Ocular emergencies: What pediatricians and frontline physicians need to know

Donny Suh, MD, FAAP

Binita R Shah

Table 1

Table 2

Table 3

Table 4

Additional resources

Five minutes. That’s how long it takes to do a basic eye exam to determine how urgent an ocular problem is and the appropriate approach for treatment. It is an exam that every pediatrician, pediatric emergency medicine physician, and other frontline clinicians need to know when presented with a child with an ocular problem, particularly those who present to the emergency department (ED).

“The first person to see the child in case of an eye emergency can be of enormous value in preventing and treating the eye injury and subsequent visual loss,” says Donny Suh, MD, FAAP, chief of Pediatric Ophthalmology and Adult Strabismus, Children’s Hospital and University of Nebraska Medical Center, Omaha, Nebraska.

As a pediatric ophthalmologist, Suh typically is not the first person to see an eye injury in a child and relies on the diagnostic and clinical skills of pediatricians and other frontline clinicians to know when an eye injury warrants referral to an ophthalmologist.

To help pediatricians and other frontline clinicians better understand when such a referral is needed, and how timely that referral needs to be, Suh provided some basic information about how to diagnose and triage a child who presents to the ED with an eye injury.

At the 2018 American Academy of Pediatrics (AAP) National Conference and Exhibition in Orlando, Florida, Suh presented such information during a session titled “Pediatric ocular emergencies you can’t afford to miss.” He was joined by Binita R. Shah, MD, FAAP, Distinguished Teaching Professor of Emergency Medicine and Pediatrics, State University of New York (SUNY) Downstate Medical Center, Brooklyn, New York, who spoke from the perspective of pediatric emergency medicine physician. Together they presented a number of case studies in an interactive presentation in which audience members were invited to participate to test and improve their knowledge of how to diagnose a given eye problem and, importantly, how to triage the patient based on the urgency of the injury.

“The presentation provides a practical step-by-step guide to evaluate and manage the pediatric ocular injuries resulting from trauma, infections, and tumors,” says Suh.

5 questions in 5 minutes

Suh began the presentation by talking about the importance of the simple 5-minute eye test that consists of 5 eye exams that every clinician needs to know (Table 1).

According to Shah, these eye exams are well known to physicians and are a part of their medical training. For children who arrive in the ED with an eye injury, using this 5-minute test is critical to appropriately triage the child based on the urgency of the condition.

“This is very important,” says Shah. “Within 5 minutes, you can do 5 essential eye examinations that will enable you to figure out if the patient has an emergency problem, an urgent problem, or a routine problem.”

Table 2 lists conditions considered as emergency, urgent, and routine. For both a child who has an injury that is considered an emergency (immediate) or one that is considered urgent (can wait to be evaluated/treated within 24 to 48 hours), a pediatric ophthalmologist should be included to either confirm the diagnosis and/or manage treatment.

The rest of the presentation was devoted to presenting case studies to illustrate how a pediatrician, pediatric emergency physician, or other frontline clinician would approach a child presenting with given symptoms by first using the 5-minute exam and then deciding on the appropriate triage.

Case studies

A number of case studies were presented to illustrate the diagnostic and triage approach to each. Shah opened each case study by describing the presenting symptoms of a child, giving the audience time to weigh in (online using an app downloaded onto their smartphones, iPads, and other devices) on the diagnosis and/or initial treatment, and then discussing the correct answer.

“As the focus of our presentation was on ocular emergencies (related to either acute injuries, infections, or tumors), every case study included the need for an ophthalmologist,” says Shah, adding that each case study required referral to an ophthalmologist either for confirmation of the diagnosis or referral for treatment.

Table 3 lists 9 case studies along with presenting symptoms, diagnosis, and main take-home points.

Summary

It is important for pediatricians, pediatric emergency room physicians, and other frontline clinicians to implement a 5-minute eye exam when presented with a child with an eye injury to quickly recognize whether the injury warrants emergency attention, urgent attention, or is routine.

Referral to a pediatric ophthalmologist is warranted for most emergency and urgent cases. The case studies in this presentation illustrate injuries that would involve referral to an ophthalmologist. Table 4 provides a list of changes to your practice that both Suh and Shah recommend.

For more information on specific eye injuries, see “Eye terms and conditions” on the American Association for Pediatric Ophthalmology and Strabismus website: www.aapos.org.

Readers also can explore additional information in the Resources section of this article.

References:

1. Shah B, Suh D. Pediatric ocular emergencies you can’t afford to miss. Presented at: American Academy of Pediatrics (AAP) National Conference and Exhibition; November 2-6. 2018; Orlando, FL. Available at: https://www.eventscribe.net/2018/AAPExperience/ajaxcalls/PresentationInfo.asp?efp=SldBSlBKR1M2NzIw&PresentationID=372193&rnd=0.156869. Accessed January 17, 2019.