Pediatric emergency medicine trisk 0595 0595
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FIGURE 28.4 Patient is looking upward. Right inferior orbital wall blowout fracture causes
restriction of upward gaze in right eye. Note light reflexes (Hirschberg test). Left reflex (arrow
) is lower in reference to pupil than right reflex, indicating the presence of a right hypotropia.
The physical examination should be complete, with specific focus on the
neurologic and ophthalmologic evaluation. The ophthalmologic examination
should include visual function, pupillary activity, and extraocular movements.
The presence or absence of ptosis, lid retraction, proptosis, or enophthalmos
should be noted.
The Hirschberg light reflex is a helpful screening test in determining whether
strabismus is present. The physician should shine a penlight or direct
ophthalmoscope light at the patient’s eyes from 2 to 3 ft while the patient is told
to look at the other end of the room. In younger children, the patient may choose
to look at the light itself, but efforts should be made to distract the child with a
more distant target. The examiner should observe the white dot light reflex that
appears on the cornea, overlying the iris or pupil of each eye. In the normal state,
the light reflex should be located in a nearly symmetric position and falls slightly
off-center in the nasal direction in both eyes ( Fig. 28.5 ). If the eyes are
misaligned, symmetry of the Hirschberg light reflex would not be preserved (
Figs. 28.4 and 28.6 ).
The cover/uncover test further helps to tease out tropia (manifest strabismus)
from phoria (latent strabismus). For the cover test, with the patient fixating at a
distance, cover one eye and observe the other. If the uncovered eye moves or
shifts into alignment, an ipsilateral tropia is present. The uncover test will divulge
