Pediatric Eye Emergencies: 4 Red Flags Not to Miss

“It is essential to promptly recognize ophthalmic emergencies in children to optimize both visual outcomes and overall prognosis,” said Guylène Le Meur, MD, ophthalmologist and professor at the University Hospital Nantes (CHU de Nantes), Nantes, France, during a press briefing ahead of the 132nd Congress of the French Society of Ophthalmology (SFO), held May 9-11, 2026, in Paris, France. Beyond Vision Delayed diagnosis can have consequences that extend beyond vision loss. “A delay in diagnosis or treatment, even by just a few weeks, can lead to irreversible consequences, such as severe amblyopia or permanent vision loss, in conditions such as leukocoria (a white pupillary reflex) or certain forms of early-onset strabismus,” Le Meur explained. In rare cases, a patient’s life may also be at risk. Certain ophthalmic findings can be the first sign of a serious underlying disease requiring immediate evaluation and treatment. Leukocoria may indicate retinoblastoma. Acute onset of strabismus or papilledema may indicate intracranial hypertension, possibly caused by a brain tumor. Rapidly progressive proptosis may suggest orbital rhabdomyosarcoma. Speaking with Medscape’s French edition, Le Meur said, “The prevalence of retinoblastoma is very low, but it can be fatal. However, effective treatments are available. That’s why it’s so important not to miss the diagnosis.” When asked which clinical findings should prompt referral to a specialist, Le Meur identified leukocoria, enlarged corneal diameter, and clear tearing accompanied by corneal enlargement and photophobia. “Regarding watery eyes: If the discharge is cloudy, it’s an infection, and it’s nothing serious. This is something that your primary care physician should handle. However, if the child has watery, clear discharge in both eyes, is sensitive to light, and feels like their eyes are swollen, this is a sign of glaucoma and requires an urgent visit to an ophthalmologist,” she said. Four Emergencies During the congress session, experts reviewed the pediatric ophthalmic conditions most likely to require urgent evaluation and highlighted practical guidance to help clinicians distinguish emergencies from less urgent presentations. The discussion focused on four conditions: leukocoria, orbital rhabdomyosarcoma, acute-onset strabismus, and papilledema. Leukocoria Although uncommon, leukocoria is an ophthalmic emergency that requires immediate diagnostic evaluation. It may be the first sign of retinoblastoma but can also result from congenital cataracts, retinal abnormalities, or persistent fetal vasculature. Each condition requires prompt diagnosis and condition-specific management. Orbital Rhabdomyosarcoma Orbital rhabdomyosarcoma is the most common primary malignant orbital tumor in children. Its presentation can be deceptive because it may initially resemble a benign orbital infection. Clinical examination typically reveals unilateral nonaxial proptosis accompanied by periorbital inflammatory signs. Other findings may include ophthalmoplegia, choroidal folds, and corneal perforation resulting from exposure keratopathy. This therapeutic emergency requires prompt multidisciplinary management involving diagnostic imaging, pediatric oncology, and ophthalmology. Current treatments, centered on chemotherapy and, when indicated, radiotherapy or surgery, have substantially improved outcomes. Early recognition of warning signs remains essential, as Le Meur emphasized. Acute Strabismus Strabismus is common in children and is one of the leading reasons for referral to a pediatric ophthalmologist. Although most cases are benign and do not require immediate intervention, certain presentations should raise concerns. “When strabismus is permanent, there is no family history, and it develops suddenly, particularly when it is accompanied by reduced visual acuity or neurologic signs suggestive of stroke, a brain tumor should be considered,” Le Meur said. Distinguishing children who require urgent evaluation from those who can be managed through routine follow-up is essential to avoid both delayed diagnosis and unnecessary emergency referrals. Papilledema Papilledema in children is a neuro-ophthalmic emergency. In addition to risking irreversible optic atrophy, it may indicate a life-threatening underlying condition. Its presence should immediately raise suspicion of intracranial hypertension, which requires urgent investigation. Several conditions can mimic papilledema, including buried optic disc drusen, congenital pseudopapilledema, optic nerve infiltration, papillitis associated with posterior uveitis, and inflammatory or infectious optic neuritis. However, true papilledema warrants prompt evaluation. The diagnostic workup includes a neurologic examination, brain imaging, and, when appropriate, lumbar puncture. Diagnostic Challenges In conclusion, Le Meur emphasized the importance of being vigilant when evaluating children because diagnosing ophthalmic diseases in pediatric patients can be particularly challenging. Clinical examination is often limited by the child’s age, lack of cooperation, and inability to accurately describe symptoms. In addition, the medical history frequently relies on parental observation, which may be incomplete or delayed. “It is not always possible to obtain a complete history from a child. In particular, a traumatic event may never be mentioned. In cases of retinal detachment, for example, the injury may not be immediately apparent, and the child may not mention being injured while playing with a stick because they know they were not supposed to,” Le Meur explained. Therefore, reliable clinical assessment, early recognition of warning signs, and careful consideration of the child’s overall health are essential. “The presence of neurologic disorders or a family history of strabismus may justify referral to an ophthalmologist, even if the situation is not necessarily an emergency,” she said. This story was translated from Medscape’s French edition.