Pediatric Examination and Board Review (87 page)

A 30-month-old child is brought to see you by his mother, who has noticed redness of his left eye for the last few weeks. She reports very little discharge and no surrounding swelling or redness. He attends daycare 5 days a week and has had several colds in the last 3 months, most recently 3 weeks prior. He currently has no associated upper respiratory symptoms. His mother does not think that he is bothered by the eye problem.

On examination you find a friendly, interactive toddler. He points to animals on the wallpaper, smiles at his mother, and plays interactively with his toys. He is afebrile. You note unilateral moderate conjunctival injection but no discharge. There are no other findings, including on your fundoscopic examination, during which he is quite fussy.

SELECT THE ONE BEST ANSWER

1.
What is your
best
next action?

(A) begin antibiotic eye drops

(B) begin steroid eye drops

(C) ask them to return for a follow-up visit in a few days if the redness is not resolved

(D) begin anti-allergy eye drops

(E) begin an oral antihistamine

2.
The mother misses the follow-up appointment and comes in 3 months later because she now has the sense that the left eye is “growing” faster than the other. She says that the redness is still present and he also has some tears that leak out of that eye. On examination you note the same unilateral moderate conjunctival injection but now also tearing and an enlarged globe. You cannot perform a fundoscopic examination because of lack of cooperation of the child. What is your working diagnosis?

(A) corneal abrasion

(B) viral conjunctivitis

(C) allergic conjunctivitis

(D) bacterial conjunctivitis

(E) glaucoma

3.
Which test that can be conducted in the office of a general pediatrician is most indicated during the evaluation of the suspected condition for the patient in this case?

(A) Snellen chart testing

(B) fundoscopic examination

(C) corneal diameter

(D) pupillary reaction to light

(E) B and C

4.
Which of the following is the best treatment for a 2-year-old with glaucoma?

(A) beta-blocker

(B) alpha-agonist

(C) trabeculotomy

(D) A and B

(E) none of the above

5.
All of the following are associated with glaucoma in childhood except

(A) congenital rubella

(B) congenital syphilis

(C) Sturge-Weber syndrome

(D) Marfan syndrome

(E) neurofibromatosis

6.
A 12-year-old who wears contact lenses comes to see you because of several days of right eye redness, pain, and now light sensitivity and blurry vision. She has no other symptoms, does not wear glasses, and recalls no trauma to the eye. What is the most likely diagnosis?

(A) glaucoma

(B) viral conjunctivitis

(C) allergic conjunctivitis

(D) bacterial conjunctivitis

(E) corneal abrasion

7.
What is the best way to diagnose this condition?

(A) slit lamp examination

(B) fundoscopic examination

(C) visual acuity testing

(D) fluorescein examination

(E) pupillary reaction to light

8.
In addition to discontinuing contact lens use, which additional treatment(s) would be best to treat this condition?

(A) topical antibiotics

(B) oral antibiotics

(C) eye patch

(D) topical steroids

(E) B and D

9.
You see a 3-day-old healthy full-term infant in the hospital for her newborn examination and on your fundoscopic examination, you note the absence of a red reflex on one side. Instead you see a white discoloration. If you suspect congenital cataracts, which of the following tests would be part of your workup?

(A) thyroid-stimulating hormone (TSH) and free thyroxine (T
₄
)

(B) rubella antibody titers

(C) galactose-1-phosphate

(D) glucose-6-phosphate dehydrogenase (G6PD)

(E) B and C

10.
Approximately what percentage of unilateral congenital cataracts are hereditary?

(A) 5%

(B) 25%

(C) 50%

(D) 75%

(E) 90%

11.
Approximately what percentage of bilateral congenital cataracts are hereditary?

(A) 5%

(B) 25%

(C) 50%

(D) 75%

(E) 90%

12.
You see a 6-month-old girl in your office for a health prevention visit and on your fundoscopic examination notice a unilateral white discoloration in place of her red reflex. Which of the following is not associated with this finding?

(A) retinoblastoma

(B) Down syndrome

(C) retinopathy of prematurity

(D) incontinentia pigmenti

(E) retinal detachment

13.
After referral to an ophthalmologist, you are told that she has a cataract. Which of the following are associated with infantile cataracts?

