Is this urgent? When a child's eye should be seen today, this week, or at a routine visit

Draft, awaiting Dr Chan's sign-off

The urgency thresholds on this page have not yet been signed by Dr Chan Li Yen (see review/is-this-urgent-thresholds.md). Until this notice is gone the page is a working draft, not published advice.

How to read this page

Today means the nearest hospital emergency department or an eye clinic the same day, at any hour. Do not wait for morning or for an appointment.
This week means phone today, say exactly what you have seen, and ask for an urgent appointment within days.
Routine means book an ordinary appointment. A few weeks is fine, but do book it rather than watching for months.
This page cannot tell you what is wrong. It tells you how soon your child should be examined by someone who can.
When you cannot decide between two buckets, choose the sooner one. Nobody in an eye clinic minds a child who came early.

Most of the messages I get from worried parents are some version of the same question. Not "what is it?", but "can this wait until Monday?" That is the right question, and it is the only one this page tries to answer. It cannot tell you what is wrong with your child's eye. Nothing written on a screen can. What it can do is tell you how soon that eye should be looked at by someone who can examine it, and what to do in the meantime.

I use three words throughout. Today means go now, to the nearest hospital emergency department or an eye clinic that can see you the same day, and do not wait for an appointment or for morning. This week means phone today, say exactly what you have seen, and ask for an urgent appointment within days. Routine means book an ordinary appointment; a few weeks is fine, but do book it rather than watching for another few months. When you are unsure which of the three you are in, choose the sooner one. I have never once been annoyed by a parent who came too early.

This is not a diagnosis. It is a guide to timing. If your child's eye is worrying you, that worry is reason enough to be seen.

I saw a white glow, or a white pupil, in my child's eye in a photo

This week. Phone today and ask for an urgent appointment, and use the words "white pupil" when you book. If the eye is also red, painful or swollen, or your child seems unwell, make it today.

A white or pale reflection in the centre of the eye, in a flash photo or in dim light, is something I want to look at within days rather than at the next routine check. Many turn out to be the angle of the flash, and only an examination can say which. A few are a cataract, a rare retinal condition, or retinoblastoma, a childhood eye cancer that is very treatable when found early. The point of moving quickly is to keep it that way. I have written at length about the white glow in photos and what happens at the visit. The short version is that a doctor with a dilated pupil and the right light can usually settle the question at that visit, and a photo cannot.

See an eye doctor if you have seen a white, pale or yellow reflection in one or both eyes in a photo (one photo is enough), or once in ordinary light, or if a squint has appeared alongside it, and do not wait to collect more photos first.

One eye turns in or out, and my baby is past three or four months old

Routine if it comes and goes; this week if it is there all the time. A turn that still comes and goes after about three to four months should be booked in, and an ordinary appointment within a few weeks is right. An eye that is turned constantly, at any age, or a turn that has newly appeared and stays, moves up a bucket: phone this week.

In the first weeks of life a baby's eyes wander now and then while they learn to work as a pair, and that settles by around three to four months. A true squint is not outgrown, and the reason for not waiting is that a turned eye can quietly become a lazy eye while it is being watched. Very often the visit ends with me showing you that a wide nasal bridge is creating the illusion, which is exactly what crossed eyes in newborns is about. That reassurance is worth the trip, and only an examination can give it.

See an eye doctor if the turn is constant at any age, is still coming and going past about three to four months, or your child regularly tilts their head or closes one eye to look at things.

My older child's eye has suddenly started turning, and it was straight before

Today if an older child's eye that was straight has suddenly started to turn, and without question if there is also double vision, a new head tilt, a headache, vomiting, a drooping lid, one big pupil, or it followed a knock to the head or an illness. This week for a turn that has crept in gradually, or a new turn in a baby or toddler without any of those.

A child whose eyes were straight last month and are not this month has a different problem from a baby whose eyes have always drifted a little. Older children with a new inward turn often see double, and a sudden turn can be the sign of a weak eye-movement nerve, which in children can follow an injury or a viral illness, or point to pressure inside the head. That is the reason a same-day examination is the right call when the turn is sudden, and more so when it comes with any of those.

See an eye doctor today if an eye that used to be straight has suddenly started to turn, and do not wait at all if there is double vision, headache, vomiting, a droopy lid, a large pupil, or a recent head injury.

