A 3-year-old female came to clinic with a 2 hour history of sudden onset of pain and photophobia. She was traveling in the car with the windows rolled down when she started to cry and said her left eye hurt. Her mother stopped the car and examined the eyes which she said appeared normal. Her mother had some saline eye drops with her and irrigated the left eye and then they returned home. Again her mother irrigated the eye, but the child continued to complain of pain and photophobia. The mother stated that she continued to rub the left eye intermittently, but less so since leaving to come to clinic.
The past medical history showed visits for strep throat, otitis media and atopic dermatitis. The family history was positive for some visual acuity problems in both sides of the family as family members aged. There weres no neurological problem including migraine headache, but the mother said that she had intermittent musculoskeletal related headaches. The review of systems was negative.
The pertinent physical exam showed a cooperative child with mild erythema of the left sclera who preferred the room to be dimmed, but would tolerate full illumination. Visual acuity was 20/20. There were no obvious visual field defects. There was some very minor erythema of the left lid compared to the right without obvious trauma such as an insect bite. The ophthalmological examination revealed all extra ocular movements to be intact. Pupils were 3 mm, equal, round and reactive to light and accomodation. The sclera was mildly injected. No obvious foreign body was seen or discharge noted on the sclera, palpebral conjunctiva and with eversion of the upper lid. Fluorescein dye and a Wood’s lamp revealed a corneal abrasion about 1 cm in length just lateral to the limbus and running in an 11 o’clock to 5 o’clock position. The right eye and neurological examination was normal as was the rest of her examination.
The diagnosis of a corneal abrasion was made. A topical anesthetic was applied for patient comfort. A topical antibiotic ointment was also applied and the eye patched. The patient’s clinical course showed her going home and sleeping. She kept the patch on for an addition 2 hours and then took it off just before bed and was not complaining of pain or photophobia. Her ophthalmological examination was normal the next day including no evidence of corneal abrasion on fluorescein dye testing.
Corneal abrasions are common problems in children that can be caused from a variety of trauma. Children’s fingernails and toys are frequent culprits along with dust particles particularly under windy circumstances. A review of treatment for corneal abrasions and a brief differential diagnosis of painful eyes can be found at: To Patch or Not to Patch, That is the Question
Photophobia is excessive light sensitivity and can be caused by a variety of entities. The differential diagnosis includes:
- Ophthalmological problems
- Glaucoma, congenital
- Retinitis pigmentosa
- Amoebic meningoencephalitis
- Lyme Disease
- Lymphocytic Choriomeningitic Virus
- Rociky Mountain Spotted Fever
- Typhus – Rickettsia prowazekii
- Viral and bacterial keratoconjunctivitis
- Systemic disease
- Acrodermatitis enteropathica
- Cyclic vomiting
- Juvenile Idiopathic Arthritis
- Kawasaki Disease
- Sjogren-Larsson Syndrome
- Vitamin A deficiency
- Reiter syndrome
- Lymphoproliferative disorders
- Corneal abrasion, irritation, ulceration
- Retinal detachment
Questions for Further Discussion
1. What is the differential diagnosis of ptosis?
2. What is the differential diagnosis of nystagmus?
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
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Medicine San Frontiers. Clinical Guidelines Diagnosis and Treatment Manual. Available from the Internet at http://www.refbooks.msf.org/msf_docs/en/Clinical_Guide/CG_en.pdf (rev. 2007, cited 5/11/09).
Centers for Disease Control Yellow Book Chapter 4 – Rickettsial InfectionsAvailable from the Internet at wwwn.cdc.gov/travel/yellowbook/ch4/rickettsial.aspx (cited 5/11/09).
eMedicine. Available from the Internet at http://emedicine.medscape.com/ (rev. 2009, cited 5/11/09).
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
5. Patients and their families are counseled and educated.
7. All medical and invasive procedures considered essential for the area of practice are competently performed.
8. Health care services aimed at preventing health problems or maintaining health are provided.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital