children in association
with COVID-19, multisystem inflammatory syndrome
in children (MIS-C), can also present with conjunctivi-
tis.120 Treatment is aimed at addressing the underly-
ing disease.
Zika virus disease is usually asymptomatic, but
there may be ocular manifestations such as conjunc-
tivitis and retro-ocular pain.121 This should be consid-
ered in patients with a history of travel to an endemic
area.54 Treatment is supportive care. When suspect-
ed, both COVID-19 and Zika virus disease should be
reported to the public health system.
n Controversies and Cutting Edge
Transient Smartphone Blindness
“Transient smartphone blindness” was described in
the New England Journal of Medicine in 2016.122 It
is a phenomenon of transient monocular vision loss
when viewing the bright screen of a smartphone us-
ing a single eye in a dark space. As one eye is accus-
tomed to light and the other to dark, when both are
again exposed to light, the eye that had seen light
may not be adapted and become functionally “blind”
for up to 30 minutes.
Potential Diagnoses
• Uveitis
• Glaucoma
• Keratitis
• Posterior chamber pathology
• Persistent corneal abrasion
• Cataracts
• Scleritis or episcleritis
• Persistent subconjunctival hemorrhage
• Persistent nasolacrimal duct abnormalities
• Persistent eyelid pathology requiring removal (eg, chalazion)
• Persistent blepharitis
• Blepharitis with suspected corneal involvement
• Periorbital cellulitis
• Subconjunctival hemorrhage
www.ebmedicine.net
©2021 EB MEDICINE
Nonmydriatic Fundus Photography
Nonmydriatic fundus photography refers to the use
of compact, user-friendly, handheld devices that can
take photographs of the ocular fundus in the ab-
sence of pharmacologic dilation. These devices have
been shown to improve recognition and triage of eye
complaints in the ED in comparison to direct ophthal-
moscopy.123 Images obtained from these devices can
be rapidly shared and viewed by subspecialists for
interpretation, if desired.124
Topical Antibiotics for Childhood
Conjunctivitis for Return to School
The use of topical antibiotics for childhood conjunc-
tivitis outside of medical necessity is controversial.
Surveys across the United States reveal school exclu-
sion practices for children diagnosed with conjunctivi-
tis, with several states allowing return to school based
on initiation of topical antimicrobial therapy.125 While
this practice may not be medically indicated, the use
of topical antimicrobial therapy in young children may
facilitate earlier return to school.126
n Disposition
Most pediatric patients who are seen for nontraumatic
ocular complaints can be discharged safely from the
hospital with or without outpatient ophthalmology
follow-up.2 See Table 4, page 16 for recommended
ophthalmology follow-up. Disposition will depend on
suspected diagnosis, severity, red flags, and risk of
complications. The need for a more thorough evalua-
tion and family comfort will also inform the disposition
plan. Some patients may need hospital admission or
transfer for subspecialty care, depending on the ur-
gency of the condition and risk for serious sequelae.
n Summary
Nontraumatic ocular complaints in children are com-
mon, but difficult to diagnosis. Common complaints
may include red eyes, painful eyes, or vision changes.
Etiologies for symptoms may arise from pathology in
the extraocular structures, the anterior chamber, or
the posterior chamber of the eye. Using history and
physical examination findings, the emergency clinician
must have the ability to identify potentially vision- or
life-threatening diagnoses among a plethora of benign
etiologies. Furthermore, using the differential diag-
nosis, the clinician must have the skills to determine
the need for further workup with diagnostic studies,
additional evaluation, and appropriate subspecialty
involvement. Correct diagnosis is essential, as treat-
ment options may vary from expectant management to
medical management to surgical management.
GROUP SUBSCRIPTIONS: groups@ebmedicine.net
n Time- and Cost-Effective Strategies
• Routine culture of the eyes in the setting of
routine conjunctivitis poses a significant cost
burden in the healthcare system.30,127 Excep-
tions include neonatal conjunctivitis and hyper-
purulent conjunctivitis.
• Use of ultrasound may be both time- and cost-
effective in the diagnosis of posterior segment
eye disease such as retinal detachment and optic
neuritis. Risk management caveat: These diag-
noses should be made with consulting pediatric
ophthalmologists and neurologists, who will
ultimately guide definitive care.
n References
Evidence-based medicine requires a critical appraisal
of the literature based upon study methodology and
number of subjects. Not all references are equally
robust. The findings of a large, prospective, random-
ized, and blinded trial should carry more weight than
a case report.
To help the reader judge the strength of each refer-
ence, pertinent information about the study, such as the
type of study and the number of patients in the study is
included in bold type following the references, where
available. The most informative references cited
in this paper, as determined by the authors, are noted
by an asterisk (*) next to the number of the reference.
1. Channa R, Zafar SN, Canner JK, et al. Epidemiology of eye-
related emergency department visits. JAMA Ophthalmol.
2016;134(3):312-319. (Retrospective; 11,929,995 patients)
2. Olver JM, Hague S. Children presenting to an ophthalmic
casualty department. Eye (Lond). 1989;3 (Pt 4):415-419. (Cross-
sectional; 475 patients)
3. Vaziri K, Schwartz SG, Flynn HW Jr, et al. Eye-related emergen-
cy department visits in the United States, 2010. Ophthalmol-
ogy. 2016;123(4):917-919. (Retrospective; 1,996,735 patients)
4. Fleisher G L, S, Rose JS. Textbook of Pediatric Emergency
Medicine. 4th ed. Philadelphia: Lippincott Williams & Wilkins;
2000. (Book)
5. McCulloch DL. The infant patient. Ophthalmic Physiol Opt.
1998;18(2):140-146. (Review)
6.* Prentiss KA, Dorfman DH. Pediatric ophthalmology in the emer-
gency department. Emerg Med Clin North Am. 2008;26(1):181-
198. (Review) DOI: 10.1016/j.emc.2007.11.001
7. Raucci U, Parisi P, Vanacore N, et al. Acute diplopia in the pedi-
atric emergency department. A cohort multicenter Italian study.
Eur J Paediatr Neurol. 2017;21(5):722-729. (Retrospective; 621
patients)
8. Fonseca C, Silva AM, Freire S, et al. Ocular toxocariasis: atypi-
cal clinical course. BMJ Case Rep. 2019;12(4):e228717. (Case
report)
9. Khadka D, Sharma AK, Shrestha JK, et al. Ocular manifestations
of childhood acute leukemia in a tertiiary level eye centre of
Kathmandu, Nepal. Nepal J Ophthalmol. 2014;6(2):197-204.
(Case report)
10. Shafique M, Muzaffar W, Ishaq M. The eye as a window to a rare
disease: ectopia lentis and homocystinuria, a Pakistani perspective.
Int Ophthalmol. 2016;36(1):79-83. (Case series; 10 patients)
17 © 2021 EB MEDICINE. ALL RIGHTS RESERVED.
 Case Conclusions
CASE 1 The 6-year-old boy with autism who was brought to the ED for swelling of his right eye…
By engaging the family and using video for distraction, you obtained an ocular examination that was
notable for right-sided proptosis and ophthalmoplegia. Given the proptosis and associated headache, you
obtained a CT scan, which revealed orbital cellulitis complicated by subperiosteal abscess. Ophthalmology
and otolaryngology were consulted and broad-spectrum antibiotics were initiated.