(A) trisomy of chromosome 13

(B) trisomy of chromosome 18

(C) deficiency of galactose-1-uridyltransferase

(D) chromosome 5 short arm deletion

(E) all of the above

14.
You see a 2-week-old in your office for a newborn checkup and on eye examination find that he has a very small amount of iris tissue. You diagnose aniridia. His mother and father say that no one else in the family has anything similar. What other test does this infant most need?

(A) echocardiogram

(B) renal ultrasound

(C) spinal ultrasound

(D) electroencephalogram (EEG)

(E) complete blood count (CBC) with differential

15.
What is the mode of inheritance for most children with this disease?

(A) sporadic

(B) autosomal dominant

(C) autosomal recessive

(D) X-linked

(E) not known

16.
Which of the following is
not
associated with a coloboma?

(A) trisomy 13

(B) trisomy 18

(C) VATER

(D) CHARGE

(E) sebaceous nevus

17.
The mother of a 4-year-old brings her daughter in after she was hit in the eye with a small toy. She has been very irritable since it happened and says that her eye hurts. On examination you note frank red blood filling the lower third of the anterior chamber. You cannot perform a fundoscopic examination because she is uncooperative. What is her most likely diagnosis?

(A) intraorbital tumor

(B) hyphema

(C) keratitis

(D) coagulopathy

(E) foreign body

18.
Which of the following is
not
a recommended treatment for this disorder?

(A) bed rest

(B) oral steroids

(C) head elevation

(D) surgical drainage

(E) topical steroids

19.
What is the
most
common complication of this disorder?

(A) glaucoma

(B) blood loss

(C) rebleeding

(D) loss of vision

(E) corneal abrasion

ANSWERS

1.
(C)
Because the diagnosis at this point is unclear, and the diagnostic possibilities include viral infections, bacterial infections, allergic disorders, and other ophthalmologic diseases, the best action is reassurance, with a follow-up visit if it does not resolve spontaneously.

2.
(E)
Infantile glaucoma (2 months to 3 years of age) is diagnosed mainly by signs and symptoms. The triad of tearing, photophobia, and blepharospasm is typical but only occurs in 30% of children with glaucoma. Findings on examination may include increased corneal diameter (>12 mm), cloudy cornea, conjunctival injection, and ocular enlargement.

3.
(E)
Fundoscopic examination needs to be performed both to look for orbital nerve cupping (secondary to the increase in pressure) and to rule out intraorbital pathology. You should attempt to measure a corneal diameter in this case with your ophthalmoscope. Children’s corneas reach adult size (12.0 mm) by 2-3 years old. An increase of even 1 mm over the average is considered abnormal and should prompt an immediate referral to an ophthalmologist. A 2-year-old is too young to cooperate with a Snellen chart. The pupillary reaction to light should be maintained in glaucoma. An ophthalmologist may be able to measure intraocular pressure, which will aid in diagnosis.

4.
(C)
Surgical management is the mainstay of congenital and pediatric glaucoma. Side effects from medical therapies and the difficulty of instilling drops into children’s eyes each day keep these medications from being as useful as they are in adults.

5.
(B)

6.
(E)
These are the classic symptoms of a corneal abrasion: an acute onset with no other symptoms except photophobia and loss of visual acuity.

7.
(A)
Although the other answers listed are a standard part of the eye examination when considering corneal abrasion, slit lamp examination is considered the gold standard. After installation of fluorescein dye, inspection of the cornea with a blue-filtered light is necessary (available on a slit lamp, ophthalmoscope, or Wood lamp).

8.
(A)
Prophylactic antibiotics should be applied until the epithelium is completely healed, usually 7-10 days. Several recent studies have suggested no benefit from the use of an eye patch. Steroids are not necessary in this situation. Contact lenses should not be used during the healing process.

9.
(E)
The most common cause of leukocoria in infants (
Figure 54-1
) is a congenital cataract. The workup includes rubella titers for congenital infection, galactose-1-phosphate for galactosemia, glucose for hypoglycemia, Venereal Disease Research Laboratory test (VDRL) for syphilis, urine protein for Alport syndrome, urine amino acids for Lowe syndrome, homocysteine for homocystinuria, copper level for Wilson disease, and a karyotype to detect a possible trisomy. Thyroid abnormalities and G6PD are unrelated.