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Evaluation of acute visual changes in the pediatric emergency department: Etiologies and red flags
Bilge Akkaya1, Ahmet Serkan Özcan1, Fatma Şule Erdem1
1Department of Pediatric Emergency Medicine, Ankara Etlik City Hospital, Ankara, Turkey.
Insights
Acute visual changes in children can indicate serious neurological issues. Specific exam findings like focal deficits and abnormal pupillary reflexes help identify children needing further neuroimaging.
Area of Science:
- Pediatric Emergency Medicine
- Pediatric Neurology
- Ophthalmology
Background:
- Acute visual changes in children present diagnostic challenges due to communication barriers.
- Common symptoms include blurred vision, double vision, and vision loss.
Purpose of the Study:
- Characterize the causes of acute visual changes in children presenting to a pediatric emergency department.
- Identify clinical predictors of abnormal neuroimaging findings in these children.
Main Methods:
- Retrospective, single-center study of 444 patients (1 month to 18 years) from 2022-2024.
- Patients identified via electronic medical records using keywords related to visual changes.
- Clinical features compared between patients with normal and abnormal neuroimaging results.
Main Results:
- Neurological (29%), ocular (23%), and systemic (18%) causes were most common.
- Neuroimaging revealed pathology in 35% of 178 patients who underwent the procedure.
- Focal neurological deficits, eye movement pain, and abnormal pupillary reflexes independently predicted abnormal imaging.
Conclusions:
- While many pediatric visual changes are benign, a significant portion indicate serious intracranial pathology.
- Certain neurological examination findings can identify children at higher risk.
- Further multicenter studies are needed to validate these predictors and optimize imaging strategies.
Introduction:
Acute visual changes-including blurred vision, diplopia, photopsia, visual hallucinations, and vision loss-pose a diagnostic challenge in children due to limited symptom description and limited cooperation during examination. We aimed to (1) characterize the etiologies of children presenting to a pediatric emergency department (PED) with acute visual changes and (2) identify clinical predictors of pathologic neuroimaging findings.
Methods:
We conducted a retrospective, single-center study at a tertiary PED between 2022 and 2024. Patients aged 1 month to 18 years were identified through structured chief complaint fields and keyword searches of electronic medical records (e.g., "blurred vision," "vision loss," "double vision"). Acute visual changes were defined as sudden-onset symptoms occurring within 72 h before presentation. Clinical features were compared between patients with pathologic neuroimaging findings and those with normal imaging results.
Results:
We included 444 patients in the study. The most common etiologies were neurological (29%), ocular (23%), and systemic (18%). Neuroimaging was performed in 178 patients (40%); among them, 63 (35%) demonstrated pathologic findings. Vision loss, pain with eye movements, focal neurological deficits, signs of meningeal irritation, dysmetria, tremor, papilledema, abnormal pupillary light reflexes, and a positive Romberg sign were significantly more frequent among patients with pathologic neuroimaging findings (p < 0.001). In multivariable analysis, focal neurological deficits, pain with eye movement, paresthesia, tremor, and abnormal pupillary light reflex abnormalities were independently associated with pathologic imaging findings.
Conclusion:
Although most pediatric acute visual changes are benign, a clinically important proportion are associated with significant neuroimaging abnormalities. Specific neurological examination findings may help identify children at higher risk for intracranial pathology. Prospective multicenter studies are needed to validate these predictors and refine imaging strategies in the PED.
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