The 4-year-old girl who was brought to the urgent care clinic by her mother for red, matted eyes…
CASE 2

The constellation of wintertime presentation of conjunctivitis with morning matting in a young child raised
your suspicion for bacterial conjunctivitis. To decrease the duration of symptoms, and to meet school
requirements, you initiated topical antibiotics.

The 17-year-old girl who presented to the ED with acute left-sided vision loss…
CASE 3

Monocular painless vision loss, especially in the setting of pre-existing cardiac disease, raised your
suspicion for retinal artery occlusion. You initiated a stroke code to facilitate early neurology involvement.
Ophthalmology was called immediately to the bedside. Local and systemic thrombolytics improved vision.

Risk Management Pitfalls for Pediatric Patients

With Nontraumatic Ocular Complaints

1. “The 4-year-old boy with a red eye must have
viral conjunctivitis. He can be discharged
home quickly.” Although infectious conjunctivitis
accounts for the majority of cases of “red eye”
in pediatric patients, it is important to assess
alternative causes. Emergency clinicians should
be wary of making the diagnosis of infectious
conjunctivitis in the setting of antecedent trauma,
pain, or photophobia, which may indicate pa-
thologies such as corneal abrasion, scleritis, or
uveitis.
2. “I had only the Snellen eye chart, so I skipped
the visual acuity assessment for the 4-year-
old patient with eye redness. I figured the
patient’s vision was likely normal.” The LEA
symbols chart or the HOTV matching chart can be
accessed easily online and used for the preliter-
ate child. Visual acuity assessment is an important
aspect of the evaluation of a child with an ocular
complaint and should not be skipped.
3. “The baby had big, beautiful eyes, but they
wouldn’t stop tearing. I recommended gentle
massage of the nasolacrimal duct.” For infants
with tearing and enlarged corneas, the diagno-
sis of infantile glaucoma should be considered.
Given the risk for vision loss, urgent ophthalmol-
ogy referral is indicated.
4. “The 8-year-old with autism and red swelling
around the eye likely had periorbital cellulitis,
but he wouldn’t open his eye for an eye exam.
I decided he would probably be fine and
discharged him with oral medications.” While
periorbital cellulitis is more common than orbital
cellulitis, it is important to complete a thorough
assessment for signs of orbital cellulitis. This is
possible only with a full eye examination, and
all efforts should be made to obtain it, whether
through the aid of distraction, child-life special-
ists, or pharmacologic anxiolysis. Orbital cellulitis
is associated with risk for vision- and life-threaten-
ing complications.
5. “The 5-year-old boy returned to the ED the
next week with a red eye. His parents didn’t
give the antibiotics long enough to work. I
sent him home to continue his current treat-
ment.” While it may take a few days for con-
junctivitis to resolve, refractory red eyes should
prompt further evaluation. In addition to con-
sideration of typical bacterial, viral, or allergic
etiologies of pediatric conjunctivitis, clinicians
who care for children should consider herpetic
keratitis. Patients with herpetic keratitis may have
nearby vesicular lesions, and a fluorescein stain
may reveal a dendritic pattern of staining. Making
this diagnosis is important because of therapeutic
implications and the risk for complications.

