Case study in the Journal of AAPOS highlights need for vigilance

It has been estimated that roughly 4% to 6% of child abuse victims present first to an ophthalmologist. In a case study in the April issue of the Journal of American Association of Pediatric Ophthalmology and Strabismus, doctors at the University of Washington and the Seattle Children's Hospital describe a case of a 13-month-old girl who was initially diagnosed with corneal abrasion and a mild infection. She was eventually identified as a victim of child abuse.

"In retrospect, there were clinical and laboratory findings that might have raised concerns about child abuse earlier in the course of the condition," says senior author Avery H. Weiss, MD, Roger Johnson Clinical Vision Laboratory, Division of Ophthalmology, Seattle Children's Hospital. "This troubling case is a reminder to be vigilant for the possibility of child abuse in chronic or recurrent keratoconjunctivitis with dermatitis of an uncertain etiology."

The child presented with left lower eyelid swelling, sensitivity to light, and increased tearing. Her vision was reduced compared with normal for children her age. She was treated with topical and oral antibiotics, but her condition progressively worsened over the course of two weeks. During a three-day stay in the hospital, her condition improved and she was discharged. Despite continued therapy, the irritation and inflammation persisted. She was then brought to a local trauma hospital a brain hemorrhage and bruising consistent with child abuse. The patient's antibacterial eye drops were confiscated, and found to have been laced with household bleach. Criminal charges are pending.

Dr. Weiss notes that looking back, several features of the examination were more consistent with a locally applied irritant than with infection, including the isolated lower eyelid swelling, the inferior corneal abrasion, and inflammation confined to the lower conjunctiva.

Journal of AAPOS Editor-in-Chief David G. Hunter, MD, PhD, of the Children's Hospital Boston and Harvard Medical School, comments, "This tragic story of an unexpected manifestation of mental illness serves as a reminder to physicians in all specialties to remain vigilant for child abuse whenever a patient fails to improve despite what appears to be appropriate therapy."