Urgent advice line: 01708 435 000 Ext. 6662

Please fill in the urgent eye care referral form [docx] 17KB and email it to bhrut.urgenteyecare@nhs.net

Paediatric ophthalmology

  1. Sticky/watery eyes
  2. Squint and motility: acute onset vs. chronic
  3. Allergic eye disease
  4. Conjunctivitis and ophthalmia neonatorum
  5. Blepharitis/ chalazion and periorbital/orbital cellulitis
  6. No red reflex
  7. Cataract
  8. Unexplained bilateral visual loss and amblyopia
  9. Paediatric uveitis and JIA screening
  10. Pupil abnormalities
  11. Optic nerve abnormalities

Visual acuity in children:

Older children may be assessed as adults. In younger children, test binocular vision first and then if possible test uniocular vision.

Assessment measure by age
Age Visual acuity assessment measure
6 weeks and older

-Fix and follow (Use face, an interesting toy or light)

-Is fixation central, steady, maintained, eccentric or nil?

-Assess objection to occlusion of each eye

-Preferential looking (Cardiff cards or Keelers gratings)

2-4 years (illiterate children) Kay’s pictures crowded test (at 6 meters)
3 years and older (literate children) Test type cards/LogMar chart

Dilating drops in children:

All drops may be repeated after 5-15 minutes.

  • Under 6 months: 0.5% Cyclopentolate +/- 2.5% Phenylepherine
  • Over 6 months:  1% Cyclopentolate +/- 2.5% Phenylepherine

1. Sticky/watery eyes

Epiphora (excessive eye watering) may be due to a number of causes including conjunctivitis, foreign body, sinus disease or may occur in babies due to a blocked nasolacrimal duct (NLD).

If the underlying cause is apparent, treat as necessary.

Blocked NLD: This presents as a watery and sticky eye since birth with no conjunctivitis.

Children under the age of one with blocked NLD do not require referral unless the problem is recurrent or the eye is red.

For babies, advise regular massage of the area of skin between the medial canthus of the eye and the nose (i.e. over the lacrimal sac) 10 times, around six times a day.

2. Squint and motility: acute onset vs. chronic

Squint or strabismus is a relatively common presentation to paediatric ophthalmology. Most squints are benign.

It is important to establish a thorough history: age and mode of onset, intermittent or constant, level of vision, refractive error, accompanying features.

Also record past medical history, birth history, developmental milestone history and any behavioural or personality changes.


If the squint is consistent with a cranial nerve palsy with sudden change in vision, motility or diplopia or the child is systemically unwell then they need urgent discussion and referral to the paediatric team. Please also call the Emergency Eye Clinic on 01708 435 000 ext. 6662.

Intermittent squint under the age of six months is normal and doesn’t necessarily need referral. Any other squints with no red flag features should be referred routinely.

3. Allergic eye disease

Seasonal allergic conjunctivitis is more common and generally mild, whereas vernal keratoconcunctivitis is less common and more aggressive with significant conjunctival involvement such as giant papillae, limbitis, or even corneal involvement such as a plaque ulcer.

Treatment should involve:

  • Children with corneal involvement should be referred to the paediatric ophthalmology team within two weeks
  • Education to avoid the precipitating allergen
  • Regular lubricating eye drops (at least four times a day and up to half hourly.
  • Olopatidine (Opatanol) BD for six weeks or throughout the hay fever season or sodium chromoglycate QDS
  • Treatment of facial eczema with topical agents and treatment of blepharitis with warm compresses.

If controlled on the above then no referral to ophthalmology services is necessary. Please refer routinely for review if chronic and not settling with above management.

4. Conjunctivitis and ophtalmia neonatorum

Viral conjunctivitis
See Conjunctivitis section above in Cornea/ sclera/ conjunctival section B.

*Note: Viral conjunctivitis is highly contagious. Instruct parent/ patient to avoid sharing towels/ bedding etc, encourage frequent hand washing and avoid personal contact for at least two weeks. Symptoms usually last between 5-14 days and there is no active treatment. Artificial tears, cold compresses and analgesia may help relieve some symptoms.

Bacterial conjunctivitis:

See Conjunctivitis section above in Cornea/ sclera/ conjunctival section B.

1st line management is G. Chloramphenicol 0.5% QDS for 5-10 days (alternative includes G Azithromycin 1.5% (preservative free) BD for 3 days.

Herpes Simplex Conjunctivitis

This may occur as a conjunctivitis or as a skin infection around the eye. It usually resolves spontaneously in 5-7 days unless complications occur.

