Pediatric Ophthalmology in the Emergency Room Evaluation
and Treatment, 1st Edition
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V
Preface
Thank you for interest in Pediatric Ophthalmology in the Emergency
Room.
This text represents 15 years of experience in managing acute oph-
thalmic problems in children that bring them to the emergency room,
and the passion I have in doing so. The chapter authors represent a
diverse group of specialists from ophthalmology, emergency medicine,
pediatrics, and radiology who offer their expertise in the multidisci-
plinary team management that I feel yields the best care for children.
Many of the authors practice at busy level one trauma centers with a
large volume of pediatric visitors.
This text is intended for a diverse group of healthcare professionals
that include anyone who cares for children in an acute setting from ini-
tial assessment to final treatment and follow up. This includes pediatri-
cians, emergency room physicians, nurses, physician assistants, trauma
surgeons, medical students, residents, fellows, neurologists, neurosur-
geons, and ophthalmologists among others.
The information presented in this text should give the reader a broad
insight into the common ophthalmic conditions that may bring a child
in for an acute healthcare visit. Each chapter should give a logical
approach to the evaluation and management of these various condi-
tions. The text highlights various ways in which children present differ-
ently and necessitate different treatment algorithms from adults with
similar conditions. With an abundance of clinical and radiographic
images, clinicians will be visually aided in their diagnostic care. The
important skills of patience and compassion towards children and their
parents are highlighted throughout the book, as are the specialized
diagnostic and surgical skill needed in caring for pediatric patients. It is
my hope that this text serves as a valuable resource in the management
of pediatric ophthalmic conditions with the ultimate goal of preserving
or improving the vision of our children.
Roman Shinder, MD, FACS
Brooklyn, NY, USA
VII
Contents
I Introduction
1 ediatric Patient Encounter in the Emergency
P
Department . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Nizar Tejani, Danielle A. S. Holmes, and Nooruddin R. Tejani
2 Ocular Motility in the Pediatric Emergency Room . . . . . . . . . . . . 15
James A. Deutsch and John R. Kroger
3 Imaging the Pediatric Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Aslan Efendizade, Suraj Patel, Zerwa Farooq,
and Vinodkumar Velayudhan
II Ophthalmic Trauma
4 Orbital Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Stella Y. Chung and Paul D. Langer
5 Eyelid Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Adam R. Sweeney and Richard C. Allen
6 The Nasolacrimal System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Nora Siegal and Christopher B. Chambers
7 Pediatric Corneal Emergencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
Douglas R. Lazzaro and Jennifer Barger
8 Anterior Chamber and Lens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Laura Palazzolo, Nicole Lanza, and Allison E. Rizzuti
9 Retina and the Posterior Segment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
Ekjyot S. Gill, Eric M. Shrier, and Ilya Leskov
10 Neuro-Ophthalmic Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
Laura Palazzolo, Daniel Wang, and Valerie I. Elmalem
III Infections
11 Ocular Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
Charles G. Miller and Frank Cao
12 Extraocular Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
Liza M. Cohen and Daniel B. Rootman
VIII Contents
IV Inflammations