My child has eye pain and is vomiting, or a severe headache with eye symptoms

Today. Eye pain together with vomiting, or a severe headache together with blurred or double vision or light hurting the eyes, is an emergency-department visit, not a clinic appointment.

The reasons sit outside the eye as often as inside it: raised pressure inside the head shows itself through headaches, sickness and vision changes, and after any knock to the eye or head, vomiting is a sign to be seen at once. In a small child who cannot describe pain, watch for an eye that is squeezed shut, a child who will not open it, or one who screams when the light is turned on. Do not settle for a painkiller and a wait to see how the night goes. Go, and let the doctors work out what the pain is.

See an eye doctor, or the emergency department, today if your child has eye pain with vomiting, a severe headache with any change in vision, or eye pain and sickness after an injury.

One of my child's eyelids is drooping

Today if it is new; this week if it has always been there and covers part of the pupil; routine if it is mild, lifelong and clear of the pupil. The question I need answered first is when the droop started.

A lid that has dropped over hours or days, especially with a large pupil, an eye that sits out and down, double vision, a headache or a recent head injury, can be the first sign of a problem with the nerve that lifts the lid, and that is a same-day matter. A droop that has been there since birth is a different thing, and it is not an emergency. But if the lid sits over part of the pupil, or your child lifts the chin to see under it, the vision on that side can fail to develop properly. That is why I want to see it within days rather than months. A mild lifelong droop that leaves the pupil clear can be booked routinely, and it still needs one proper check to confirm that the vision behind it is developing well.

See an eye doctor if a lid droops at all, and go today if the droop is new, or comes with a big pupil, a turned eye, double vision, headache or a head injury.

My child's eye is red and the light hurts, or they will not open it

Today. When a red eye comes with light sensitivity, real pain, or a change in how well the child sees, I stop assuming it is ordinary pink eye, and it needs an examination the same day.

An ordinary pink eye is red, gritty and messy; a child who hides from daylight has more than that until an examination says otherwise. Two or more of redness, light sensitivity, a vision change and pain is the combination eye doctors treat as urgent in children, because some of the causes damage sight if treatment is delayed, and only an examination can tell them apart. A red, painful, light-shy eye the evening after a long day at the beach or pool belongs here too. Sunburn of the eye is very painful and needs to be seen, even though it usually heals within days.

See an eye doctor today if a red eye comes with light sensitivity, pain, blurred vision, a very dark red colour, or your child will not open it.

Something sharp has hit or gone into my child's eye

Today, at the emergency department, and do almost nothing on the way. If anything has cut the eye or gone into it, or the eye has been hit by something small travelling fast, do not rinse it, do not press on it, do not rub it, and do not try to pull anything out. Cover the eye loosely, a paper cup taped over the socket does the job, keep your child as still and calm as you can, and go straight to the nearest hospital emergency department.

This is the one place where the instinct to help can do harm. Blood inside the eye, a cut eyelid, a pupil that looks the wrong shape, or a child who cannot open or move the eye all mean the same thing: go now. The full first-aid list, and the difference between this and a chemical splash, is in eye safety at home.

See an eye doctor, at the emergency department, today if anything sharp has hit or entered the eye, the eye was hit at high speed, the lid is cut, there is blood in the eye, or the pupil looks unusual.

A chemical, cleaner, detergent pod or glue has gone into my child's eye

Today, but rinse first. Hold the eye open under gently running clean water, or pour water across it from a jug or bottle, for at least fifteen minutes and twenty if you can, tilting the head so the water runs away from the other eye. Then go to the emergency department and take the bottle, packet or a photo of it with you.

Here the rule is the opposite of a sharp injury: water is the treatment, and every minute of it counts. It will be a struggle with a small child; do it anyway, in the shower or over the sink, and keep rinsing on the way if you can. Bleach, oven cleaner and the brightly coloured laundry pods that toddlers squeeze at face height are the ones that come up most often. If superglue is involved, rinse the same way and never force glued lids apart; the doctors will free them.

See an eye doctor, at the emergency department, today if any chemical or strong liquid has gone into the eye, after rinsing for at least fifteen minutes.

My child suddenly cannot see properly, in one eye or both

Today. Sudden loss of sight, sudden blurring, a dark shadow or curtain across the vision, or sudden double vision is an emergency at any age, and that includes a child who says the world went grey for a few seconds and then came back.

