Ashika Shah, 4th year Medical Student; Dr Vikram Baicher, PEM Consultant; Ms Siobhan Wren, Consultant Ophthalmologist
Emergencies involving the eye are thankfully uncommon in Paediatrics. However, we all need to know something about the basics of managing ophthalmic emergencies in paediatrics so we can make safe assessments and get the initial management right.
This article will outline the common presentations that you’re most likely to see, and at the end of each case there are further resources that you may find helpful.
Picture yourself working a shift in Children’s A+E where all you see is eye problems! Let’s get to our first patient…
Corneal abrasion
Your first patient is 6 year old Kuldeep. Kuldeep was playing in a sandpit yesterday and was hit in the eye when another child threw their bucket and spade. Kuldeep’s dad Harish has brought him to the emergency department because it’s been 24 hours and Kuldeep’s eye is watering a lot and is uncomfortable all of the time.
You can’t see any foreign bodies in Kuldeep’s eye but wonder if he has a corneal abrasion. One of the nurses suggests you use some fluorescein – see how to do this here.
(This video shows fluorescein strips. Fluorescein drops are also available)
You see a small abrasion and prescribe Chloramphenicol ointment. You explain to Kuldeep and Harish that the abrasion will likely heal in the next few days but may take a week. The role of the antibiotic eye ointment is to prevent infection.
Harish should keep a watch out for worsening pain, redness, yellow/green discharge or visual disturbance. In these instances a further medical review would be required.
Further resources: Moorfields patient information leaflet
Trauma
You are pre-alerted to your next patient via the emergency phone! A paramedic crew are inbound with a 15 year old patient who has multiple stab wounds involving the chest and face. He is currently cardiovascularly stable but the crew are concerned as he appears to have been stabbed in the left eye.
In situations such as this you need to put out a Paediatric Trauma call and it’s worth pre-alerting the on call Ophthalmologist of the potential serious eye injury. Make sure you follow the usual A-E approach. Missing a potentially serious injury somewhere else could be devastating should you become distracted by any injury to the eye. It’s a good idea to include this in your pre-brief so that the whole team is aware.
When Jaimie arrives he is stable. Primary survey reveals two stab wounds one the right flank and another traversing the left eye lid. Jaimie has an obvious laceration across both his upper and lower eyelids, he has no proptosis and the globe appears normal if a little injected. Jaimie describes blurred vision in his left eye but can count fingers and identify colours. You follow Royal College of Radiologists guidance on imaging and perform a CT Chest/abdomen and Pelvis and take photos of Jamie’s injuries which go onto his electronic medical notes. Whilst Jaimie is in CT you consult with Ophthalmology. They advise the following basic management:
- 1. Appropriate pain relief
- 2. Comment on appearance of eye compared to other side, including pupil size and response to light
- 3. If there is no globe trauma (which can be assessed with fluorescein drops or strips), the eye team will be over to evaluate and address the lid laceration, as soon as possible
- 4. Topical antibiotics will be usually topical DROPS (ointment may interfere with surgical correction)
Jaimie’s CT scan shows superficial soft tissue injuries only and he goes to theatre for washout and closure of his wounds. He receives some antibiotics as per your hospital guideline and you go on to check his tetanus status.
Trauma involving the eye is almost always going to involve a consultation with the Ophthalmology team. Here are some top tips on the basic assessment and management of trauma to the eye in children and young people….
1. Make the patient comfortable (topical anaesthesia may help)
2. Look for (a)symmetry: bulging eye, proptosis (consider retro-orbital haemorrhage) or flat lid against deflated eye (penetrating globe injury)
3. Open eyelid – take care to apply no pressure to the eyeball. Look at gross appearance. Redness, clarity of cornea, anterior chamber and pupil size, then reaction to light.
4. Fluorescein dye, with a blue light, shines up an abrasion (Seidels sign, is where leaking of fluid can be seen from penetration trauma).
5. If penetrating trauma is suspected, the patient’s head is ideally elevated (depending on the general status)
Further reading/resources: Paediatric ophthalmology: Siobhan Wren at DFTB19
Wound care of an eyelid laceration
Here are some examples of Globe injuries – they can be subtle, so take a close look when you examine any patient’s eye and have a low threshold for escalating.