Management includes acyclovir cream to any skin lesions around the eye and to refer the child to the Emergency Eye Clinic for an assessment if conjunctival or corneal involvement within the next 24 hours.

If there is recurrent conjunctivitis please refer routinely to paediatric ophthalmology.

Ophthalmia Neonatorum

This is a conjunctivitis occurring in the first four weeks of life. It is no longer considered a notifiable disease by the HPA.

Onset may help determine the causative organism but a swab is required to confirm:

Pathogen swab guidance
Onset Pathogen
1-3 days N. Gonorrhoea
2-5 days Commensals: Strep, Staph, Pseudomonas, Hemophilus, colliforms
1-14 days Herpes simplex
4-28 days Chlamydia

Ophthalmia neonatorum needs discussion and review by the paediatric team and the paediatric ophthalmology service.

Management: A conjunctival swab should be sent and marked for chlamydia, gonococcus and HSV testing. Another swab taken and set on a glass slide should be sent for gram stain. Treat all purulent conjunctivitis as gonorrhoea until proven otherwise.

Follow the trust micro-guidelines for treatment,

5. Blepharitis, chalazion, and periorbital and orbital cellulitis


Blepharitis is a common condition and refers to inflammation of the eyelid margins. The meibomian glands may become clogged up leading to dry eye symptoms.


  • Education, good hydration and omega 3 supplements/ flaxseed oil may help in an age appropriate dose.
  • Lid hygiene: Warm compresses applied to the closed eye lids for 5 minutes 1-4 times a day. Massage and cleaning of any discharge/secretions away with a cotton bud dipped in boiled, cooled water.
  • Topical Lubrication:
  • Oral low dose antibiotics if recurrent chalazion or to break a frequent, uncomfortable attack: If >12 years old Doxycycline OD for 6 weeks. If <12 years: erythromycin BD for 3 months


See Oculoplastic section C above

Periorbital cellulitis and orbital cellulitis

See Oculoplastic section C above.

*These patients should be referred to the paediatric team if they require admission for IV antibiotics or are systemically unwell.

Follow the Trust paediatric micro-guidelines for antibiotics:

6. No red reflex

If a newborn or baby is found to have an absent red reflex then please call the urgent advice line on 01708 435 000 ext. 6662. Do not send the patient to the Emergency Eye Clinic without prior discussion. If out of hours or no answer, fill in the urgent eye emergency referral form [docx] 17KB and email it to bhrut.urgenteyecare@nhs.net. Include the parent or guardian’s contact details and we will arrange a review.

7. Cataract in a child

If suspected, please refer on a semi-urgent basis to the paediatric ophthalmology department. Please fill in the urgent eye emergency referral form [docx] 17KB and email it to bhrut.urgenteyecare@nhs.net. Include the parent or guardian’s contact details and we will arrange a review.

8. Unexplained bilateral visual loss and amblyopia (under 8 years old)

A normal full term baby should start to fix and follow within the first few weeks after birth. If there is a history of prematurity, developmental delay, seizures, dysmorphic features, or maternal/infant infections then these are red flags which should prompt a referral to general paediatrics and paediatric ophthalmology for a review over the next week.

In older children visual loss may be due to a refractive error or eye pathology. If the visual acuity is good and there are no obvious eye abnormalities on examination please refer routinely.

Discuss with the Paediatric Ophthalmology team if there is sudden unexplained loss of vision that is worse than 6/18 bilaterally or worse than 6/24 in one eye.

9. Paediatric uveitis and JIA screening

Uveitis is rare in children but may occur alongside Juvenile Idiopathic arthritis (JIA). Other causes include herpes, HLA B27, sarcoid, toxoplasmosis, TB, Syphilis and Behcet’s disease. It often presents as a painless, chronic anterior uveitis. Patients are usually asymptomatic and have a white eye.

All children diagnosed with JIA under a rheumatologist should be referred within six weeks for paediatric ophthalmology review and screening.

Any symptomatic patients should be referred for a review within one week.

10. Pupil abnormalities

See Neuro-ophthalmology section A above.

A neurological cause needs to be excluded for any anisocoria (unequal pupils).

An anisocoria of less than 1mm is likely to be physiological.

If an acute Horner’s or third nerve palsy is suspected, then immediate referral for investigation and treatment is required.

Ask about ptosis, diplopia (double vision), headache, neck pain or other neurological symptoms. Refer to the general paediatric team and call the Emergency Eye Clinic for advice if in hours on 01708 435 000 ext. 6662.

11. Optic nerve abnormalities

See Neuro-ophthalmology section A above.


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