Children rarely say "I cannot see". They cover one eye, bump into things on one side, hold a book strangely, or become quiet and clumsy. If you cover each eye in turn with your hand and your child objects to one being covered far more than the other, that is telling you something. Do not wait for it to happen again to be sure. Go, and describe exactly what you saw and when it started.

See an eye doctor, or the emergency department, today if your child's sight has suddenly dropped, blurred or gone dark in one or both eyes, even briefly.

One eye looks pushed forward, bigger, or set differently from the other

Today if it came on over hours or days, or comes with fever, a swollen red lid, pain on moving the eye or a change in vision; this week if it has crept in over weeks without fever.

An eye that has suddenly started to look pushed forward, with a hot swollen lid and a feverish child, is treated as an infection in the tissue behind the eye until an examination says otherwise, and that means a hospital admission, not a course of drops at home. It can follow a sinus infection or a stye that has spread. Pain when the eye moves, and a child who sees double or less clearly, are the two things that push this from this week to today. An eye that has slowly begun to look bigger or more forward over weeks, in a child who is otherwise well, is not an emergency, but it is not something to watch either: it needs an examination within days to find the cause.

See an eye doctor if one eye looks more forward or larger than the other, and go today if there is fever, a red swollen lid, pain on moving the eye, or any change in vision.

My baby is under a month old and has a red or sticky eye

Today. Phone your paediatrician or go to the nearest hospital emergency department or paediatric clinic today, and say the words "newborn" and "red eye" so that the timing is understood.

In an older baby a watery or mildly sticky eye with no redness is very often a blocked tear duct, and it can wait. In a newborn, redness or discharge in the first four weeks is treated as urgent, because some of the infections a baby can pick up around birth can damage the front of the eye quickly. This is not a wipe-with-cooled-boiled-water situation until a doctor has looked.

See an eye doctor today if a baby under one month old has a red eye, a swollen lid, or yellow or green discharge.

My baby's eye waters, screws up in the light, or looks cloudy or unusually large

This week, and phone today; today if the front of the eye looks cloudy. A watery eye on its own in a baby is usually a blocked tear duct, and I would not want a page like this to send every watery baby to emergency. What changes the picture is the company the watering keeps.

A baby who is bothered by ordinary light, who squeezes one eye shut, whose cornea (the clear front window of the eye) looks hazy, or whose eye looks bigger than its pair, is a different matter. Those are the signs of childhood glaucoma, a rare condition in which the pressure inside the eye is too high while the eye is still growing. It can damage sight quickly, and prompt treatment gives the best chance of protecting it, which is why this pattern is booked within days rather than weeks. Many such visits end with reassurance. The few that do not are the reason to make the call today.

See an eye doctor if a watery eye comes with light sensitivity, eyelid squeezing, or one eye that looks larger than the other, and go today if the front of the eye looks hazy or cloudy.

What if my child's symptom is not on this list?

Then use the rule I use. Eye doctors teach parents four things to watch for in a child: redness, sensitivity to light, a change in vision, and pain. Any one of them is a reason to book an appointment. Two or more together is a reason to be seen more urgently, today or tomorrow. That single rule covers most of what turns up in my clinic.

If the thing worrying you is none of those, a habit like rubbing, a head tilt, sitting close, a family history of eye problems, it still deserves an ordinary appointment. A child does not need to read to have a full eye test. And if it worries you and you cannot say why, book anyway. Parents notice things a chart does not, and a visit that finds nothing is still a visit that answered your question. To say it once more, because it matters: nothing on this page is a diagnosis. It tells you how soon your child should be examined by someone who can make one.

See an eye doctor if your child has any one of redness, light sensitivity, a change in vision or pain, and sooner if there are two or more.

Go today if…

Anything sharp has hit or gone into the eye, or a chemical has splashed into it (rinse for at least fifteen minutes first, then go).
Your child's sight has suddenly dropped, blurred or gone dark in one or both eyes, even briefly.
A red eye comes with light sensitivity, real pain, or a change in vision, or your child will not open the eye.
There is eye pain with vomiting, or a severe headache with blurred or double vision or light hurting the eyes.
An older child's eye that was straight has suddenly started to turn, or a droopy lid has appeared suddenly, and without question if there is also double vision, one large pupil, headache or a knock to the head.
One eye looks pushed forward with fever, a hot swollen lid, or pain on moving the eye.
A baby's eye looks cloudy or hazy at the front, or a white pupil comes with a red, painful or swollen eye.
A baby under one month old has a red or sticky eye.

