What investigations and physical exams should be done for a 5-year-old child who poked her right eyeball with a stick, presenting with blurry vision in the affected eye, but with Pupils Equal Round Reactive to Light (PERRL), intact sclera, and no signs of erythema, discharge, or swelling?

Comprehensive Eye Evaluation for a 5-Year-Old with Ocular Trauma

A 5-year-old child with ocular trauma from a stick injury requires immediate and thorough ophthalmologic evaluation, including visual acuity assessment, slit lamp examination, fluorescein staining, and dilated fundus examination to rule out serious eye injuries despite normal external appearance.

Initial Assessment

• Perform a detailed ocular history including the exact mechanism of injury, timing, and any changes in vision or symptoms since the injury occurred 1
• Document the presence of blurry vision, which is a concerning symptom despite normal external appearance 1
• Assess visual acuity in both eyes using age-appropriate methods (HOTV or LEA SYMBOLS® charts are preferred for this age group) 1
• Compare the visual acuity between the affected and unaffected eyes to determine the degree of visual impairment 1

Critical Physical Examination Components

• Perform a thorough external examination of both eyes, including:

  • Inspection of eyelids and periocular tissues for swelling, lacerations, or foreign bodies 1
  • Assessment of ocular motility in all directions of gaze 1
  • Corneal light reflex test to detect subtle misalignment 1
  • Cover/uncover test to assess for strabismus that may have resulted from the trauma 1

• Conduct a detailed anterior segment examination:

  • Slit lamp examination (if available) to evaluate for corneal abrasions, foreign bodies, or anterior chamber reaction 1, 2
  • Fluorescein staining to identify corneal epithelial defects that may not be visible on gross examination 2
  • Assessment of anterior chamber depth and clarity 1

• Perform pupillary examination:

  • Check for direct and consensual pupillary responses 1
  • Test for a relative afferent pupillary defect (RAPD), which may indicate optic nerve injury 1

Advanced Diagnostic Testing

• Perform dilated fundus examination to assess:

  • Vitreous for hemorrhage or cells 1
  • Retina for tears, detachment, or commotio retinae 1
  • Optic disc for edema or pallor 1
  • Peripheral retina for tears or holes 1

• Consider additional imaging studies:

  • B-scan ultrasonography if media opacity prevents adequate fundus visualization 1
  • Orbital CT scan if there is concern for intraocular foreign body or orbital fracture 2

Special Considerations for Pediatric Patients

• Use age-appropriate visual acuity testing methods:

  • HOTV or LEA SYMBOLS® charts are recommended for 5-year-olds 1
  • Ensure proper occlusion of the fellow eye during testing 1
  • If the child is uncooperative, consider instrument-based vision screening such as photoscreening or autorefraction 1

• For the uncooperative child:

  • Consider examination under sedation if a complete assessment cannot be performed and there is high suspicion for serious injury 2
  • At minimum, ensure red reflex testing is performed to rule out media opacities 1

Red Flags Requiring Immediate Ophthalmology Referral

• Decreased visual acuity that doesn't improve with pinhole testing 1, 3
• Presence of corneal abrasion or foreign body 2
• Abnormal pupillary response or RAPD 1
• Abnormal red reflex or asymmetry between eyes 1
• Hyphema or blood in the anterior chamber 1, 2
• Any signs of globe penetration or rupture 2
• Persistent blurry vision despite normal external appearance 2

Follow-up Recommendations

• All children with ocular trauma and visual complaints should be referred to ophthalmology even if initial examination appears normal 3, 2
• Follow-up within 24 hours for corneal abrasions to ensure proper healing 2
• Regular vision screening should continue throughout childhood as recommended by the American Academy of Pediatrics 4, 1