Test Your Clinical Acumen

Case 1: This child fell from his bicycle 3 days ago and suffered mild head trauma. He lacerated his forehead and sustained some abrasions and bruises in the surrounding scalp. His mother now seeks medical care because the child’s eyelids have become so swollen that he can hardly open his eyes. What is the cause of the eyelid swelling?Case 1: The eyelid swelling is the result of edema secondary to trauma. Gravity has forced the edematous fluid to descend from the forehead whenever the child is upright. There is no intraocular pathology. The eyelids are particularly prone to swelling because of the underlying lax subcutaneous tissue. They collect edematous fluid in cases of trauma just as they do in angioneurotic edema secondary to allergic reactions and in generalized edema, as occurs in the nephrotic syndrome. No treatment is necessary; reassure the child and the parent that the swelling will resolve in several days- as it did in this patient.Case 2: A 9-year-old girl is brought to your office with right eye redness and swelling of several days’ duration. During the past few days, some discharge and crusting has been present and a mass in the conjunctiva of the right lower eyelid was noticed. What is this lesion, and how would you treat it?Case 2: This child has a pyogenic granuloma of the conjunctiva. It is probably the result of an internal hordeolum involving the meibomian gland. The differential diagnosis includes other soft tissue masses in the eye, such as a hordeolum, chalazion, or cyst. A pyogenic granuloma is a deep red, pedunculated lesion that may be associated with a chalazion or a hordeolum; it may also develop several days after trauma or surgery involving the conjunctiva or skin. The lesion may be excised or treated with a topical antibiotic/corticosteroid combination. A pyogenic granuloma in the eye region should be followed by an ophthalmologist. The intraocular pressure must be monitored if topical corticosteroids are used for several weeks. If the granuloma does not respond to medical treatment, surgical excision is necessary.

Case 3: This 13-year-old boy who lives in the deep south has a history of asthma. Several weeks during the past summer, he has complained of episodes of severe eye itching; during these episodes, mild ocular erythema develops, as does a thick clear discharge when he awakens in the morning. What is the most likely diagnosis?

Case 3: The diagnosis is vernal conjunctivitis. Cobblestone papillae in the tarsal upper eyelids confirm this diagnosis. Eyelid eversion is necessary for visualization-not an easy procedure in a young child. Referral to an ophthalmologist may be indicated to manage such complications as corneal “shield” ulcers and other keratopathies. Vernal conjunctivitis is a more severe form of seasonal, recurrent allergic conjunctivitis that often occurs in children and young adults. It is especially common in young boys-particularly those who have a history of allergies and asthma-during the spring and summer. Because vernal conjunctivitis, or hay fever conjunctivitis, is frequently related to a grass/weed allergy, it usually occurs in children who play outdoors. Symptoms include pruritus, light sensitivity, blinking, and a mucoid tear discharge. Papillary hypertrophy occurs when cellular infiltrates develop in the mucous membrane lining of the upper eyelid; this creates a roughened, cobblestone- like conjunctival surface. These roughened inner eyelids can scratch the cornea continually with blinking, which causes eye irritation and occasionally corneal abrasion. Treatment may include cool compresses, NSAIDs, and mast-cell stabilizers, such as cromolyn sodium. Other frequently used medications include topical antihistamines, such as olopatadine or ketotifen, and even topical corticosteroids in more severe cases. Vernal conjunctivitis tends to resolve as children mature.Case 4: This adolescent thought he could fix an old television set without having the technical know-how to do so. He tried to pry open the back cover of the set when a piece of metal sprung out and lodged in his left eye. How will you manage?Case 4: When the patient struggled to open the television, a staple popped out of the set and embedded itself in the boy’s eye. He was sent directly to surgery, which was performed by an ophthalmology team. The eye was saved, although visual acuity was somewhat impaired.