Acute red eye in children: A practical approach

Acute red eye in a child is a common presentation in general practice.¹ It can arise from inflammatory, infective or traumatic processes involving the globe itself or the structures around it.¹ The differential diagnosis list is therefore extensive; however, with careful history-taking and clinical examination techniques, a diagnosis can usually be made. This article outlines the diagnosis and management of acute red eye conditions, highlighting those that require immediate referral to ophthalmic care (Table 1 – PDF download only).

History

In children with shorter attention spans, it is best to obtain a brief history first, then examine the patient and obtain a more detailed history later. The history-taking should begin with determining the duration of redness and involvement of one or both eyes, inquiring about any possible causes and seeking information regarding associated symptoms and signs such as blurring, photophobia, loss of vision, discharge and ocular pain, discomfort or itch.² For a young child (aged ≤6 years), the history is often taken from the accompanying family member, who may not necessarily know the full story. Further history may need to be obtained from other family members or witnesses.

It is important to elicit a history of recent trauma. This could be a physical impact, a foreign body or chemical exposure. Taking an accurate history of trauma can pose a challenge, such as in the case of a pre-verbal child or a teenager who might be reluctant to communicate, especially in the presence of a parent.² In such cases, where trauma is suspected but the mechanism of injury cannot be clearly determined, talking to the child alone in a friendly and non-accusatory manner may be beneficial. If the history is inconsistent with the signs, consider non-accidental injury. If this becomes more obvious during the consultation, a report will need to made to the relevant state child protection agency.

Previous ocular history is particularly important, as ‘acute-onset vision loss’ may arise from amblyopia or more chronic eye issues. The medical history should include recent illness, systemic abnormalities, medications, allergies and prenatal and birth history. A family history of eye and any relevant medical conditions can also be helpful.

Examination

The examination begins as soon as the general practitioner (GP) calls the child into the room. Are they rubbing their eyes while remaining active and engaging with others, or do they appear miserable with photophobia? Depending on the age, temperament and discomfort of the child, an eye examination may present an enormous challenge. Putting the child at ease and gaining their trust is critical. It is important to ensure the child is at the same eye level, use age-appropriate vocabulary (with toys if appropriate) and give plenty of praise and opportunities for them to vocalise.³

An opportunistic approach is recommended, first carrying out the most relevant examination pertaining to the patient’s history and chief complaint, with later systemic examination as required.³ On occasion, if the child is very young and/or unable to hold still, a photograph of the affected eye or eyes is very useful to instantly capture any pathology for detailed examination. For infants, the ideal time for an examination of the eye is during sleep. If it is impossible to perform the examination in the clinic, GPs should consider referral to hospital for examination under sedation or anaesthesia.

Examination steps

1. Assessment of vision should always be attempted. For infants and toddlers, this involves testing their ability to fix and follow. For children over the age of three years, the use of an eye chart is recommended, and the exact chart (eg Lea, HOTV symbol matching, Snellen) depends on their level of literacy. Test each eye independently, with the opposite eye properly occluded as children often peek. Children develop 6/7.5 vision around the age of six years.⁴ (A two-line difference in visual acuity between the eyes in a child always requires further investigation.)
2. The patient’s lids and ocular surface need to be examined with magnification (eg head loupes) and good illumination from a direct ophthalmoscope, pen torch and/or a slit lamp if available. Look for signs of swelling, redness, discharge, trauma or lid malposition such as entropion.
3. Inspect the conjunctiva for swelling and/or intense injection, particularly if diffuse rather than sectorial.
4. In the cornea, inspect for any foreign bodies, haze, infiltrates or ulceration. An epithelial defect is better visualised after the instillation of fluorescein dye and the use of a cobalt blue light. It is important to note the size and location of any corneal ulcers. Any epithelial defect with an infiltrate is suspicious of microbial keratitis.
5. Check for protrusion and/or peaking of the iris that indicates perforation of the cornea, requiring urgent emergency referral.⁵
6. The fornix under the upper lid can be further examined by lid eversion, specifically looking for foreign bodies. The ability to evert the lid is dependent on the cooperation of the child and is not possible if the eyelid is very swollen.
7. The anterior chamber of the eye can be inspected for a hypopyon (pus in the anterior chamber). This may be sterile because of an inflammatory reaction or may indicate intraocular spread of severe microbial keratitis into the eye causing endophthalmitis.
8. Irregularity of the pupils may indicate posterior synechiae (adhesion of the iris to the anterior capsule of the lens) due to anterior uveitis.
9. The intraocular pressure may be elevated. However, measurement of intraocular pressure requires the use of a tonometer.⁶
10. The red reflex can be simultaneously compared between the eyes with the child looking into the light of a direct ophthalmoscope (Brückner test).⁷ Asymmetry of the reflexes can indicate media opacities, retinal abnormalities, significant refractive errors and deviations of the eye.

Box 1 outlines features in the history and examination that indicate a potentially more serious disease and lower the threshold for referral to ophthalmic care.

Summary

Assessment of acute red eye in children is challenging and heavily dependent on the cooperation of the patient. The history tends to indicate the diagnosis, so eliciting key symptoms is important for successful management. Examination may not be possible; hence sedation and examination under anaesthesia are important considerations. If the child is distressed and uncooperative because of a painful eye, instillation of a drop of local anaesthetic into the eye may make examination possible. Urgent referral to ophthalmology of potentially eye-threatening conditions may save a child’s vision.