Additional History:
The father noticed that the left eye has always been slightly bigger than the right eye. However, the asymmetry has been more noticeable in recent months. The patient has also been more light sensitive. He denies any eyelid swelling, trauma, recent illness, fever, chills, and rashes. The patient was born spontaneously at 38 weeks weighing 3800 grams (75th percentile). The Apgar scores were 7 and 9 at 1 and 5 minutes, respectively. There is no history of birth trauma. The patient has met all developmental milestones at appropriate ages. The patient’s mother received prenatal care and had no complications or illness during the pregnancy. The patient does not have any other siblings. There is no family history of malignancy or eye disease. The patient has no prior eye surgery. Vaccinations are up-to-date.
Physical Exam:
General appearance: Irritable baby, with frequent eye rubbing. Does not want to open eyes. Buphthalmos OS. No dysmorphic features.
Vitals: Temp: 37C, BP: 93/60, HR: 130 bpm, RR 27, O2 sat: 99%, Weight: 9.5 kg (55th percentile), Height: 73 cm
Visual acuity: Fixes and follows OD. Reduced fixation OS. Squeezes eyes shut and cries in response to penlight OS.
Pupillary reflex: Red pupillary reflex OU.
Pupils: OD round and reactive, OS sluggish with 1+rAPD
EOM: full OU, no nystagmus, no gaze deviation OU
Intraocular pressures (IOP): Soft to palpation OD. Firm to palpation OS.
Below is an external photo of the patient’s eyes:
Based on the physical exam findings, the pediatrician refers the patient urgently to a pediatric ophthalmologist.
Click here for the ophthalmology exam!
Peds ophtho Case 3 Index
Peds Ophtho Case 3 Introduction