Article Type : Case Report
Authors : Campo GC and Loeches AA
Keywords : Actinic keratitis; Red eye; Corneal pathology
Red eye is one of the most frequent
reasons for consultation in pediatric emergency departments. The differential
diagnosis of red eye in children includes three main entities: conjunctivitis,
keratitis and anterior uveitis. Keratitis can be of infectious or
non-infectious origin. Actinic keratitis is due to exposure to ultraviolet
radiation. Signs appear within a few hours of such exposure. It is diagnosed
clinically and treated topically with antibiotics and lubrication.
Red eye is one of the most frequent reasons for consultation
in paediatric emergency departments. It can sometimes be a diagnostic challenge
for paediatricians, therefore it is important to know the characteristics of
the hyperemia, whether it is associated with pain and whether it is accompanied
by secretions. The three most frequent entities in this age group, and which
should therefore be considered in the presence of a red eye, are
conjunctivitis, keratitis and anterior uveitis [1]. In the case of corneal
pathology, it should be suspected when a red eye is accompanied by pain,
epiphora, photophobia, blepharosmasm and sometimes loss of visual acuity. In
these cases, it is important to ask the patient about a history of previous
trauma, if he/she is a contact lens wearer, previous eye surgery or systemic
diseases (ichthyosis, vitamin A deficiency, Steven Johnson syndrome, etc.) or
diseases of the ocular surface.
A 15-year-old adolescent who attended the paediatric
emergency department in the early hours of the morning due to the impossibility
of bilateral ocular opening since waking up. He reported that he had not
presented any ocular symptoms the previous day. He is not a contact lens
wearer. No ocular secretions or tearing. He denies other symptoms. Physical
examination shows normal vitals and a stable paediatric assessment triangle.
The patient's eyes were closed at all times. There is mild bilateral soft
palpebral edema without erythema and blepharospasm. During the examination,
passive ocular opening was attempted, but the patient reported intense
bilateral ocular pain. It was decided to administer fluotest eye drops (topical
fluorescein and oxybuprocaine hydrochloride) in both eyes and the patient was
subsequently examined, which revealed intense ocular hyperemia and a bilateral
corneal epithelialisation defect with a stippled appearance. In addition, a
complete physical and neurological examination was carried out, with no
significant alterations. In view of these findings, the ophthalmology
department was contacted for a thorough assessment. The slit-lamp examination
revealed a papillary reaction in the tarsal conjunctiva and diffuse keratitis
in both eyes, with no corneal infiltrates and negative Tyndall. No conjunctival
foreign bodies were observed. On re-historying the patient, he reported that
the previous day he had been with his father watching him weld without wearing
eye protection. Finally, the patient was diagnosed with actinic keratitis of
both eyes secondary to welding. Treatment was prescribed with tobramycin
ointment, cycloplegic eye drops, oral analgesia and artificial tears. He was
followed up in the ophthalmology department and progressed well. He is
currently asymptomatic and has no ocular sequelae.
The causes of keratitis in the paediatric age group
can be both infectious and non-infectious. Infectious causes mainly include
bacterial ulcers, herpetic keratitis and fungal keratitis. With regard to
non-infectious ulcers, apart from the physical ones, as in our case, there are
also those of traumatic and chemical origin. Actinic keratitis is caused by
exposure to ultraviolet rays, which produce superficial necrosis of the cornea
[2-4]. It is typically seen in welders who do not use adequate eye protection
or after prolonged exposure to the sun (beach, snow, etc.), such as in skiers.
It usually takes 6 to 10 hours from exposure to the onset of symptoms, with the
most common symptoms being intense eye pain, perichoaratic hyperemia,
photophobia, blepharospasm and tearing [2-4]. Occasionally it may be associated
with reduced visual acuity. Diagnosis is essentially clinical, requiring a
correct anamnesis and ocular examination. Fluorescein staining of the cornea
reveals corneal stippling, known as punctate keratitis, usually predominating
in the inferior region [2,3]. Treatment consists of cycloplegic eye drops
(cyclopentolate hydrochloride 1%) and oral analgesia due to the intense pain
experienced by these patients [2-4]. In addition, it is very important to
lubricate the eye intensively using artificial tears containing hyaluronic acid
during the day and to apply an epithelialising ointment at night [3]. In
addition, it is recommended to add topical antibiotics, either in the form of
eye drops or ointment 3. In the case of welders, it is recommended to look for
conjunctival foreign bodies [2]. Subsequently, strict ophthalmological control
and follow-up is required, as the possible complications are very serious and
disabling (perforation, vascularised scarring and blindness).