13 Ocular Inflammation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
Levon Djenderedjian and David Mostafavi
14 Extraocular Inflammation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191
Valerie H. Chen and Edward J. Wladis
V Ophthalmic Cancer and Masses
15 Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217
Andrei P. Martin, Lauren A. Dalvin, Li-Anne S. Lim,
and Carol L. Shields
16 Ophthalmic Plastics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241
Sana Ali Bautista and William Rocamora Katowitz
17 Headache, Visual Loss and Papilledema . . . . . . . . . . . . . . . . . . . . . . . 257
Valerie I. Elmalem, Duaa Sharfi, and Daniel Wang
Supplementary Information
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 283
IX
Contributors
Richard C. Allen, MD, PhD, FACS Baylor College of Medicine, Department of
Ophthalmology, Houston, TX, USA
[email protected]Jennifer Barger, MD NYU Grossman School of Medicine, Department of
Ophthalmology, New York, NY, USA
[email protected]Sana Ali Bautista, MD The Children’s Hospital of Philadelphia, Division of
Ophthalmology, Philadelphia, PA, USA
[email protected]Frank Cao, MD Millman-Derr Center for Eye Care, Rochester Hills, MI, USA
[email protected]
Christopher B. Chambers, MD, FACS Department of Ophthalmology,
Harborview Eye Institute, University of Washington, Seattle, WA, USA
[email protected]Valerie H. Chen, MD Lions Eye Institute, Department of Ophthalmology,
Albany Medical College, Albany, NY, USA
[email protected]Stella Y. Chung, MD, MS Rutgers New Jersey Medical School, The Institute of
Ophthalmology and Visual Science, Newark, NJ, USA
[email protected]
Liza M. Cohen, MD Division of Orbital and Ophthalmic Plastic Surgery, Stein
and Doheny Eye Institutes, University of California, Los Angeles, Los Angeles,
CA, USA
[email protected]Lauren A. Dalvin, MD Wills Eye Hospital, Ocular Oncology Service, Philadel-
phia, PA, USA
Mayo Clinic, Department of Ophthalmology, Rochester, MN, USA
[email protected]James A. Deutsch, MD Department of Ophthalmology, SUNY Downstate
Medical Center/Kings Counter Hospital Center, Brooklyn, NY, USA
[email protected]Levon Djenderedjian, MD SUNY Downstate Medical Center, Brooklyn,
NY, USA
[email protected] X Contributors
Aslan Efendizade, DO Department of Diagnostic Radiology, SUNY Down-
state Medical Center, Brooklyn, NY, USA
[email protected]Valerie I. Elmalem, MD New York Eye and Ear Infirmary of Mount Sinai,
Department of Ophthalmology, New York, NY, USA
[email protected]
Zerwa Farooq, MBBS Department of Diagnostic Radiology, SUNY Down-
state Medical Center, Brooklyn, NY, USA
[email protected]Ekjyot S. Gill, MD SUNY Downstate Medical Center, Brooklyn, NY, USA
[email protected]Danielle A. S. Holmes, MSc, MD SUNY Downstate Health Sciences Center,
Brooklyn, NY, USA
[email protected]William Rocamora Katowitz, MD The Children’s Hospital of Philadelphia,
Division of Ophthalmology, Philadelphia, PA, USA
[email protected]John R. Kroger, MD Department of Ophthalmology, SUNY Downstate
Medical Center, Brooklyn, NY, USA
[email protected]Paul D. Langer, MD, FACS Rutgers New Jersey Medical School, The I nstitute
of Ophthalmology and Visual Science, Newark, NJ, USA
[email protected]
Nicole Lanza, MD, MEd Department of Ophthalmology, SUNY Downstate
Medical Center, Brooklyn, NY, USA
[email protected]Douglas R. Lazzaro, MD, MBA, FACS NYU Grossman School of Medicine,
Department of Ophthalmology, New York, NY, USA
[email protected]Ilya Leskov, MD, PhD SUNY Downstate Medical Center, Brooklyn, NY, USA
[email protected]
Li-Anne S. Lim, MBBS Wills Eye Hospital, Ocular Oncology Service, Philadel-
phia, PA, USA
[email protected]
Andrei P. Martin, MD, DPBO Wills Eye Hospital, Ocular Oncology Service,
