Patient History

HPI: The patient is an 11-year-old male who reports a 4-day history of irritation and itching, initially in the left eye followed by the right eye one day later. Both eyes also had mild yellowish discharge and eyelid swelling, making it difficult to open the eyes in the morning. There is minimal ocular redness but no sensation of a foreign body, flashes, floaters, decreased vision, or double vision. No eye drops used. No environmental eye exposures.

Past Ocular History: No history of eye trauma, surgery, amblyopia, or strabismus. No history of contact lens use.

Ocular Medications: None

Past Medical History: Term birth without complications

Surgical History: None

Past Family Ocular History: No history of glaucoma, macular degeneration, or other blinding diseases.

Social History: No smoking at home

Medications: None

Allergies: None

ROS: Exposure to common cold (neighbor's friend). No history of environmental allergies, recent cold, CNS, heart, lung, GI, skin, or joint problems.

Ocular Examination

Visual Acuity (cc): OD: 20/20 OS: 20/25

IOP (tonometry): OD: 17 mmHg OS: 14 mmHg

Pupils: Equal, round, and reactive to light, no relative afferent pupillary defect (RAPD)

Extraocular Movements: Full in both eyes, no nystagmus

Visual Fields by Confrontation: Full to finger counting in both eyes

External: Normal appearing orbital structures; no redness or swelling in either eye

Slit Lamp Examination:

Lids and Lashes: Dry, crusted material on lashes in both eyes, no follicles in inferior or superior fornix in either eye. No foreign bodies in fornices.

Conjunctiva/Sclera: Mild conjunctival injection in both eyes, no chemosis

Cornea: Clear in both eyes, no infiltrates

Anterior Chamber: Deep and quiet in both eyes

Iris: Normal in both eyes

Lens: Normal in both eyes

Anterior Vitreous: Clear in both eyes

Dilated Fundus Examination: OD: Clear view, optic disc with sharp margins, flat macula with normal foveal light reflex, normal vessels and peripheral retina OS: Clear view, optic disc with sharp margins, flat macula with normal foveal light reflex, normal vessels and peripheral retina

Others: No enlargement of pre-auricular or submandibular lymph nodes

Diagnosis and Discussion Diagnosis: Acute conjunctivitis in both eyes

Discussion: Differential Diagnosis:

The presentation above is consistent with viral conjunctivitis. Other possible diagnoses include allergic conjunctivitis (typically with itching), atopic conjunctivitis (usually with a history of eczema), bacterial conjunctivitis (usually with purulent discharge and intense redness), medication toxicity (e.g., patient on chronic eye drops), exposure toxicity (e.g., exposed to fumes from fire or other toxic chemicals), and pediculosis (eyelash lice infestation with chronic follicular conjunctivitis).