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15-05-2012 | Legal medicine | Article

Persistent keratoconjunctivitis raises red flags about child abuse

Abstract

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MedWire News: Young children presenting with chronic or persistent keratoconjunctivitis should be considered potential victims of abuse, say researchers.

In a short report published in the Journal of American Association for Pediatric Ophthalmology and Strabismus, Avery Weiss (Seattle Children's Hospital, Washington, USA) and colleagues highlight the case of a 13-month-old girl presenting with chronic keratoconjunctivitis with dermatitis.

She was initially diagnosed with a corneal abrasion and a mild infection and was treated with topical and oral antibiotics. After failing to respond to standard therapy, however, she was later identified as a victim of abuse.

"In retrospect, there were clinical and laboratory findings that might have raised concerns about child abuse earlier in the course of the condition," Weiss commented in a press release accompanying the report.

"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."

When the patient first presented to the ophthalmology clinic, she had left lower eyelid swelling, photophobia, and increased tearing for two days. On examination, her binocular visual acuity was 20/400 and she was intolerant of monocular visual acuity testing because of severe photophobia.

After the initial diagnosis of corneal abrasion, the infant returned to the hospital twice over 10 days with episodic exacerbations.

One examination revealed eyelid swelling with epidermal loss, marked conjunctival inflammation, and corneal epithelial sloughing. This resulted in a 3-day hospitalization that improved her condition.

Over the next 2 weeks, the girl returned another three times because of episodic exacerbations. On the eighth examination, she presented to the hospital trauma clinical due to increasing lethargy. She was diagnosed and admitted to hospital with a subdural hemorrhage and midline shift without a skull fracture.

In addition to bruises on the arms consistent with abuse, the child's confiscated eye drops were found to be laced with household bleach. Criminal charges are pending and a no-contact order was issued to the mother.

In hindsight, Weiss and colleagues said that several features of the examination - the isolated lower eyelid swelling, inferior corneal abrasion, and inflammation in the lower conjunctiva - were more consistent with the application of a locally applied irritant than with periorbital cellulitis as first diagnosed.

In addition, the improvements in her ocular status after the 3-day hospitalization should have raised concerns about child abuse, states Weiss.

Although ophthalmologists are frequently called to consult in cases of suspected child abuse, particularly cases of head trauma, just 4-6% of child abuse victims present to the ophthalmologist first.

Overall, the incidence of child abuse might be underestimated given the reluctance of medical providers to consider this diagnosis, add the researchers.

By MedWire Reporters

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