Philadelphia, PA, USA
[email protected]
XI
Contributors
Charles G. Miller, MD, PhD Department of Ophthalmology, SUNY Down-
state Medical Center, Brooklyn, NY, USA
[email protected]David Mostafavi, MD Mostafavi Eye Institute, Staten Island, NY, USA
[email protected]Laura Palazzolo, MD Department of Ophthalmology, SUNY Downstate
Medical Center, Brooklyn, NY, USA
[email protected]Suraj Patel, MD Department of Diagnostic Radiology, SUNY Downstate
Medical Center, Brooklyn, NY, USA
[email protected]Allison E. Rizzuti, MD Department of Ophthalmology, SUNY Downstate
Medical Center, Brooklyn, NY, USA
[email protected]Daniel B. Rootman, MD, MS Division of Orbital and Ophthalmic Plastic Sur-
gery, Stein and Doheny Eye Institutes, University of California, Los Angeles,
Los Angeles, CA, USA
[email protected]Duaa Sharfi, MD New York Eye and Ear Infirmary of Mount Sinai, Depart-
ment of Ophthalmology, New York, NY, USA
[email protected]
Carol L. Shields, MD Wills Eye Hospital, Ocular Oncology Service, Philadel-
phia, PA, USA
[email protected]Roman Shinder, MD, FACS Professor of Ophthalmology, Otolaryngology,
Department of Ophthalmology, Otolaryngology, SUNY Downstate Medical
Center, Brooklyn, NY, USA
[email protected]Eric M. Shrier, MD SUNY Downstate Medical Center, Brooklyn, NY, USA
[email protected]Nora Siegal, MD, PhD Department of Ophthalmology, Harborview Eye Insti-
tute, University of Washington, Seattle, WA, USA
[email protected]Adam R. Sweeney, MD Baylor College of Medicine, Department of Ophthal-
mology, Houston, TX, USA
[email protected]Nizar Tejani, MD Louisiana State University Health Shreveport,
Shreveport, LA, USA
[email protected] XII Contributors
Nooruddin R. Tejani, MD, FAAP SUNY Downstate Health Sciences Center,
Brooklyn, NY, USA
[email protected]Vinodkumar Velayudhan, DO State University of New York Downstate
Medical Center, Department of Radiology, Brooklyn, NY, USA
[email protected]Daniel Wang, MD New York Eye and Ear Infirmary of Mount Sinai, Depart-
ment of Ophthalmology, New York, NY, USA
[email protected]
Edward J. Wladis, MD, FACS Lions Eye Institute, Department of Ophthalmol-
ogy, Albany Medical College, Albany, NY, USA
[email protected] 1 I
Introduction
Contents
Chapter 1 Pediatric Patient Encounter in the
Emergency Department – 3
Nizar Tejani, Danielle AS Holmes, and
Nooruddin R. Tejani
Chapter 2 Ocular Motility in the Pediatric
Emergency Room – 15
James A. Deutsch and John R. Kroger
Chapter 3 Imaging the Pediatric Patient – 29
Aslan Efendizade, Suraj Patel, Zerwa Farooq,
and Vinodkumar Velayudhan
3 1
Pediatric Patient Encounter
in the Emergency Department
Nizar Tejani, Danielle A. S. Holmes, and Nooruddin R. Tejani
Contents
1.1 Introduction – 4
1.2 Pediatric Eye Anatomy and Visual Development – 4
1.3 valuation of Children with Ophthalmic Complaints
E
in the ER – 5
1.3.1 istory – 5
H
1.3.2 Physical Exam – 6
1.4 Conclusion – 11
References – 12
© Springer Nature Switzerland AG 2021
R. Shinder (ed.), Pediatric Ophthalmology in the Emergency Room,
https://doi.org/10.1007/978-3-030-49950-1_1
4 N. Tejani et al.
1.1 Introduction by understanding the physiological develop-
1 ment of vision in the pediatric population. It
Eye-related visits in the pediatric population is incumbent upon the emergency medicine
represent a small portion of total emergency physician to know when to seek the consulta-
department visits. In 2010, roughly 2 million, tion of the ophthalmologist. This chapter
or 1.5%, of emergency department visits reviews the comprehensive evaluation of a
received an ophthalmic principle diagnosis. Of child presenting to the emergency department
these visits, 27.8% were attributed to patients with an eye complaint.
