Pediatric emergency medicine trisk 3665 3665
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HISTORY
The emergency provider should quickly assess the child’s relevant past history in
order to assess the expected baseline visual acuity. The mechanism of injury
should also be ascertained in order to understand the risk of serious ocular
pathology and predict injury patterns. Finally, the patient should be asked about
current symptoms including pain, decrease in vision, foreign body sensation,
photophobia, or tearing.
Assessment of Prior Eye Pathology and Relevant Medical
History
It is important to establish the child’s prior ocular history in order to assess the
anticipated baseline visual acuity. A history of poor vision including use of
contact lenses or glasses, amblyopia, or strabismus surgery should be queried. If
the child is wearing contact lenses, they should be removed if this can be done
safely. A history of systemic disorders may predispose some children to specific
injuries or worse outcomes. For example, patients with collagen disorders are
more prone to open-globe injuries or intraocular hemorrhage, and patients with
sickle cell anemia have a higher incidence of complications from hyphema.
Assessment of Injury Mechanism
Clinicians should assess the exact mechanism of injury as the type of trauma and
the nature of the force inflicted may predict injury patterns and prognosis. For
example, significant blunt impact directly to the globe (e.g., baseballs),
projectiles, and sharp objects (e.g., sticks or pencils) have high risk of intraocular
damage. Severe blunt trauma may cause orbital fractures and can also rupture the
globe. Projectiles pose great risk to the globe, and globe rupture sustained
following gun injury often leads to poor visual outcome. Hammering, drilling,
filing, and nailing are particularly high-risk behaviors for intraocular foreign
bodies, especially if safety eyewear use is suboptimal.
PHYSICAL EXAMINATION
Every attempt should be made to examine the eye with the child in a position of
comfort in order to minimize agitation, particularly if the history or gross
appearance of the eye suggests the possibility of an open-globe injury. If the
examination is concerning for an open-globe injury, the physician should stop the
examination, shield the eye, and consult an ophthalmologist emergently. Pain
medications and antiemetics can help reduce common causes of elevated
intraocular pressure that can lead to further prolapse of intraocular contents.