FEBRUARY 2021 • www.ebmedicine.net 18 ©2021 EB MEDICINE

11. Chandler JR, Langenbrunner DJ, Stevens ER. The pathogen-
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2018;83:32-37. (Randomized controlled trial; 101 patients)
15. Bossart PJ, Stephen RL, Herr RD, et al. Visual acuity after topical
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18.* Wallace DK, Morse CL, Melia M, et al. Pediatric Eye Evaluations
6. “The 1-month-old baby was very fussy, but
there was no obvious finding on my physical
examination.” The combination of poor hand-
eye coordination and long fingernails frequently
produces corneal abrasions in young infants and
should be considered in the differential diagnosis
of the fussy infant. Although treatment of corneal
abrasion may help the infant, it is important to
remain vigilant to alternative pathologies on the
differential diagnosis. It remains unclear whether
small corneal abrasions in infants should be con-
sidered a cause for fussiness.
7. “The 2-week-old with bilateral conjunctivitis
and mild discharge likely had bacterial conjunc-
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ics.” Neonatal conjunctivitis is a unique entity,
and high suspicion for Neisseria, Chlamydia, and
herpes should be maintained. Local and systemic
cultures are prudent, as well as consideration for
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tain cases warrant systemic treatment and admis-
sion.
8. “The 4-year-old with autism would not cooper-
ate for the eye exam. I gave him procedural
sedation in order to obtain it.” While in rare cir-
cumstances sedation is necessary to obtain a full
eye examination, using strategies such as gaining
as much information as possible from a distance,
GROUP SUBSCRIPTIONS: groups@ebmedicine.net
Preferred Practice Pattern®: I. Vision screening in the primary
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9. “I was worried about the 15-year-old with vi-
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on a fundoscopic exam. I decided he needed
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certain abnormalities in the posterior chamber,
such as signs of optic disk swelling or vitreous/
retinal hemorrhage, and it may guide subsequent
need for further imaging.
10. “The parents of this 2-year-old said that his
eyes looked funny in photographs. I’m suspi-
cious of disease in the posterior segment, but I
didn’t have tools in my setting to evaluate it.”
Although the use of an ophthalmoscope is famil-
iar to general pediatricians, its use in evaluating
posterior segment disease in the ED should not
be understated. Diseases such as cataracts and
retinoblastoma may present with an asymmetric
red reflex, and an ophthalmoscope should be
considered a routine part of the physical exami-
nation for children with eye complaints.
19 © 2021 EB MEDICINE. ALL RIGHTS RESERVED.
 clinical efficacy of funduscopic examinations performed in the
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66.* Azari AA, Barney NP. Conjunctivitis: a systematic review of diag-
nosis and treatment. JAMA. 2013;310(16):1721-1729. (System-
atic review; 86 articles) DOI: 10.1001/jama.2013.280318
67. Meltzer JA, Kunkov S, Crain EF. Identifying children at low
risk for bacterial conjunctivitis. Arch Pediatr Adolesc Med.
2010;164(3):263-267. (Prospective; 368 patients)
68. Rose PW, Harnden A, Brueggemann AB, et al. Chloramphenicol
treatment for acute infective conjunctivitis in children in primary
care: a randomised double-blind placebo-controlled trial. Lan-
cet. 2005;366(9479):37-43. (Randomized controlled trial; 326
patients)
69. Rietveld RP, ter Riet G, Bindels PJ, et al. Predicting bacte-
rial cause in infectious conjunctivitis: cohort study on infor-
mativeness of combinations of signs and symptoms. BMJ.
2004;329(7459):206-210. (Prospective; 184 patients)
70. McAnena L, Knowles SJ, Curry A, et al. Prevalence of gono-
coccal conjunctivitis in adults and neonates. Eye (Lond).
2015;29(7):875-880. (Retrospective; 74,814 patients)
71. Bingen E, Cohen R, Jourenkova N, et al. Epidemiologic
study of conjunctivitis-otitis syndrome. Pediatr Infect Dis J.
2005;24(8):731-732. (Prospective; 419 patients)
72. Sheikh A, Hurwitz B, van Schayck CP, et al. Antibiotics versus
placebo for acute bacterial conjunctivitis. Cochrane Database
Syst Rev. 2012(9):CD001211. (Meta-analysis; 11 studies, 3673
patients)
73. Ullman S, Roussel TJ, Culbertson WW, et al. Neisseria gonor-
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531. (Retrospective; 47 patients)
74. United States Centers for Disease Control and Prevention. “Pre-
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75. Owen CG, Shah A, Henshaw K, et al. Topical treatments
for seasonal allergic conjunctivitis: systematic review and
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76. Mimura T, Usui T, Yamagami S, et al. Recent causes of subcon-
junctival hemorrhage. Ophthalmologica. 2010;224(3):133-137.
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77. DeRidder CA, Berkowitz CD, Hicks RA, et al. Subconjunctival
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trauma. Pediatr Emerg Care. 2013;29(2):222-226. (Case series;
14 patients)
78. Wieringa WG, Wieringa JE, ten Dam-van Loon NH, et al. Visual
outcome, treatment results, and prognostic factors in patients
with scleritis. Ophthalmology. 2013;120(2):379-386. (Retro-
spective; 104 patients)
79. Jabs DA, Mudun A, Dunn JP, et al. Episcleritis and scleritis:
clinical features and treatment results. Am J Ophthalmol.
2000;130(4):469-476. (Retrospective; 134 patients)
80. Poole SR. The infant with acute, unexplained, excessive crying.
Pediatrics. 1991;88(3):450-455. (Retrospective; 56 patients)
81. Shope TR, Rieg TS, Kathiria NN. Corneal abrasions in young
infants. Pediatrics. 2010;125(3):e565-e569. (Prospective; 96
patients)
82. Wipperman JL, Dorsch JN. Evaluation and management of
corneal abrasions. Am Fam Physician. 2013;87(2):114-120.
(Review)
83. Calder LA, Balasubramanian S, Fergusson D. Topical nonsteroi-
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dal anti-inflammatory drugs for corneal abrasions: meta-analysis
of randomized trials. Acad Emerg Med. 2005;12(5):467-473.
(Meta-analysis; 11 trials, 459 patients)
84. Weaver CS, Terrell KM. Evidence-based emergency medicine.
Update: do ophthalmic nonsteroidal anti-inflammatory drugs
reduce the pain associated with simple corneal abrasion with-
out delaying healing? Ann Emerg Med. 2003;41(1):134-140.
(Systematic review; 5 studies)
85. Lim CH, Turner A, Lim BX. Patching for corneal abrasion.
Cochrane Database Syst Rev. 2016;7:CD004764. (Systematic
review; 12 trials)
86. Waldman N, Winrow B, Densie I, et al. An observational study
to determine whether routinely sending patients home with
a 24-hour supply of topical tetracaine from the emergency
department for simple corneal abrasion pain is potentially safe.
Ann Emerg Med. 2018;71(6):767-778. (Randomized controlled
trial; 122 patients)
87. Pharmakakis NM, Katsimpris JM, Melachrinou MP, et al. Cor-
neal complications following abuse of topical anesthetics. Eur J
Ophthalmol. 2002;12(5):373-378. (Case report)
88.* Ross M, Deschênes J. Practice patterns in the interdisciplin-
ary management of corneal abrasions. Can J Ophthalmol.
2017;52(6):548-551. (Guideline)
DOI: 10.1016/j.jcjo.2017.03.016
89. Hoyt CS, Taylor, D. Pediatric Ophthalmology and Strabismus,
Expert Consult-Online and Print. 4th ed. Elsevier Saunders;