less than 18 years of age [1]. Data from 2006 to
2011 show a similar representation of the
pediatric age group at 31.2% [2]. These encoun- 1.2 ediatric Eye Anatomy
P
ters seem to be increasing – a comparison of and Visual Development
data from 2001 to 2007 and 2006 to 2011 sug-
gests a significant rise in the annual number of . Figure 1.1 details the ocular anatomy. The
pediatric eye-related visits to the emergency eyelids are superficial to the globe and serve
department [2, 3]. While it is unclear if this three main functions: protection of the eye
increase is proportional to the overall increase from trauma through the blink reflex, clear-
in emergency department visits in the United ance of foreign bodies, and distribution of
States, this underscores the importance of a tear film across the cornea to provide a clear
strong foundation in evaluating eye-related and undistorted optical surface. The meibo-
complaints in this patient population. mian and Zeis sebaceous glands line the mar-
Pediatric ophthalmologic complaints in gin of the eyelids and secrete oils which coat
the emergency department include a wide the surface of the eye and keep the tears from
spectrum of emergent and non-emergent con- evaporating too quickly.
ditions that require thorough evaluation. Beneath the eyelids is the conjunctiva, a
Early diagnosis and management are critical mucus membrane which lines the posterior
to preserving a child’s vision and may be aided surface of the lid and extends onto the globe
.. Fig. 1.1 The ocular anatomy
Pediatric Patient Encounter in the Emergency Department
5 1
to the limbus, which represents the peripheral There are two chambers in front of the
corneal junction. The portion covering the lens – the anterior chamber is the region
globe is known as the bulbar conjunctiva, and between the cornea and the iris, and the poste-
the portion lining the posterior surface of the rior chamber is between the iris and lens. The
eyelid is known as the palpebral conjunctiva. anterior and posterior chambers are filled with
The conjunctiva is made of a non-keratinized a clear fluid called aqueous humor. The large
squamous epithelium containing goblet cells. space behind the lens is the vitreous body filled
Beneath the epithelium is the conjunctival with a gel-like fluid called vitreous humor.
stroma also known as the substantia propria, The retina is the layer that lies interior to
a highly vascularized tissue that is the site of the sclera and choroid. Light stimulates reti-
immunologic activity. On exam, the conjunc- nal photoreceptors to produce neural signals
tiva is transparent. that the optic nerve carries to the brain. The
Deep to the conjunctiva lies the sclera, the vascular choroid layer deep to the retina pro-
tough, fibrous white shell of the eye that pro- vides the retina with the nutrition it requires.
vides shape and support. Contiguous with the The ophthalmic artery provides most of the
sclera, the transparent cornea is the anterior blood supply to the orbital structures. It is a
surface of the globe. Most of the focus power branch of the internal carotid artery. The
of the eye is from the curvature of the cornea. superior and inferior ophthalmic veins drain
The cornea is avascular, composed of special- the orbital tissues into the cavernous sinus.
ized epithelial cells, and innervated by cranial
nerve V, the trigeminal nerve.
The uveal tract has three structures: the
1.3 valuation of Children with
E
choroid, the iris, and the ciliary body. The iris
gives the eye its color. The iris’ development is Ophthalmic Complaints
completed by the eighth month of gestation in the ER
developing from the ciliary body [4]. The color
which develops throughout the first year of 1.3.1 History
life is determined by the amount of pigment
and density of the iris stroma. The iris’ func- The evaluation of a child presenting with an
tion controls the size of the pupil and thus eye complaint begins with a thorough history
controls the amount of light that falls on the from both the child and the caregiver present.
