Ophthalmic case study 7 (VKC)

 

 Chief complaint:

Decreased distance visual acuity for the past four months.

Current illness history:

The patient is an eight-year-old white male who suffers from seasonal allergic rhinitis. He presents for an ophthalmic examination, complaining of a four-month history of decreased distance visual acuity. Notably, he has a history of superior flictenulosis in the right eye during the previous summer, which resolved with topical therapy of 0.5% loteprednol.

Past ocular history:

No significant history of surgery or trauma. He is mildly nearsighted with a current optical prescription of -1.75 spherical in both eyes (OU). Flictenulosis as noted above.

Medical history:

History of asthma and seasonal allergies during childhood.

Medications:

His allergic rhinitis is treated with beclomethasone dipropionate nasal spray (Vanceril) and combined oral therapy of chlorpheniramine and pseudoephedrine (Kronofed, antihistamine and decongestant).

Family history:

Maternal grandparents with cataracts, glaucoma, and macular degeneration. Multiple family members with nearsightedness.

Social history:

The patient is a well-adjusted second-grade student living with parents. No known exposure to anyone with infectious eye disease.

Eye examination:

Moderate photophobia noted during the examination.

Neurological status:

Alert and oriented x3, no focal deficits.

Visual acuity, with correction

(-1.75 sphere, OU): Right eye (OD) -- 20/40; Left eye (OS) -- 20/40 (pinhole correction to 20/25 OD and OS).

Extraocular motility:

Full, both eyes (OU).

Pupils: Normal with no relative afferent pupillary defect (RAPD).

Confrontation visual fields: Full, OU.

Intraocular pressure: OD -- 17 mmHg; OS -- 18 mmHg.

Slit-lamp examination

Superior limbal papillary reaction and superior bulbar conjunctival injection, OU (see Figure 1). Palpebral papillae are evident on the superior tarsal conjunctiva, OS, otherwise normal.

Dilated fundus examination (DFE): No disc pallor or edema, OU. Normal macular vessels and periphery, OU.

OD - Broad, gelatinous, thickened, opaque, and mucoid nodular infiltrates composed of eosinophils and epithelial remnants. Horner-Trantas dots (calcified pinpoint concretions) are present at the apices of the nodules.

OS - Limbal conjunctivitis: broad, gelatinous, thickened, opacification of the superior limbus.

Diagnosis

The course and presentation of the patient are classic for vernal keratoconjunctivitis (VKC).