Ophthalmic conditions can present to the pediatric hospitalist in several settings. Usually, it is an incidental complaint or secondary finding during the evaluation of another presenting issue; for example, a red eye in a patient being treated for bronchiolitis. Occasionally, it is the reason for admission as in orbital cellulitis. Other times, ophthalmology consultation is required for supplemental information for a complicated systemic issue as in the need for a dilated fundus exam in a setting of presumed child abuse.
This chapter will review basic ophthalmic history taking and examination skills for the pediatric hospitalist. It will also provide information about the common ophthalmic conditions encountered by the pediatric hospitalist.
As in most fields in medicine, the most important part of ophthalmologic assessment is the chief complaint and history. Many common ophthalmic diseases can be diagnosed from the history alone. Children present with eye conditions for three general reasons: “I can’t see,” “My eye(s) hurt(s),” “My kid’s eye looks funny,” or some combination of the three. Eliminating one or more of these categories helps narrow the differential diagnosis.
If the child is old enough, it is important to ask if he or she has noticed a change or loss in vision. Most children will not differentiate one eye from the other and will simply say, “Things are blurry” or “I can’t see.” In pre-verbal children, the caregiver often notes vision loss, and history taking will elicit information such as “He is sitting closer to the TV than he used to” or “She keeps tripping or bumping into things.”
It is imperative to ask about trauma to the eye. For example, children may not volunteer the history that their friend shot them in the eye with a pellet gun.
In addition to a good history, a focused and simple eye exam can help differentiate a minor issue from a vision- or life-threatening condition. If a near card is available, and the child can read numbers, the vision in each eye individually should be recorded. The vision with both eyes open is not useful. If this card is not available or if the child cannot use it, documenting if the child can count fingers or blinks to light is necessary. If a vision cannot be obtained, it is necessary to obtain an accurate history regarding any change or loss in vision. Examination of the eyelids and skin around the eyes is helpful in settings of trauma and a red eye. The pediatric hospitalist should take note of any lacerations, foreign bodies, vesicles associated with herpes simplex or zoster, or presence for a preauricular node. The conjunctiva, sclera, cornea, anterior chamber, iris, and lens compose the anterior segment of the eye. Evaluation with a penlight is useful for noting gross defects. When mild trauma is suspected, fluorescein dye can be used to evaluate for a corneal abrasion under cobalt blue light or Wood’s lamp.
In a patient with a complaint of unilateral vision loss, perhaps the most important objective test is the presence or absence of a relative afferent pupillary defect (APD). The “swinging flashlight test” is used to determine a defect in an eye’s ability to sense light (Figure 160-1).
FIGURE 160-1.
A. Intact direct and consensual light response. Both pupils react briskly to light and when the “swinging flashlight test” is performed, both pupils stay constricted. B. Left eye with a relative afferent pupillary defect (RAPD). As the light is swung from right to left, the left pupil shows a diminished direct response to light. The right eye has a similar diminished consensual response. C. Left eye with an RAPD in the setting of a fixed left pupil (i.e. traumatic pupil, left third nerve palsy, etc.). Though the left pupil has no direct response to light the RAPD in the left eye can be ascertained by the swinging flashlight test. The right pupil dilates (from a previously constricted state) when the light swings from right to left.
Two things should be noted with regard to motility. The extent of excursion (degree to which the eye moves in all positions of gaze) of each eye should be noted. Alignment of the eyes in primary gaze is also important. Gross misalignments can be assessed using the Hirschberg test. A stationary light is directed at the child’s face from 2 to 3 feet away, and the position of the light reflex off the cornea is noted in both eyes. If the reflection is not on the same position of the cornea in both eyes, then a deviation is present (exotropia or esotropia).
Perhaps the most commonly seen ophthalmologic complaint in an inpatient pediatric setting is a red eye. Figure 160-2 presents a diagnosis algorithm of the red eye. Any red eye that is associated with eye pain should have ophthalmology consultation. An exhaustive description of all causes of a red eye is beyond the scope of this chapter.
FIGURE 160-2.
Diagnosis algorithm for a red eye. This algorithm covers broad spectrums of disease. Some conditions (i.e. herpes) can fit into many of these categories. If a history of trauma is present, this algorithm is invalid. When in doubt, ophthalmology consultation is essential as more advanced exam techniques may be required.
Bacterial infection of the periocular soft tissues is differentiated by the anatomic location. Infection and resultant inflammation restricted to the eyelids and soft tissues anterior to the orbital septum is deemed preseptal cellulitis. Involvement of disease posterior to the orbital septum is considered orbital cellulitis. Preseptal cellulitis and orbital cellulitis have distinct ocular sequelae and differences in management.
For both of these conditions, children most often present with progressive edema and erythema of the eyelids. Differentiation between preseptal and postseptal disease can usually be made on clinical exam. Inflammation of structures posterior to the orbital septum can cause “orbital signs” such as proptosis, chemosis (edema of the conjunctiva), limited ocular motility, and an afferent pupillary defect (APD). A patient may complain of diplopia in cases of limited ocular motility. A complaint of decreased vision, much like an APD, can be a sign of optic nerve inflammation but is unreliable as an indicator of posterior infection as significant eyelid edema can obscure the pupil and/or cause astigmatism with pressure on the cornea.
Treatment of preseptal cellulitis in children is oral antibiotics. Typically, an empiric antibiotic that covers Staphylococcus, Streptococci, and anaerobes is chosen, such as amoxicillin-clavulanic acid or clindamycin.
Children with any systemic symptoms such as fever, poor enteral intake, severe upper respiratory infection/sinusitis, or who are failing outpatient management (worsening of eyelid edema despite antibiotics or development of orbital signs) should have a computed tomography scan of the orbits and sinuses and be admitted for intravenous antibiotics. The patient should be treated with a broad-spectrum antibiotic that covers Staphylococcus, Streptococci, and gram-negative rods.1 If intracranial extension is suspected, metronidazole should be added to cover anaerobic organisms. Patients can be discharged when there is clinical improvement of the cellulitis and patient is able to tolerate oral antibiotics to complete treatment.
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