retina. This change in size is an involuntary Chief complaints may include eye pain, dis-
reflex requiring cranial nerve II, cranial nerve charge, and changes to vision. The history of
III, and the brain stem connections. present illness should identify onset, severity,
Sympathetic stimulation dilates the pupil by ameliorating and exacerbating factors, mon-
causing iris dilator muscles to contract, ocular or binocular symptoms, previous ocu-
whereas parasympathetic stimulation causes lar history, and associated symptoms. Past
miosis, or pupillary constriction, by causing medical history encompasses the child’s birth
the iris sphincter muscles to contract. The cili- history and development as well as the mater-
ary body lies peripherally to the iris and pro- nal prenatal history. Perinatal infections with
duces aqueous humor. Ciliary muscle fibers ocular sequelae, including toxoplasmosis,
adjust the visual focus by releasing tension on rubella, CMV, HSV, and others, are of par-
the suspensory fibers, or zonules, of the lens ticular concern. The results of genetic testing
which changes the shape and focusing power may also be pertinent to the child’s past medi-
of the lens. The lens is an avascular, cal history. Other important components
transparent, elliptical structure which further include past surgical history, contact lens use,
focuses the light rays on the retina. The lens allergies to food, environmental substances
shape is determined by the ciliary muscle con- and medications, vaccination status, family
tractions. The change in the lens shape is the history, and social history. A review of sys-
mechanism by which humans accommodate tems can be used to identify any concurrent
to clearly see near objects and small print. systemic symptoms.
6 N. Tejani et al.
1.3.2 Physical Exam
1 .. Table 1.1 Eye exam mnemonic: VEM PF
1.3.2.1 Overview V Visual acuity
The ophthalmologic physical examination of E External exam
the child is vital to formulating a diagnosis
M Extraocular movements
and management plan and knowing when to
involve the ophthalmologist. The challenges P Pupillary response
to obtaining a comprehensive examination F Fundoscopy
in the emergency department are myriad: the
child may be in distress from an injury, the
infant or toddler may not be cooperative, and allows the consulting ophthalmologist to
caregivers may not be helpful in comforting determine whether the complaint requires an
their distressed child. This becomes particu- urgent evaluation or a routine follow-up in an
larly important when the child has a diagnosis outpatient setting.
of attention deficit hyperactivity disorder or Visual acuity testing should be modified
autism. based on the child’s age and development. By
There are two primary keys to examin- 3 months of age, the infant should be able to
ing a child’s eye: speed and distraction. The fixate on and follow an object. In these prever-
technique of distraction can be instrumental bal children until 3 years of age, the examiner
in examination and can be as simple as using should cover each eye and assess for smooth
a small toy to test the patient’s ability to fix tracking of the object by the uncovered eye.
and follow. The fixation reflex is useful to Patients with decreased visual acuity in one
assess vision in young infants or uncoopera- eye will often make a fuss when their better
tive patients. seeing eye is covered.
Visual acuity is examined first. The method Vision in verbal children older than 3 years
by which visual acuity is examined depends of age should be tested using standardized eye
on the age and mental status of the patient. charts. Again, the age of the patient should
A letter chart is appropriate to test vision in a be considered when interpreting the results
child’s age 5 years and older, given that they are of the exam. Children between the ages of 3
familiar with the English alphabet. Younger and 5 years should have at least 20/40 vision.
children might use a chart with easily identi- It is normal for these children to have an acu-
fied pictures. In infants, the ability to perceive ity difference of one line [5]. Children older
light is the most sensitive test for their vision. than 5 years of age should normally have
This is followed by an external examination 20/25 vision or better without any signifi-
of the eye looking for any apparent strabis- cant difference in vision between both eyes
mus, ptosis, ocular injection, or other gross [5]. Eye charts may be chosen based on the
abnormalities. Next, extraocular movement is child’s development. For example, in children
evaluated for any movement limitation, pain, who have not learned the English alphabet,
or diplopia. Pupils are assessed for reactivity the Allen card or Tumbling E chart may be
and symmetry. Using an o phthalmoscope, the used. In patients who are unable to stand and
red reflex is assessed, and the fundus is exam- view diagrams at a distance, the Rosenbaum
ined. The mnemonic VEM PF is often used near vision card or Allen reduced picture
as a memory aide in recalling the steps of the card may be placed 14 inches from the child
ophthalmic exam (. Table 1.1). [6]. The Snellen chart is commonly found
in most emergency departments and can be
1.3.2.2 Visual Acuity used in verbal children who can identify let-
Visual acuity is the vital sign of the eye and ters. Prior to any eye chart test, the examiner
should hold the highest priority in the evalua- should ensure a standardized exam. Patients
tion of a pediatric patient in the emergency should be instructed to wear their corrective
room. A standardized visual acuity exam glasses or contact lenses and to stand at the
Pediatric Patient Encounter in the Emergency Department
7 1
recommended distance. The vision of each visual deficit [7]. Hence, the rationale behind
eye should be tested independently by hav- the need for urgent ophthalmology consult in
ing the child use an occluder to cover one eye. conditions like congenital ptosis and strabis-
Children may sometimes try to cheat during mus is that it might alter the visual pathway.