Chemical Injury
You have short break then pick up your next patient. Isaiah is 3 years old. His mum Phoebe returned from the bathroom to find Isaiah crying next to the kitchen cleaning cupboard. There was a bottle of bleach on the floor next to Isaiah, with a faulty lid on the floor next to him. Isaiah is crying, his eyes look red with a clear discharge. Phoebe has brought Isaiah to ED as she is worried he might have got bleach in his eyes.
In cases of suspected chemical injury, it’s important to estimate the extent of injury and structures involved. A collateral history of how the injury occurred and which chemicals were involved is important.
It is particularly important to establish whether the chemical was acidic or alkaline. Alkaline chemicals are usually worse as they can cause liquefactive necrosis.
Symptoms of chemical eye injury include pain, red eye, blepharospasm and photophobia. If there is doubt then a cautious approach would be recommended and you should start eye irrigation as soon as possible.
- Irrigate the eye with Hartmans or normal saline for example saline for around 20-30 minutes at the very least.
- Give anaesthetic drops – irrigation is uncomfortable and the eye needs to stay open while you irrigate! Use Proxymetacaine or Tetracaine
- Test the ocular pH to check whether the pH has neutralised, after which the eye may be examined.
- Visual acuity should be assessed.
The ophthalmologist can guide further management, such as antibiotic/steroid/cycloplegic drops.
For a deeper review of how to manage chemical eye injuries in children, take a look at this great article and video.
After irrigating Isaiah’s eyes, the pH returns to normal (i.e. 7.4). You consult ToxBase to make sure there aren’t any other concerns that need to be considered with regards to the bleach and follow the guidance on observation times and management.
Top tip
Eye irrigation, especially in younger children, can be distressing. In an emergency situation, where a child is too large to swaddle, sedation can be considered when managing the injuries acutely. Do not waste time organising general anaesthesia, as the first 30-60 mins are the most likely to bear any improvement in outcomes. So if you think you are going to need help, ask for it early.
A baby with ‘Sticky Eyes’
Your next patient is 8-day-old Mya. Her mother has brought her to ED as she is concerned about discharge from Mya’s eyes.
Mya was born at 39 weeks by normal delivery. There were no antenatal concerns and she is generally well in herself. Mya’s mother, Lydia, is also well in herself. She has 2 other children who are fit and well and had no such eye problems. Lydia is worried about the discharge from Mya’s eyes as it doesn’t seem to be getting any better.
On your way to seeing Mya you run through some differentials in your head and recall seeing a helpful table somewhere…!!
You listen to Lydia’s concerns about Mya – the discharge began from her left eye on day 4 of life. Lydia wipes the yellowish discharge away but it seems to be there again within a few hours. The discharge does not run down her cheeks and is not present all the time. Mya’s eyes don’t appear to be red and there are no lumps or bumps around her eyes. Both of her eyes appear normal when you look at them. You sensitively explain to Lydia that a differential for discharge from the eyes would include maternal sexually transmitted infections. Lydia assures you that she is unaware of any STIs but understands why you had to enquire and why a swab of Mya’s eye discharge would also be helpful.
You conclude that the most likely diagnosis at this stage is Dacryostenosis (blocked tear duct). You share some information with Lydia about this and send off a swab of the discharge to check that there is indeed no infection present. You explain to Lydia, should the swab grow a bug then some antibiotics +/- further review may be required and that she should return to ED should Mya become unwell in herself or develop any swellings around the eye (e.g. Dacroyocystocele see picture below). Otherwise this problem will get better by itself over the next few months. Should it still be a problem at around 6-12 months of age then a review with the Ophthalmology team may be helpful.
In cases where suspected vertical transmission of maternal STI is suspected, discuss management with Paediatrics and Ophthalmology.
Varicella Zoster
Following a lunch break the next patient you see is Georgie. Georgie is 4 years old and she has Chickenpox. Georgie’s mother, Jane, has brought her to the Emergency Department because she has noticed a lesion on her eye and was unsure if this would need treatment.
Georgie is normally fit and well. She has no fever and no evidence of any secondary infections to any of her VZV lesions. Other than being very itchy she is her normal self. You look at her eye and see the image below. Georgie has no pain in her eye, no visual disturbance and normal eye movements.
You are unsure how to proceed so, with consent you take a picture of Georgie’s eye which goes to her electronic medical records then call the Ophthalmology doctor on call for some advice.
The Ophthalmology registrar reviews the history and picture. She says that she can see marked temporal injection with blisters. Fluorescein staining pattern can help decide whether the infection is localised or more widespread.