Common questions

Do I go to the emergency department or to an eye clinic?

For anything in the today bucket, go to whichever can see your child soonest, and outside clinic hours that means the nearest hospital emergency department. Injuries, chemical splashes, sudden vision loss and eye pain with vomiting all belong there. For this-week and routine problems, an eye clinic that sees children, or your GP or paediatrician, is the right first call. Say exactly what you have noticed when you phone; the words "white pupil", "sudden squint" or "chemical" help the person booking understand how urgent it is.

Do I need a referral letter to see a children's eye doctor in Malaysia?

Public hospital eye clinics usually ask for a referral letter from a klinik kesihatan or a GP, and it is worth getting one because it also carries the details of what was seen. Private eye clinics can usually be booked directly. For anything in the today bucket, do not wait for a letter: go to the emergency department; any onward referral is arranged from there.

The symptom has gone away. Do I still need to be seen?

For most of the items on this page, yes. A white glow that showed in three photos and not the fourth, a squint that appeared for a day, a lid that drooped and lifted, or sight that went grey for seconds and came back are all things I want to hear about, because they can come and go and still matter. Book the appointment the symptom earned when it was there, and describe what you saw and when.

Can I send a photo or a video instead of coming in?

A photo can help you describe what you saw, and I am glad when parents bring them. It cannot replace the examination. A photo cannot tell a real squint from the illusion a wide nasal bridge creates, cannot show what a pupil looks like when a light is shone into it, and cannot measure the pressure in an eye. Bring the photo, and bring the child.

Should I rinse the eye after an injury?

It depends entirely on what happened, and the two rules are opposite. If a liquid, powder or spray went into the eye, a chemical, cleaner, detergent pod or glue, rinse immediately with clean water for at least fifteen minutes and then go to the emergency department. If something solid has cut or entered the eye, or the eye was hit at high speed, do not rinse, press or rub, and do not pull anything out; cover the eye loosely and go. If you truly cannot tell what happened, go now and tell them what you know.

It is the middle of the night. Can it wait until morning?

If it is in the today bucket, no. Hospital emergency departments are open all night, and eye injuries, chemical splashes, sudden vision loss and severe pain are exactly what they are for. If it is in the this-week bucket, phone first thing in the morning and ask for the earliest appointment. Sleeping on a routine worry is fine; sleeping on a today one is not.

My toddler has a red eye but seems fine otherwise. Is that urgent?

Usually not. A red, sticky, gritty eye in a child over a month old, with no pain, no light sensitivity and no change in vision, is the pattern that can usually wait: see it routinely if it has not settled within a few days. It moves up to today if the light hurts, the eye is painful, the redness is very dark, your child will not open the eye, or their sight seems affected. And any red eye in a baby under one month old is a today problem.

What should I bring to the appointment?

The photos, if photos are how you noticed. The bottle or packet, or a photo of it, if a chemical is involved. A note of when it started, whether it comes and goes, and whether anyone in the family had a squint, a lazy eye, or an eye problem in childhood. And your child's usual glasses if they wear any. None of that delays a today visit: go first, and bring what you can.

References

NHS · Red eye: when to get help · www.nhs.uk
NHS · Retinoblastoma: symptoms and when to seek help · www.nhs.uk
AAPOS · Esotropia (any crossing beyond four months should be checked) · aapos.org
AAPOS · Sixth nerve palsy · aapos.org
AAPOS · Ptosis (droopy eyelid) in children · aapos.org
AAPOS · Third nerve palsy · aapos.org
American Academy of Ophthalmology · Child eye problems parents should never ignore (the RSVP rule) · www.aao.org
NHS · Eye injuries: chemical splash and penetrating injury first aid · www.nhs.uk
American Academy of Ophthalmology · Recognizing and treating eye injuries · www.aao.org
AAPOS · Eye injury and safety · aapos.org
NHS · Vision loss: sudden loss of sight · www.nhs.uk
American Academy of Ophthalmology EyeWiki · Orbital cellulitis · eyewiki.aao.org
AAPOS · Glaucoma in children · aapos.org
American Academy of Ophthalmology · Childhood glaucoma · www.aao.org
NHS · Squint · www.nhs.uk

By Dr Chan Li Yen. General information only. It does not replace a consultation. If you are worried about your child's eyes or vision, please see an eye doctor.