POCUS ocular en Emergencias y Medicina Crítica Pediátrica: Diámetro de la Vaina del Nervio Óptico, Pupilometría y Reflejo Fotomotor.

CRITICAL CARE & EMERGENGY MEDICINE VOL. 4

Ocular POCUS in Pediatric Emergency and Critical Care Medicine: Optic Nerve Sheath Diameter, Pupillometry, and Photomotor Reflex

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www.doi.org/10.58281/ccem25080104

Patrick Danny Caqui Vilca 1 , Javier Ponce 2 , Edwin Mauricio Cantillano Quintero 3 , David Pascual Rojas Flores 4 , Jesus Angel Domínguez-Rojas 5 .

1 Instituto Nacional de Salud del Niño San Borja. Lima, Perú.
2 Hospital Guillermo Rawson. San Juan, Argentina.
3 Hospital del Norte del Instituto Hondureño de Seguridad Social. San Pedro Sula, Honduras.
4 Hospital General Regional No. 1 del Instituto Mexicano del Seguro Social. Querétaro, México.
5 Hospital: Instituto Nacional de Salud del Niño – San Borja. Lima, Perú.
Miembros de USPed Latinoamérica.

Abstract

Early detection of elevated intracranial pressure (ICP) is crucial for the timely diagnosis and management of intracranial hypertension in critically ill pediatric patients, helping to prevent secondary brain injury and reduce mortality. Invasive ICP monitoring remains the gold standard for both initial diagnosis and follow-up assessments, providing accurate real-time measurements. The measurement of optic nerve sheath diameter (ONSD) has emerged as a valuable non-invasive method for assessing ICP, alongside various sonographic ratio-based approaches, which have demonstrated high sensitivity for detecting raised ICP. However, the relationship between the optic nerve sheath and ICP is complex.
Changes in the width and dynamics of the sheath are influenced not only by intracranial pressure but also by age, anterior fontanelle patency, and the underlying pathology. The ICP threshold above which pressure should be considered abnormal varies with age and other factors that affect ONSD measurements. Ultrasound-based evaluation of pupillary diameter and light reflex offers a simple technique to complement the neurological examination, especially in patients with eyelid abnormalities. Ocular point-of-care ultrasound (POCUS) enables the detection of sonographic signs suggestive of elevated ICP in children. It is easy to learn and perform, free of ionizing radiation, and, despite some limitations, represents a key tool in the management of neurocritical pediatric patients in emergency and intensive care settings.

 Le medición temprana de la presión intracraneal elevada es importante para el diagnóstico y tratamiento oportuno de la hipertensión intracraneal en pacientes pediátricos gravemente enfermos, previniendo el daño cerebral secundario y la mortalidad. Las mediciones invasivas de la presión intracraneal son actualmente el estándar de oro para el diagnóstico inicial y las evaluaciones de seguimiento de la misma en términos de mediciones precisas en tiempo real. La medición del diámetro de la vaina del nervio óptico es un método no invasivo útil para evaluar la presión intracraneal, así como la medición de diferentes proporciones sonográficas, las cuales son muy sensibles para la detección de elevación de la presión intracraneal. La relación entre la vaina del nervio óptico y la presión intracraneal es compleja. Los cambios en el ancho y la dinámica de la vaina del nervio óptico no solo se afectan por la presión intracraneal, sino también por la edad, la permeabilidad de la fontanela anterior y el tipo de patología. El umbral por encima del cual el nivel de presión intracraneal debe considerarse anormal también varía según la edad, y otros factores que afectan el ancho y la dinámica de los cambios en la vaina del nervio óptico. La evaluación del diámetro pupilar y el reflejo fotomotor mediante ecografía es una técnica sencilla que permite completar el examen neurológico en pacientes con alteraciones palpebrales. El ultrasonido en el punto de atención ocular nos permite detectar cambios indicativos de presión intracraneal elevada en niños, es fácil de aprender y realizar, no genera radiación ionizante, y su uso y aplicación no está exenta de limitaciones, que una vez conocidas, se vuelve una herramienta clave en el paciente neurocrítico en emergencias y la terapia intensiva.

Optic nerve sheath, POCUS, pediatrics, intracranial pressure, transverse ocular diameter.

Patrick Danny Caqui Vilca   
Instituto Nacional de Salud del Niño San Borja. Lima, Perú.

Javier Ponce 
Hospital Guillermo Rawson. San Juan, Argentina.

Edwin Mauricio Cantillano Quintero 
Hospital del Norte del Instituto Hondureño de Seguridad Social. San Pedro Sula, Honduras.

David Pascual Rojas Flores 
Hospital General Regional No. 1 del Instituto Mexicano del Seguro Social. Querétaro, México.

Jesus Angel Domínguez-Rojas 
Hospital: Instituto Nacional de Salud del Niño – San Borja. Lima, Perú. Miembros de USPed Latinoamérica.

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[1] Patrick Danny Caqui Vilca, Javier Ponce, Edwin Mauricio Cantillano Quintero, David Pascual Rojas Flores, and Jesus Angel Domínguez-Rojas. 2025. POCUS ocular en Emergencias y Medicina Crítica Pediátrica: Diámetro de la Vaina del Nervio Óptico, Pupilometría y Reflejo Fotomotor. CRITICAL CARE & EMERGENCY MEDICINE. Vol. 4, 62–70. DOI: https://doi.org/10.58281/ccem25080104.
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