2012. (Textbook)
90. Hsiao CH, Yeung L, Ma DH, et al. Pediatric microbial keratitis in
Taiwanese children: a review of hospital cases. Arch Ophthal-
mol. 2007;125(5):603-609. (Retrospective; 78 patients)
91. Keay L, Edwards K, Stapleton F. Signs, symptoms, and comor-
bidities in contact lens-related microbial keratitis. Optom Vis
Sci. 2009;86(7):803-809. (Prospective; 297 patients)
92. Coles WH. Traumatic hyphema: an analysis of 235 cases. South
Med J. 1968;61(8):813-816. (Case series; 235 cases)
93. Rothova A, Buitenhuis HJ, Meenken C, et al. Uveitis and sys-
temic disease. Br J Ophthalmol. 1992;76(3):137-141. (Prospec-
tive; 865 patients)
94. Tappeiner C, Miserocchi E, Bodaghi B, et al. Abatacept in
the treatment of severe, longstanding, and refractory uveitis
associated with juvenile idiopathic arthritis. J Rheumatol.
2015;42(4):706-711. (Retrospective; 21 patients)
95. Lee MI, Lee AW, Sumsion SM, et al. Don’t forget what you
can’t see: a case of ocular syphilis. West J Emerg Med.
2016;17(4):473-476. (Case report)
96. Camilo EN, Moura GL, Arantes TE. Clinical and epidemiological
characteristics of patients with uveitis in an emergency eye care
center in Brazil. Arq Bras Oftalmol. 2014;77(1):30-33. (Prospec-
tive; 117 patients)
97. Cheng KP, Hiles DA, Biglan AW. The differential diagnosis of
leukokoria. Pediatr Ann. 1990;19(6):376-383,386. (Review)
98. Spirn MJ, Lynn MJ, Hubbard GB 3rd. Vitreous hemorrhage in
children. Ophthalmology. 2006;113(5):848-852. (Retrospec-
tive; 168 patients)
99. AlHarkan DH, Kahtani ES, Gikandi PW, et al. Vitreous hemor-
rhage in pediatric age group. J Ophthalmol. 2014;2014:497083.
(Retrospective; 230 patients)
100. Dimaras H, Kimani K, Dimba EA, et al. Retinoblastoma. Lancet.
2012;379(9824):1436-1446. (Review)
101. Posner M, Jaulim A, Vasalaki M, et al. Lag time for retinoblas-
toma in the UK revisited: a retrospective analysis. BMJ Open.
2017;7(7):e015625. (Retrospective; 93 patients)
102. Broaddus E, Topham A, Singh AD. Survival with retinoblastoma
in the USA: 1975-2004. Br J Ophthalmol. 2009;93(1):24-27.
(Retrospective; 990 patients)
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103. Giacalone M, Mastrangelo G, Parri N. Point-of-care ultrasound 21st century: the 2017 H. Houston Merritt Lecture. Neurology.
diagnosis of retinoblastoma in the emergency department. 2018;90(4):167-175. (Lecture)
Pediatr Emerg Care. 2018;34(8):599-601. (Case report) 125. Ohnsman CM. Exclusion of students with conjunctivitis from
104. Galluzzi P, Hadjistilianou T, Cerase A, et al. Is CT still useful in school: policies of state departments of health. J Pediatr Oph-
the study protocol of retinoblastoma? AJNR Am J Neuroradiol. thalmol Strabismus. 2007;44(2):101-105. (Cross-sectional; 43
2009;30(9):1760-1765. (Retrospective; 23 children) states)
105. Buzzard AK, Linklater DR. Pediatric retinal detachment due to 126. Hill DL. School notes: managing infectious diseases in school
Coats’ disease diagnosed with bedside emergency department and child care settings. N C Med J. 2016;77(5):355-358. (Ex-
ultrasound. J Emerg Med. 2009;37(4):390-392. (Case report) pert commentary)
106. Cadis C, Wang A, Julakanti M, et al. Bilateral retinal detach- 127. Smith AF, Waycaster C. Estimate of the direct and indirect an-
ment in a pediatric patient. J Emerg Med. 2019;56(4):e55-e57. nual cost of bacterial conjunctivitis in the United States. BMC
(Case report) Ophthalmol. 2009;9:13. (Cost-analysis study)
107. Nuzzi R, Lavia C, Spinetta R. Paediatric retinal detachment: a 128. Seth D, Khan FI. Causes and management of red eye in pedi-
review. Int J Ophthalmol. 2017;10(10):1592-1603. (Case report) atric ophthalmology. Curr Allergy Asthma Rep. 2011;11(3):212-
108. Gottlieb M, Holladay D, Peksa GD. Point-of-care ocular ultra- 219. (Review)
sound for the diagnosis of retinal detachment: a systematic
review and meta-analysis. Acad Emerg Med. 2019;26(8):931- n CME Questions
939. (Meta-analysis; 11 studies)
Current subscribers receive CME credit
109. Vrablik ME, Snead GR, Minnigan HJ, et al. The diagnostic ac-
absolutely free by completing the follow-
curacy of bedside ocular ultrasonography for the diagnosis of
retinal detachment: a systematic review and meta-analysis. Ann ing test. Each issue includes 4 AMA PRA
Emerg Med. 2015;65(2):199-203.e1. (Meta-analysis; 3 studies) Category 1 CreditsTM, 4 ACEP Category I
110. Lu CW, Wang J, Zhou DD, et al. Central retinal artery occlusion credits, 4 AAP Prescribed credits, or 4
associated with persistent truncus arteriosus and single atrium: AOA Category 2-A or 2-B credits. Online testing is
a case report. BMC Ophthalmol. 2015;15:137. (Case report) available for current and archived issues. To receive
111. Oo KT, Mohd-Zain MR, Shatriah I. Central retinal artery occlu- your free CME credits for this issue, scan the QR
sion with sparing of cilioretinal artery post pulmonary artery
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stenting. Cureus. 2018;10(1):e2128. (Case report)
www.ebmedicine.net/P0221
112. Dattilo M, Biousse V, Newman NJ. Update on the management
of central retinal artery occlusion. Neurol Clin. 2017;35(1):83-
100. (Review)
113. Lee WB, Pearson PA, Moreman K. Central retinal artery occlu-
sion and disc edema in a child. J AAPOS. 2002;6(4):264-265.
(Review)
114. Sullivan TJ, Wright JE. Non-traumatic orbital haemorrhage. Clin
Exp Ophthalmol. 2000;28(1):26-31. (Case series; 115 patients)
115. MacEwen CJ, Young JD. Epiphora during the first year of life.
1. The visual acuity of a neonate is thought to be
Eye (Lond). 1991;5 ( Pt 5):596-600. (Retrospective; 4792 pa-
tients) approximately:
116. Gregory-Roberts E, Chen Y, Harper CA, et al. Solar retinopathy
a. 20/50
in children. J AAPOS. 2015;19(4):349-351. (Prospective; 5 b. 20/100
patients) c. 20/200
117. Braund CC, Roosevelt GE, McCourt EA, et al. The 2012 PEMpix d. 20/400
photograph competition award winner: making a case for
pringles-flavored carrots. Pediatr Emerg Care. 2014;30(12):900- 2. The most common nidus of orbital cellulitis is:
901. (Case report)
a. Progression of periorbital cellulitis
118.*Congdon NG, Friedman DS, Lietman T. Important causes of vi-
sual impairment in the world today. JAMA. 2003;290(15):2057-
b. Odontogenic infection
2060. (Review) DOI: 10.1001/jama.290.15.2057 c. Sinus infection
119. Wu P, Duan F, Luo C, et al. Characteristics of ocular findings of d. Brain abscess
patients with coronavirus disease 2019 (COVID-19) in Hubei
Province, China. JAMA Ophthalmol. 2020;138(5):575-578. 3. When orbital cellulitis is suspected, the most
(Case series; 38 patients) appropriate mode of imaging for definitive
120. Danthuluri V, Grant MB. Update and recommendations for diagnosis is:
ocular manifestations of COVID-19 in adults and children: a nar-
rative review. Ophthalmol Ther. 2020;9(4):853-875. (Review)
a. Computed tomography scan of the orbits
121. Petersen LR, Jamieson DJ, Powers AM, et al. Zika virus. N Engl
b. Magnetic resonance imaging of the orbits
J Med. 2016;374(16):1552-1563. (Review) c. Ultrasound of the orbits
122. Alim-Marvasti A, Bi W, Mahroo OA, et al. Transient smartphone d. No imaging is indicated
“blindness”. N Engl J Med. 2016;374(25):2502-2504. (Case
series; 2 patients)
123. Bruce BB, Lamirel C, Wright DW, et al. Nonmydriatic ocular
fundus photography in the emergency department. N Engl J
Med. 2011;364(4):387-389. (Prospective cohort; 350 patients)
124. Biousse V, Bruce BB, Newman NJ. Ophthalmoscopy in the