this test, particularly when the eye with better The rate of vision development remains steep
visual acuity is occluded. To prevent peeking, until about 2 years of life, at which time three-
the child’s guardian can hold the occluder, dimensional binocular depth perception
or an eye patch can be used. When patients develops [7]. It is not until 8 years of age that
are suspected of malingering, a useful exam the brain’s development of vision is complete.
technique is to ask them to write their name The macula (area of the retina responsible
on paper. Typically, children who truly have for central vision) in young infants is not fully
vision loss will still be able to complete this developed; therefore, the eyes do not fixate
task. The malingering child may refuse to try well centrally and do not follow objects until
to prove to the examiner that vision loss is about 3–4 months of age. The quality and
significant. duration of fixation can be an indirect mea-
The patient may not be able to complete surement of vision – if fixation is steady and
the eye chart exam for many reasons including maintained, and then visual acuity is assumed
distress, inadequate pain control, and obstruc- to be intact. However, if the fixation is inter-
tion of sight due to swelling and compromised mittent and poorly maintained, the visual
vision. Topical analgesia should be adminis- acuity is often found to be compromised.
tered to patients with pain. However, if unable Accommodation (the ability to focus on near
to complete visual acuity testing using charts, objects) develops by 4 months [8].
it is important to document vision based on Visual acuity, like all things in pediatrics, is
finger counting, detection of motion, and dependent on the patient’s age. Visual acuity
light perception. Start by standing at a dis- for newborns is approximately 20/400; how-
tance and asking the patient to cover one eye ever, a more useful measurement of visual
and to count the number of fingers held up by function is assessed by pupillary light
the examiner. If the patient is unable to do so, responses or by aversion to bright lights [9].
move closer to the patient and repeat. If unable An infant of 6 months should have a visual
to count fingers up close, then inquire if they acuity of 20/60–20/100. A child of 3 years
can detect the waving hand. In the absence should be able to use the tumbling E chart or
of motion detection, shine a light near the recognize common symbols. At this age, they
patient’s eye, and assess for light perception should see at a range of 20/25–20/30. At the
and light projection by asking the patient to age of 5 years, the patient should have a visual
identify the presence and position of the light acuity of 20/25–20/20, though some variation
source. In these circumstances, urgent oph- exists. However, if the visual acuity is less than
thalmologic consultation is imperative as the 20/20 by 8 years of age, the patient should be
threat to binocular vision loss remains even if referred to an ophthalmologist for evaluation.
visual acuity in one eye is initially preserved. A
delay in referral may increase chances of poor 1.3.2.4 External Exam
visual outcome and amblyopia. Eyelids
The external pediatric eye exam should begin
1.3.2.3 Visual Development with observation. First, the position, shape,
Pediatric visual development is a complex sys- and passive movement of the eyes should be
tem that requires visual stimulation from both observed. Asymmetry of the lids can give
eyes during the first 3–4 months of life to valuable hints to underlying defects in the
ensure proper development of neuro-ocular muscles and nerves that control eyelid func-
pathways. If any disruption of a child’s vision tion [10]. The eyelid skin should be examined
occurs during this critical period in visual for any lesions such as vesicles associated with
development, the child will develop a lifelong a herpes simplex infection or a flesh-colored
8 N. Tejani et al.
papule with an umbilicated center character- from induced astigmatism. Other causes of
1 istic of molluscum contagiosum. ptosis in children include genetic syndromes
It is essential to look at the eyelid position. such as fetal alcohol syndrome, third nerve
Telecanthus refers to widening of the medial palsy, myasthenia gravis, Horner’s syndrome,
canthal distance between each of the eyes. and trauma, among others.
