What should an eye exam include for a 2-year-old with conjunctivitis?

Eye Examination for a Two-Year-Old with Conjunctivitis

For a 2-year-old with conjunctivitis, the eye examination must include vision assessment (fixation and following), external inspection of eyes and lids, ocular motility assessment, pupil examination, red reflex examination, and careful evaluation for corneal involvement—with immediate ophthalmology referral if vision loss, severe pain, purulent discharge, or corneal findings are present. 1, 2

Essential Examination Components

Vision Assessment

• Determine if each eye can fixate on an object, maintain fixation, and follow the object into various gaze positions 1, 2
• Perform testing binocularly first, then monocularly 1
• The child must be awake and alert, as disinterest or poor cooperation can mimic poor vision response 1, 2
• Document if the child is unable to perform these maneuvers, as this indicates significant visual impairment 1

External Examination

• Evaluate for preauricular lymphadenopathy, which is particularly important in infectious conjunctivitis 1, 3, 4
• Assess eyelids for: swelling, discoloration, mattering and adherence (especially on waking), ulceration, nodules, and vesicles 1, 3, 4
• Examine conjunctiva for: laterality (unilateral vs bilateral), type of reaction (follicular vs papillary), distribution, discharge character (purulent, mucopurulent, or watery), chemosis, and hemorrhage 1, 3

Pupillary Examination

• Pupils should be equal, round, and reactive to light in both eyes 1
• Slow or poorly reactive pupils may indicate significant retinal or optic nerve dysfunction 1
• Document any asymmetry, as larger asymmetries can indicate neurologic disorders 1

Red Reflex Examination

• Perform red reflex testing to detect opacities in the visual axis and abnormalities of the posterior eye 1, 2, 4
• The red reflex should be bright reddish-yellow and identical in both eyes 1
• Any asymmetry in color, brightness, or size is abnormal 1

Corneal Examination (Critical)

• Carefully assess corneal clarity—this is the most critical component to avoid missing serious pathology 1, 3, 4
• Look for infiltrates, ulcers, or opacities 3, 4
• Failure to identify corneal involvement is a common pitfall that can lead to inadequate treatment 3

Ocular Motility Assessment

• Evaluate ocular alignment, as any persistent misalignment after 6 months of age is abnormal 2
• This may indicate strabismus that can lead to amblyopia 2

Documentation Requirements

Document the following systematically 1, 3:

• Laterality (unilateral vs bilateral)
• Character of discharge (purulent, mucopurulent, watery)
• Duration and time course of symptoms
• Presence or absence of mattering/adherence of eyelids
• Visual acuity or fixation/following ability
• Corneal clarity and absence of infiltrates or ulcers
• Preauricular lymphadenopathy

Red Flags Requiring Immediate Ophthalmology Referral

Refer immediately if any of the following are present 1, 4, 5:

• Visual loss or decreased visual acuity
• Moderate or severe pain
• Severe, purulent discharge (especially copious discharge suggesting gonococcal infection)
• Any corneal involvement (opacity, infiltrate, or ulcer)
• Conjunctival scarring
• Lack of response to initial therapy
• History of herpes simplex virus eye disease
• Immunocompromised status
• Vesicular rash on eyelids or nose

Special Considerations for This Age Group

• In children, consider internal ear examination, as bacterial conjunctivitis may be associated with otitis media 1
• Document exposure history to infected individuals in daycare or school settings 3, 4
• If gonococcal or chlamydial conjunctivitis is suspected, consider and document assessment for sexual abuse, as this must be reported in many jurisdictions 1, 3
• Cultures are not routinely needed for typical conjunctivitis but are indicated for severe, recurrent, or suspected gonococcal infection 4

Common Pitfalls to Avoid

• Never dismiss complaints without thorough corneal examination 4
• Do not assume all red, crusty eyes are bacterial—consider viral and allergic etiologies 4, 5
• Inadequate assessment during vision testing when the child is uncooperative or disinterested 2, 4
• Missing subtle corneal involvement by failing to perform careful inspection 3, 4