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4. Treatment for a neonate who presents CME Information
with suspected uncomplicated unilateral Date of Original Release: February 1, 2021. Date of
most recent review: January 15, 2021. Termination
nasolacrimal duct obstruction includes: date: February 1, 2024.
a. Urgent referral to ophthalmology Accreditation: EB Medicine is accredited by the
b. Massage of the nasolacrimal fold and warm Accreditation Council for Continuing Medical
Education (ACCME) to provide continuing medical education for
compresses physicians. This activity has been planned and implemented in
c. Systemic antibiotics accordance with the accreditation requirements and policies of the
ACCME.
d. Topical antibiotics
Credit Designation: EB Medicine designates this enduring material
for a maximum of 4 AMA PRA Category 1 CreditsTM. Physicians
5. In comparison to patients with bacterial or should claim only the credit commensurate with the extent of their
participation in the activity.
viral conjunctivitis, allergic conjunctivitis
Specialty CME: Included as part of the 4 credits, this CME activity is
typically presents with: eligible for 1 Infectious Disease CME credit and 0.25 Pharmacology
a. Purulent discharge CME credits.
b. Painful eye ACEP Accreditation: Pediatric Emergency Medicine Practice is
approved by the American College of Emergency Physicians for 48
c. Pruritus hours of ACEP Category I credit per annual subscription.
d. Vision loss AAP Accreditation: This continuing medical education activity
has been reviewed by the American Academy of Pediatrics and is
acceptable for a maximum of 48 AAP credits. These credits can be
6. Regarding hyphemas, recommended applied toward the AAP CME/CPD Award available to Fellows and
management most often is: Candidate Fellows of the American Academy of Pediatrics.
a. Use of nonsteroidal anti-inflammatory drugs AOA Accreditation: Pediatric Emergency Medicine Practice is
eligible for up to 48 American Osteopathic Association Category 2-A
for pain control or 2-B credit hours per year.
b. Eye shield Needs Assessment: The need for this educational activity was
c. Irrigation of the eye determined by a survey of medical staff, including the editorial board
of this publication; review of morbidity and mortality data from the
d. Systemic antibiotics CDC, AHA, NCHS, an ACEP; and evaluation of prior activities for
emergency physicians.
7. Corneal clouding is a sign of: Target Audience: This enduring material is designed for emergency
medicine physicians, physician assistants, nurse practitioners, and
a. Uveitis residents.
b. Conjunctivitis Goals: Upon completion of this activity, you should be able to: (1)
c. Retinal detachment demonstrate medical decision-making based on the strongest clinical
evidence; (2) cost-effectively diagnose and treat the most critical ED
d. Glaucoma presentations; and (3) describe the most common medicolegal pitfalls
for each topic covered.
8. Examination findings NOT suggestive of ante- CME Objectives: Upon completion of this activity, you should be
able to: (1) identify and stratify common serious eye complaints;
rior uveitis include: (2) provide a framework for diagnostic testing based on the history
a. Conjunctival injection and physical examination; and (3) initiate appropriate management
of ocular complaints and determine the need for and acuity of
b. Vision changes ophthalmology referral.
c. White blood cells in the anterior chamber on Discussion of Investigational Information: As part of the
slit-lamp examination journal, faculty may be presenting investigational information
d. Fluorescein staining revealing dendritic lesions about pharmaceutical products that is outside Food and Drug
Administration approved labeling. Information presented as part of
this activity is intended solely as continuing medical education and is
9. The most common presentation of not intended to promote off-label use of any pharmaceutical product.
retinoblastoma in children includes: Faculty Disclosure: It is the policy of EB Medicine to ensure objectivity,
balance, independence, transparency, and scientific rigor in all CME
a. Leukocoria activities. All faculty participating in the planning or implementation of
b. Strabismus a CME activity are expected to disclose to the participants any relevant
financial relationships and to assist in resolving any conflict of interest
c. Fixed pupil that may arise from the relationship. In compliance with all ACCME
d. Proptosis accreditation requirements and policies, all faculty for this CME activity
were asked to complete a full financial disclosure statement. The
information received is as follows: Dr. Iqbal, Dr. Langhan, Dr. Rotruck,
10. In a pediatric patient presenting with per- Dr. Soma, Dr. Kriegel, Dr. Sanders, Dr. Mishler, Dr. Claudius, Dr.
sistent painless vision loss from a suspected Horeczko, and their related parties report no significant financial
interest or other relationship with the manufacturer(s) of any
posterior chamber pathology, the most appro- commercial product(s) discussed in this educational presentation.
priate involvement of ophthalmology is: Commercial Support: This issue of Pediatric Emergency Medicine
a. Emergent (0-24 hours) Practice did not receive any commercial support.
b. Urgent (24-72 hours) Earning Credit: Two Convenient Methods: (1) Go online to www.
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 Clinical Pathway for Diagnostic Evaluation
of the Pediatric Red Eye