This is often due to a widening of the nasal The motion of the eyelids should also be
bridge most commonly secondary to trauma evaluated at rest as the inability to completely
or congenital syndromes. Hypertelorism close the eyelids is known as lagophthalmos.
describes an increased distance between the Most often this is a complication of scarring
bony orbits and clinically presents as an or fibrosis of the eyelid or facial nerve palsy.
increased interpupillary distance. This abnor- Lagophthalmos can result in drying out,
mality can be seen with midline defects or in infection, or ulceration of the cornea.
syndromes such as Down syndrome, fetal Eyelid cilia (eyelashes) emerge from the
alcohol syndrome, cri du chat syndrome, anterior half of the eyelid margin. Epiblepha-
Klinefelter syndrome, Turner syndrome, ron describes a condition in which an excess
Ehlers-Danlos syndrome, and Waardenburg skin fold is seen just under the lower eyelid
syndrome [11]. margin usually medially and leads to the lower
Eyelid movement is responsible for the lid lashes being oriented vertically upward [14].
distribution of the tear film across the cornea. It is most commonly seen in Asian or Hispanic
This provides a clear and undistorted optical children and is usually asymptomatic and self-
surface by evenly distributing the tear film limiting and resolves within the first few years
across the eye and clears foreign bodies. On of life. Rarely the lashes will rub on the ocular
closure, the upper eyelid moves down to cover surface and be symptomatic or cause keratop-
the cornea, and the lower eyelid only moves athy in which case surgical correction would be
up slightly. The muscles responsible for upper required [14].
lid retraction are the levator palpebrae supe- There are many small sebaceous glands
rioris and Muller muscle [12]. The predomi- found in the eyelid that secrete oils that are
nant retractor is the levator palpebrae part of the tear film and prevent the tears
superioris, which is under voluntary control from evaporating too quickly [15]. The meibo-
by the oculomotor nerve (cranial nerve III). mian glands are found in the tarsal plate,
The minor retractor is the Muller muscle while the glands of Zeis are in close proximity
which is under sympathetic innervation. to the eyelash follicles.
Dysfunction of either eyelid retractor can Hordeolum and chalazion are the most
result in ptosis or drooping of the upper lid. common acquired eyelid lesions in childhood.
It is important to remember when evaluating A hordeolum, also known as a stye, is an
a patient for ptosis that the etiology could be infection of either the meibomian gland
due to disease in the upper lid retractors, ocu- (internal hordeolum) or gland of Zeis (exter-
lomotor nerve, sympathetic chain, neuromus- nal hordeolum) [16]. It presents as an acute,
cular junction, and birth trauma, among erythematous, tender focal nodule of the eye-
others [13]. Ptosis related to pathology of the lid and can at times have purulent discharge.
sympathetic pathway will be mild (~2 mm), The most common bacterial cause is
while ptosis related to oculomotor nerve Staphylococcus sp. A Chalazion is a lipogran-
pathology will be significant. Congenital pto- ulomatous inflammation of one of these seba-
sis is frequently diagnosed on a well-child ceous glands. In the acute setting, it is
visit because of parental concern about the challenging to distinguish a chalazion from a
asymmetry of the eyes. It can be inherited in hordeolum, as an acute chalazion can have a
an autosomal dominant form with variable similar clinical presentation although will not
penetrance and may be either bilateral or uni- have any purulent discharge. As the inflamma-
lateral [13]. Ptosis should always be evaluated tory process subsides within a few days, a
by an ophthalmologist as amblyopia can chronic chalazion may remain as a nontender
develop either from visual deprivation or focal subcutaneous nodule.
