Acute Vision Loss in Children
1. 📌 Key concept
- เด็กมัก present ช้า → มักพบตอน vision loss รุนแรงแล้ว
- ต้องคิดเสมอว่าอาจเป็น vision-threatening หรือ
life-threatening condition
2. 🧩 Framework การประเมิน
🔑 Core questions
1.
Trauma หรือไม่
2.
Painful vs painless
3.
Red eye vs white eye
4.
Monocular vs binocular
3. ⚠️ Red flags (ต้อง consult
ด่วน / emergency)
- open
globe injury
- chemical
burn
- orbital
cellulitis
- CRAO
- endophthalmitis
- intracranial
pathology (ICP ↑
/ tumor / stroke)
4. 🧠 Etiology (จัดตาม anatomy)
🔴 A. Media (anterior
segment)
1. Open globe injury
- trauma
→ obvious laceration /
irregular pupil
👉 ห้ามกดตา / ใส่ shield / consult ด่วน
2. Chemical burn
- alkali
> acid severity
👉 irrigation ทันที + consult
3. Keratitis
- pain
+ red eye + photophobia
- contact
lens → bacterial
(Pseudomonas)
4. Hyphema
- trauma
→ blood in anterior
chamber
- risk:
glaucoma, rebleed
5. Endophthalmitis
- pain +
↓vision + hypopyon
👉 emergency (intravitreal antibiotics)
🟡 B. Retina
1. Retinal detachment
- floaters
+ flashes + curtain
- painless
👉 consult <24 hr
2. CRAO (rare but critical)
- sudden
painless severe loss
- cherry-red
spot
👉 emergency reperfusion
3. CRVO
- subacute
blurred vision
- “blood
and thunder”
4. Retinoblastoma
- leukocoria
👉 malignancy → urgent referral
5. Retinal hemorrhage
- infant
→ suspect child
abuse
🔵 C. Neurovisual pathway
1. Optic neuritis
- pain
with eye movement
- ↓ color vision
- post-infectious
/ MS
2. Orbital cellulitis
- fever
+ proptosis + painful eye movement
👉 IV antibiotic + CT + consult ENT + ophthalmology
3. Cavernous sinus thrombosis
- severe
infection + neuro deficit
👉 life-threatening
4. IIH (pseudotumor cerebri)
- headache
+ papilledema
- risk
permanent vision loss
5. Brain lesions / stroke
- binocular
loss
- homonymous
field defect
🟣 D. Others
1. Trauma-related
- vitreous
hemorrhage
- optic
nerve avulsion
- retinal
injury
2. Toxins
- methanol
→ optic nerve
damage
- CO → cortical blindness
3. Functional (conversion)
- exam ปกติ
- optokinetic
reflex ปกติ
5. 👶 Pediatric-specific
clues
History
- trauma
(สำคัญมาก)
- contact
lens → keratitis
- abuse
→ retinal hemorrhage
- migraine
/ seizure
- systemic
disease (SCD, thrombophilia)
Symptoms pattern
|
Symptom |
Suggestion |
|
pain |
cornea / glaucoma / neuritis |
|
painless |
retina / vascular |
|
photophobia |
keratitis / uveitis |
|
floaters/flashes |
retinal detachment |
|
fever + proptosis |
orbital cellulitis |
6. 🩺 Physical exam (key
points)
Must do
- visual
acuity (or visual behavior inเด็กเล็ก)
- pupils
→ RAPD
- red
reflex
Important findings
- leukocoria
→ tumor / cataract
- RAPD
→ optic nerve lesion
- proptosis
→ orbital disease
- hyphema
/ hypopyon → anterior
pathology
7. 🧪 Investigation
Imaging
- CT
orbit → trauma /
orbital cellulitis
- MRI
brain/orbit →
optic nerve / tumor
Labs (selective)
- CBC,
coagulation
- infection
workup
- toxicology
8. ⚡ Practical algorithm
Step 1: Trauma?
- Yes → rule out open globe first
Step 2: Pain?
- Painful
→ anterior segment /
optic neuritis
- Painless
→ retina / neuro
Step 3: Red eye?
- Yes → keratitis / uveitis /
glaucoma
- No → retina / optic nerve /
brain
Step 4: Fundus + pupil
- abnormal
fundus → retinal cause
- RAPD
→ optic nerve
🔑 Take-home messages
- เด็กมักมาช้า → ต้องคิด severe cause เสมอ
- Trauma
+ abuse ต้องถามทุกเคส
- leukocoria
= cancer until proven otherwise
- orbital
cellulitis / endophthalmitis = emergency
- CRAO
= rare but vision emergency
- ถ้า exam ปกติ → คิด functional
/ cortical
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