Child presents with red eye

Consider:
Is there periorbital swelling? YES
• Orbital cellulitis
• Periorbital cellulitis
NO • Dacryocystitis
• Endophthalmitis
• Orbital neoplasm

Minimal or no pain Discharge present? Significant pain

YES NO

Hyperacute
Type of discharge Perform fluorescein test (Class III)
conjunctivitis

Mucopurulent Fluorescein staining visible?

None/serous discharge
discharge

YES NO
Bacterial Pruritic Minimally pruritic
conjunctivitis • Allergic conjunctivitis • Viral conjunctivitis

Consider: Consider:
• Corneal abrasion • Uveitis
• Corneal foreign body • Iritis
• Corneal ulcer • Episcleritis
(circular) • Scleritis
• Herpes simplex virus • Glaucoma
keratitis (dendritic) • Endophthalmitis
• Keratitis

Class of Evidence Definitions

Each action in the clinical pathways section of Pediatric Emergency Medicine Practice receives a score based on the following definitions.

Class I Class II
• Always acceptable, safe • Safe, acceptable Class III Indeterminate
• Definitely useful • Probably useful • May be acceptable • Continuing area of research
• Proven in both efficacy and effectiveness • Possibly useful • No recommendations until further
Level of Evidence: • Considered optional or alternative research
Level of Evidence: • Generally higher levels of evidence treatments
• One or more large prospective studies • Nonrandomized or retrospective stud- Level of Evidence:
are present (with rare exceptions) ies: historic, cohort, or case control Level of Evidence: • Evidence not available
• High-quality meta-analyses studies • Generally lower or intermediate levels • Higher studies in progress
• Study results consistently positive and • Less robust randomized controlled trials of evidence • Results inconsistent, contradictory
compelling • Results consistently positive • Case series, animal studies, • Results not compelling
consensus panels
• Occasionally positive results

This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a patient’s individual
needs. Failure to comply with this pathway does not represent a breach of the standard of care.
Copyright © 2021 EB Medicine. www.ebmedicine.net. No part of this publication may be reproduced in any format without written consent of EB Medicine.

FEBRUARY 2021 • www.ebmedicine.net 24 ©2021 EB MEDICINE

 Clinical Pathway for Diagnostic Evaluation
of Acute Pediatric Vision Loss

Child presents with acute vision loss

Is there pain?
YES NO

Normal-appearing eye, Red eye, consider:

Obtain ocular ultrasound (Class III)
consider: • Uveitis/iritis
• Optic neuritis • Keratitis
• Other neurologic • Corneal ulcer
etiologies • Orbital hemorrhage
• Endophthalmitis Was the ultrasound normal?

YES NO

Consider: Consider:
• Retinal artery occlusion • Retinoblastoma
• Retinal vein occlusion • Vitreous hemorrhage
• Cerebrovascular • Retinal detachment
accident
• Migraine
• Functional vision loss
• Sudden discovery of
pre-existing vision loss

For Class of Evidence definitions, see page 24.