There can be sight threatening issues (corneal and retinal pathology) so all redness should be aggressively managed. This can vary from topical antivirals (ganciclovir) to chloramphenicol (for ulceration) to steroids and non-steroidal drops for secondary inflammation, which will need antiviral cover. At the end of the call the Ophthalmology doctor advises a review in their clinical area for a final plan and follow up arrangements to be made.
Top tip – management of VZV eye lesions can be varied – if in doubt escalate to a senior in your department and Ophthalmology.
Orbital / periorbital cellulitis
Your next patient is 8 year old Charlie. Charlie has been brought to the Emergency Department by his mother Amy. Charlie’s left eye seems to be red and swollen. He has recently had some cough and cold symptoms and an intermittent fever over the past few days. This morning Amy noticed his eye was swollen and wasn’t sure what was wrong with it.
Charlie is normally fit and well, and he’s been eating and drinking normally.
Orbital and peri-orbital/pre-septal cellulitis can be confusing. The ‘septum’ is a fibrous layer, that is not fully developed until around age four. It divides the superficial tissues from the orbital contents
Hopefully the summary that follows can help with that…
Pre-septal cellulitis – Anterior to the orbital septum. Infection of the skin and other soft tissues around the eye.
Common. Unilateral eyelid swelling and erythema. Possibly slight pain or discomfort. White eye with normal motility. Mild cases can be managed with oral antibiotics and clear safety net advice/return instructions in cases that are getting worse or no better.
Orbital cellulitis – Posterior to the orbital septum. Infection involving the orbit and its contents. The tell tale signs (although these may not be present early in the disease process) are restricted or painful eye movements, reduced visual acuity, proptosis. Headache suggests intracranial involvement.
Orbital cellulitis is an Ophthalmic emergency. Serious complications include vision loss, rapid spread to an intracranial infection and cavernous sinus thrombosis. Urgent ENT and Ophthalmology opinions are required.
There is significant overlap in the symptoms and examination findings with Orbital and Peri-orbital cellulitis. It’s worth seeking senior advice in all cases and be especially vigilant where there is history of visual symptoms, headache, vomiting, sleepiness or drowsiness.
Styes (chalazion)
Your next patient is 3 year old Frankie. Frankie has been brought to the emergency department by her dad Winston. Frankie has a lump on her eyelid and it seems to be getting bigger. Several people have commented on it and Winston is concerned that Frankie may need some antibiotics or an operation.
You go and see Frankie and Winston. Frankie appears well in herself, she is apyrexial and happily playing. Winston explains that Frankie had a similar lump in her eyelid a few weeks ago and it went away by itself. Frankie has a normal appearing eye, normal eye movements, there is no discharge. Winston denies any history of trauma and you cannot see any foreign bodies. You examine Frankie’s eye and see a lesion as per picture below.
A stye is a localised infection on the eyelid which forms due to the blockage of a meibum gland or eyelash follicle. Most are self-limiting issues that resolve with time and supportive management.
You print out the Moorfields information leaflet and reassure Frankie and her dad outlining the safety net advice regarding evidence of infection spread or it not resolving.
It’s the end of your shift seeing lots of eye problems. You reflect back on the patients you have seen.
- Kuldeep with his corneal abrasion – how to use fluorescein and to prescribe Chloramphenicol ointment.
- Jaimie with his stab wounds – don’t get distracted by the eye injury – you still need to do an A-E assessment and have a low threshold for escalation.
- Isaiah with his chemical eye injury – irrigate, irrigate irrigate! This may only be possible with anaesthetic. You also now know how to check ph of the eye
- Mya – the baby discharging eyes. Always consider infections but also beware this could be a benign issue.
- Georgie with possible VZV lesions in his eye – management can be varied. Phone a friend if you need to.
- Charlie – pre-septal cellulitis vs orbital cellulitis – one is benign and the other an emergency – don’t be afraid to ask for help
- Frankie with a Stye – the appearance of these lesions can be upsetting for the child and parents alike, spending time and explaining what is going on and safety-netting appropriately will help allay some anxieties resources from Moorfields can be helpful
Authors: Ashika Shah – 4th year Medical Student, University of Nottingham; Vikram Baicher – PEM Consultant, Nottingham University Hospitals; Siobhan Wren – Consultant Ophthalmologist, Imperial College Trust London
Further useful resources
Moorfields Eye Hospital, How to clean eyelids in children and babies:
Moorfields Eye Hospital, How to administer eye drops in children and babies: