Aimee Vos, MD
Pediatric Neck Pain
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Chief complaint: Left eye injury
History of present illness: 21-year-old female presents with a left eye injury that occurred the day prior. Patient states she was rushing and was putting her jacket on when the zipper struck her in the left eye. Patient states she woke up in the morning and found her left eye appeared odd, with a cloudy spot and a bulging appearance. Patient denies pain, vision changes, photo sensitivity, eye discharge or tearing. Patient states she wears glasses regularly but denies contact use.
Pertinent physical exam: Eye exam: EOMI, PERRLA, no pain on extraocular movements. There is a focal opaque area of stoma corneal edema that is markedly elevated compared to the rest of the corneal. No epithelium defect noted. Vision testing: 20/200 left eye and 20/70 on the right, without glasses. Fluorescein stain: mild uptake at the 3 o’clock position. No hyphema was noted. A slit lamp examination demonstrated a conical protrusion from the cornea not in the visual field. Negative Seidel sign.
Patient was evaluated at bedside by the ED resident and attending. Visually notable defect on the anterior surface of the left eye was examined. Fluorescein stain did show mild uptake at 3 o’clock position. Visual acuity exam was performed and was at baseline for the patient.
Ophthalmology was consulted, and the case was discussed. Since the patient was comfortable at bedside with no complaints of pain, visual acuity change, and no Seidel sign noted, it was decided that no emergent interventions were needed. The patient was discharged with ophthalmology follow-up the next morning and given a prescription for ciprofloxacin eyedrops.
Upon further questioning, patient stated that she had corrective glasses since she was a child but never had perfect vision. Patient stated she consistently has changing prescriptions for her glasses. Follow up with patient and ophthalmologist was done and patient was diagnosed with corneal hydrops from an undiagnosed keratoconus. Patient was given a course of hypertonic saline eye drops and referral to an anterior chamber specialist for contact lens fitting.