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The Pediatric Emergency Medicine Practice Editorial Board
EDITORS-IN-CHIEF
Ilene Claudius, MD
Associate Professor; Director, Process &
Quality Improvement Program, Harbor-
UCLA Medical Center, Torrance, CA
Tim Horeczko, MD, MSCR, FACEP,
FAAP
Associate Professor of Clinical Emergency
Medicine, David Geffen School of Medicine,
UCLA; Core Faculty and Senior Physician,
Los Angeles County-Harbor-UCLA Medical
Center, Torrance, CA
EDITORIAL BOARD
Jeffrey R. Avner, MD, FAAP
Chairman, Department of Pediatrics,
Professor of Clinical Pediatrics,
Maimonides Children's Hospital of
Brooklyn, Brooklyn, NY
Steven Bin, MD
Associate Clinical Professor, UCSF School
of Medicine; Medical Director, Pediatric
Emergency Medicine, UCSF Benioff
Children's Hospital, San Francisco, CA
Richard M. Cantor, MD, FAAP,
FACEP
Professor of Emergency Medicine and
Pediatrics; Section Chief, Pediatric
Emergency Medicine; Medical Director,
Upstate Poison Control Center, Golisano
Children's Hospital, Syracuse, NY
Steven Choi, MD, FAAP
Chief Quality Officer and Associate Dean for
Clinical Quality, Yale Medicine/Yale School
of Medicine; Vice President, Chief Quality
Officer, Yale New Haven Health System,
New Haven, CT
Ari Cohen, MD, FAAP
Chief of Pediatric Emergency Medicine,
Massachusetts General Hospital; Instructor
in Pediatrics, Harvard Medical School,
Boston, MA
Jay D. Fisher, MD, FAAP, FACEP
Clinical Professor of Emergency Medicine
and Pediatrics, University of Nevada, Las
Vegas School of Medicine, Las Vegas, NV
Direct all inquiries to:
Phone: 678-366-7933
Fax: 770-500-1316
3475 Holcomb Bridge Rd, Suite 100,
Peachtree Corners, GA 30092
E-mail: ebm@ebmedicine.net
Website: www.ebmedicine.net
ISSN info and disclaimer:
Pediatric Emergency Medicine Practice (ISSN Print: 1549-9650, ISSN Online: 1549-9669, ACID-FREE) is published monthly (12 times per year) by EB
Medicine (PO Box 1671, Williamsport, PA 17703). Opinions expressed are not necessarily those of this publication. Mention of products or services
does not constitute endorsement. This publication is intended as a general guide and is intended to supplement, rather than substitute, professional
judgment. It covers a highly technical and complex subject and should not be used for making specific medical decisions. The materials contained
herein are not intended to establish policy, procedure, or standard of care. Pediatric Emergency Medicine Practice is a trademark of EB Medicine.
Copyright © 2021 EB Medicine All rights reserved. No part of this publication may be reproduced in any format without written consent of EB
Medicine. This publication is intended for the use of the individual subscriber only, and may not be copied in whole or in part or redistributed in any
way without the publisher’s prior written permission – including reproduction for educational purposes or for internal distribution within a hospital,
library, group practice, or other entity.
GROUP SUBSCRIPTIONS: groups@ebmedicine.net
Marianne Gausche-Hill, MD, FACEP,
FAAP, FAEMS
Medical Director, Los Angeles County EMS
Agency; Professor of Clinical Emergency
Medicine and Pediatrics, David Geffen
School of Medicine at UCLA; Clinical
Faculty, Harbor-UCLA Medical Center,
Department of Emergency Medicine, Los
Angeles, CA
Michael J. Gerardi, MD, FAAP,
FACEP, President
Associate Professor of Emergency Medicine,
Icahn School of Medicine at Mount Sinai;
Director, Pediatric Emergency Medicine,
Goryeb Children's Hospital, Morristown
Medical Center, Morristown, NJ
Sandip Godambe, MD, PhD
Chief Quality and Patient Safety Officer,
Professor of Pediatrics, Attending Physician
of Emergency Medicine, Children's Hospital
of The King's Daughters Health System,
Norfolk, VA
Ran D. Goldman, MD
Professor, University of British Columbia,
Pediatric Emergency Physician, BC
Children’s Hospital, Vancouver, BC, Canada
Joseph Habboushe, MD, MBA
Assistant Professor of Emergency Medicine,
NYU/Langone and Bellevue Medical
Centers, New York, NY; CEO, MD
Aware LLC
Alson S. Inaba, MD, FAAP
Pediatric Emergency Medicine Specialist,
Kapiolani Medical Center for Women &
Children; Associate Professor of Pediatrics,
University of Hawaii John A. Burns School of
Medicine, Honolulu, HI
Madeline Matar Joseph, MD,
FACEP, FAAP
Professor of Emergency Medicine and
Pediatrics, Assistant Chair, Pediatric
Emergency Medicine Quality Improvement,
Pediatric Emergency Medicine Division,
University of Florida College of Medicine-
Jacksonville, Jacksonville, FL
Stephanie Kennebeck, MD
Associate Professor, University of Cincinnati
Department of Pediatrics, Cincinnati, OH
27 © 2021 EB MEDICINE. ALL RIGHTS RESERVED.
Anupam Kharbanda, MD, MSc
Chief, Critical Care Services, Children's
Hospital Minnesota, Minneapolis, MN
Tommy Y. Kim, MD
Health Sciences Clinical Professor of
Pediatric Emergency Medicine, University
of California Riverside School of Medicine,
Riverside Community Hospital, Department
of Emergency Medicine, Riverside, CA
Melissa Langhan, MD, MHS
Associate Professor of Pediatrics and
Emergency Medicine; Fellowship Director,
Director of Education, Pediatric Emergency
Medicine, Yale University School of
Medicine, New Haven, CT
Robert Luten, MD
Professor, Pediatrics and Emergency
Medicine, University of Florida,
Jacksonville, FL
Garth Meckler, MD, MSHS
Associate Professor of Pediatrics, University
of British Columbia; Division Head, Pediatric
Emergency Medicine, BC Children's
Hospital, Vancouver, BC, Canada
Joshua Nagler, MD, MHPEd
Associate Division Chief and Fellowship
Director, Division of Emergency Medicine,
Boston Children's Hospital; Associate
Professor of Pediatrics and Emergency
Medicine, Harvard Medical School,
Boston MA
James Naprawa, MD
Attending Physician, Emergency
Department USCF Benioff Children's
Hospital, Oakland, CA
Joshua Rocker, MD
Associate Chief and Medical Director,