Pediatric Patient Encounter in the Emergency Department
9 1
Nasolacrimal Outflow System trauma. In preverbal children, non-acciden-
The tears are drained from the eye by the lac- tal trauma should always be ruled out [20].
rimal outflow system. This network begins Spontaneous resolution, over days to weeks,
with the superior and inferior puncta on the will occur, but parents should be informed to
medial lids and courses distally via the cana- expect a shift of the blood and a change in
liculi, lacrimal sac, and eventually the naso- color as the blood is reabsorbed.
lacrimal duct which drains into the nose below Conjunctivitis can be from bacterial, viral,
the inferior turbinate. It is important to or allergic causes. Bacterial conjunctivitis
understand that the medial canthal tendon is presents with thick mucopurulent discharge
superior to the lacrimal sac; therefore, pathol- often resulting in the lids being stuck together
ogy of the lacrimal sac or duct will be seen in the morning. The tympanic membranes
below the medial canthal tendon. should also be evaluated when considering
Newborn infants can rarely present with a bacterial conjunctivitis as frequently there is
bluish firm mass in the lacrimal sac fossa co-infection of the eustachian tube and mid-
called a dacryocele [17]. This requires immedi- dle ear known as unilateral conjunctivitis-
ate ophthalmology and otolaryngology con- otitis media syndrome [21]. Viral conjunctivitis,
sultation given the possibility of infection most commonly caused by adenovirus, pres-
and, in rare circumstances, sepsis that can ents with tearing and clear discharge and
develop. In older infants, classically 3–5 weeks enlarged preauricular lymph nodes [22].
after birth, congenital nasolacrimal duct Allergic conjunctivitis presents with bilateral
obstruction can become clinically apparent clear and stringy tearing, swelling of the lower
with swelling below the medial canthus and eyelids, and intense pruritus [23].
tearing and mucopurulent discharge from the The age of the patient is also important as
puncta [18]. This can be seen in as many as neonatal conjunctivitis, occurring within
30% of newborns [18]. To confirm the diagno- 2–4 days after birth, presenting with copious
sis, apply gentle pressure over the lacrimal sac purulent discharge, is classically due to gonor-
which may cause reflux of sac contents from rhea [24]. In this case, there is a possibility of
the puncta. corneal involvement, and if not treated it can
result in corneal scarring, thus making it an
Conjunctiva ophthalmologic emergency. However, if the
The conjunctiva is a thin transparent mucous patient presents after 8–14 days with watery
membrane that lines the posterior aspect of discharge and conjunctivitis, chlamydia tra-
the lids and the surface of the globe up to chomatis is the more likely offender. Still,
the cornea. The portion covering the globe other pathogens must be considered including
is known as the bulbar conjunctiva, and the Staphylococcus sp., Streptococcus sp., and
portion covering the lids is known as the pal- Enterococcus sp.
pebral conjunctiva. The conjunctiva is made
of non-keratinized squamous epithelium 1.3.2.5 Extraocular Movement
containing goblet cells [19]. These goblet cells The movement of the eye is controlled by six
produce mucin, which is part of the tear film. extraocular muscles that are innervated by the
Beneath the epithelium is the conjunctival oculomotor, trochlear, and abducens nerves
stroma, which is highly vascularized and is the (. Table 1.2). Examination of extraocular
site of immunologic activity. movement begins with observing the child’s
On exam, the conjunctiva appears trans- gaze at rest. Take note of abnormal head pos-
parent, except when inflamed when it appears ture as it may signify a compensatory response
red because of dilated blood vessels often to ocular misalignment. It is important to
referred to as conjunctival injection. Subcon- understand normal visual development in chil-
junctival hemorrhages will appear as striking dren and modify the exam accordingly. Infants
bright red discolorations. These hemorrhages will fixate but not follow objects until 3–4 months
might occur spontaneously, with coughing of age. For this age group, the examiner can
and Valsalva maneuvers, or secondary to move the child’s head or instruct the caretaker to