Assistant Professor of Pediatrics and
Emergency Medicine, Cohen Children's
Medical Center of New York, New Hyde
Park, NY
Steven Rogers, MD
Associate Professor, University of
Connecticut School of Medicine, Attending
Emergency Medicine Physician, Connecticut
Children's Medical Center, Hartford, CT
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Associate Professor, Emergency Medicine,
Pediatrics, and Medical Education; Director,
Pediatric Emergency Medicine; Director,
Simulation; Icahn School of Medicine at
Mount Sinai, New York, NY
Adam E. Vella, MD, FAAP
Associate Professor of Emergency Medicine
and Pediatrics, Associate Chief Quality
Officer, New York-Presbyterian/Weill Cornell
Medicine, New York, NY
David M. Walker, MD, FACEP, FAAP
Chief, Pediatric Emergency Medicine,
Department of Pediatrics, Joseph M. Sanzari
Children’s Hospital, Hackensack University
Medical Center; Associate Professor of
Pediatrics, Hackensack Meridian School of
Medicine, Hackensak, NJ
Vincent J. Wang, MD, MHA
Professor of Pediatrics and Emergency
Medicine; Division Chief, Pediatric
Emergency Medicine, UT Southwestern
Medical Center; Director of Emergency
Services, Children's Health, Dallas, TX
INTERNATIONAL EDITOR
Lara Zibners, MD, FAAP, FACEP,
MMEd
Honorary Consultant, Paediatric Emergency
Medicine, St. Mary's Hospital Imperial
College Trust, London, UK; Nonclinical
Instructor of Emergency Medicine, Icahn
School of Medicine at Mount Sinai, New
York, NY
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Emergency Medicine Pharmacist, Program
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Brittany M. Newberry, PhD, MSN,
MPH, APRN, ENP-BC, FNP-BC
Faculty, Emory University School of Nursing,
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Atlanta, GA; Nurse Practitioner, Erlanger
Western Carolina Hospital Murphy, NC
 Points & Pearls
QUICK READ
FEBRUARY 2021 | VOLUME 18 | ISSUE 2
Points
• Helpful techniques to evaluate neonatal vision
include dimming the lights, rocking, gently lower-
ing the head below the body, or having the parent
hold the patient upright over their shoulder.
• Topical anesthesia is a valuable adjunct to the
ophthalmologic examination and can serve as a
diagnostic tool to differentiate surface patholo-
gies from deeper processes.
• Beyond fundoscopy, ophthalmoscopes are help-
ful in assessing posterior chamber and posterior
segment pathology through evaluation of the
red reflex. An abnormal red reflex can alert the
clinician to vision-threatening disease such as
neoplasm, cataract, or hemorrhage
• If available, use ocular point-of-care ultrasound to
detect abnormalities in the lens, vitreous, retina,
and optic nerve. It is contraindicated when globe
rupture or high intraocular pressure is suspected,
as pressure on the eye can prompt further injury.
• Orbital cellulitis is usually the result of sinus
disease but may occur after contiguous spread
from an odontogenic focus. There are no con-
clusive data that orbital cellulitis can result from
periorbital cellulitis.
• Treat orbital cellulitis with IV ampicillin-sulbactam
or third-generation cephalosporins. Metronida-
zole or clindamycin can be added for anaerobic
coverage. Vancomycin may be added if methicil-
lin-resistant Staphylococcus aureus is suspected
based on risk factors and community prevalence.
• Neonatal conjunctivitis should raise suspicion
for aggressive underlying infection as the result
of Gonococcus, Chlamydia, or herpes. Superfi-
cial ocular cultures are always indicated in this
population. All infants with suspected gonococ-
cal or herpetic disease require evaluation for
disseminated disease, including blood tests and
a lumbar puncture.
• Hyperacute conjunctivitis with severe mucopuru-
lent discharge should raise suspicion for gono-
coccal or chlamydial conjunctivitis.
• Do not routinely order ocular-surface Gram stain
or culture for conjunctivitis, except for neonatal
conjunctivitis, hyperacute conjunctivitis, or her-
FEBRUARY 2021 • www.ebmedicine.net 28
An Evidence-based Approach
to Nontraumatic Ocular
Complaints in Children
Pearls
l In the setting of conjunctivitis, consider using a
clinical decision rule to risk stratify patients likely
to a have nonbacterial source or a negative bac-
terial culture. This includes patients who: (1) are
aged ≥6 years, (2) present in April-November,
(3) have absence of watery discharge, and/or (4)
absence of “glued” eye in the morning.
l The use of topical antibiotics for childhood
conjunctivitis to allow return to school is controver-
sial. It may not be medically indicated; however,
children may be allowed to return to school earlier.
l Recent data suggest that corneal abrasions may
be common in infants. It remains unclear wheth-
er small corneal abrasions in infants should be
considered a cause for fussiness.
pes simplex virus keratitis.
• Prescribe topical antihistamines and mast cell
stabilizers for suspected allergic conjunctivitis.
• Consider topical fluoroquinolones for Pseudo-
monas coverage for corneal abrasions in contact
lens wearers, and recommend they refrain from
wearing contact lenses until fully healed.
• For patients with corneal abrasions, do not use
cycloplegics, patching, corticosteroids, or topical
anesthesia on discharge.
• In atraumatic cases of hyphema, consider sys-
temic diseases. Hyphemas that occupy >50% of
the anterior chamber are more likely to have as-
sociated increased intraocular pressure and risk
of rebleeding. Place an eye shield and counsel
patients to avoid nonsteroidal anti-inflammatory
drugs and restrict activity.
• Always consult an ophthalmologist before pre-
scribing topical corticosteroids.
• Retinal artery occlusion is rare in children, but
is a true nontraumatic ocular emergency that
should be suspected in patients with painless,
severe vision loss in the setting of a predispos-
ing condition.
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