Pediatric Examination and Board Review (249 page)

FIGURE 141-6
.
(top) Linear scleroderma (LS) involving the left leg. (bottom) Right foot of the same patient demonstrating an LS streak starting at the 2nd toe and extending over the dorsum of the distal foot.

23.
(F)
vasculitis of small and medium-size vessels

24.
(E)
sicca complaints (dry eyes and decreased oral secretions)

25.
(I)
linear scleroderma of the face

26.
(B)
positive cANCA (antineutrophil cytoplasmic antibodies)

27.
(K)
treatment with IVIG

28.
(G)
presents 7-14 days after antigen exposure

29.
(C)
severe uveitis of anterior and posterior uveal tracts

30.
(J)
noncaseating granulomas

31.
(A)
large-vessel vasculitis

32.
(D)
a type of panniculitis

33.
(H)
elevated anti-DNase B titers

S
UGGESTED
R
EADING

Emery HM. Pediatric scleroderma.
Semin Cutan Med Surg.
1998;17:41-47.

Feldman BM, Rider LG, Reed AM, Pachman LM. Juvenile dermatomyositis and other idiopathic inflammatory myopathies of childhood.
Lancet.
2008;371:2201-2212.

Klein-Gitelman M, Reiff A, Silverman E. Systemic lupus erythematosus in childhood.
Rheum Dis Clin North Am.
2002;28:561-577.

Kone-Paut I, Piram M, Guillaume S, Tran TA. Lupus in adolescence.
Lupus.
2007;16:606-612.

Petty RE, Laxer RM. Systemic lupus erythematosus. In: Cassidy JT, Petty RE, Laxer RM, Lindsley CB, eds.
Textbook of Pediatric Rheumatology.
5th ed. Philadelphia, PA: Elsevier Saunders; 2005:342-391.

Saulsbury FT. Henoch-Schönlein purpura in children. Report of 100 patients and review of the literature.
Medicine (Baltimore).
1999;78:385-409.

Wagner-Weiner L. Laboratory evaluation of pediatric rheumatic diseases.
Pediatr Ann.
2002;31:362-371.

Weening JJ, D’Agati VD, Schwartz MM, et al. The classification of glomerulonephritis is systemic lupus erythematosus revisited.
J Am Soc Nephrol.
2004;15:241-250.

Chapter 18

OPHTHALMOLOGY

CASE 142: A CHILD WITH A LAZY EYE

A child presents to you for evaluation of “lazy eye.” The onset has been recent and the problem is intermittent, but the parent is able to offer few other details, such as which eye is affected. The parent wonders whether this is truly an abnormality or whether it could just be a “normal thing.”

SELECT THE ONE BEST ANSWER

1.
You assess both red reflexes of the child simultaneously using a direct ophthalmoscope at a distance of several feet in a darkened room. You note that one reflex is darker than the other, diagnose asymmetric red reflexes, and refer the child for ophthalmologic consultation. Potential explanations for the findings on physical examination include all of the following except

(A) esotropia

(B) unilateral optic nerve hypoplasia

(C) different refractive errors of the 2 eyes

(D) large retinoblastoma involving the macula of 1 eye

(E) all of the above

2.
You note that the child has epicanthal folds. The most sensitive method of excluding the presence of true strabismus in the straight ahead position is

(A) cover testing

(B) evaluation of old photos showing the parent’s point of concern

(C) corneal light reflex test

(D) checking to make sure the child can follow a toy into all eccentric positions of gaze

(E) autorefraction (assessing the refractive error of each eye using a handheld automated device)

3.
Assuming the child has true esotropia, a common cause would be

(A) uncorrected astigmatism

(B) uncorrected nearsightedness

(C) uncorrected farsightedness

(D) a wide nasal bridge

(E) a wide interpupillary distance (distance between the pupil of each eye)

4.
The child has a large-angle constant esotropia and alternates fixation freely between the two eyes (no amblyopia). There is no significant refractive error, so glasses are not prescribed. The child’s ophthalmologist recommends strabismus surgery, sooner rather than later. A prolonged delay in performing surgery may

(A) limit the chance for good visual acuity of each eye

(B) increase the chance of needing glasses in the future

(C) increase the chance of intraoperative complications

(D) limit the chance for good binocular fusion (depth perception) postoperatively

(E) all of the above

5.
A parent is concerned because she notes intermittent crossing of her infant’s eyes. You examine the infant. Observation without referral to an ophthalmologist is appropriate if

(A) you believe the child has pseudostrabismus and not true esotropia

(B) you identify an intermittent esotropia in a 6-month-old, which only occasionally is evident

(C) you identify an intermittent esotropia in a 3-week-old, who is visually immature, and the esotropia only occurs occasionally

(D) you identify a constant esotropia in a 1-monthold

(E) A and C

6.
A 6-year-old child is newly diagnosed with amblyopia in 1 eye due to a higher refractive error in that eye compared with the fellow sound eye. Despite compliance with eyeglass wear, the vision of the amblyopic eye fails to improve sufficiently. Appropriate supplemental therapy includes

(A) patching of the amblyopic eye

(B) atropine in the sound eye

(C) patching of 1 eye on odd dates and patching of the other eye on even dates

(D) it would not be worthwhile to attempt further therapy, given the age of the child

(E) A and B

7.
A child tilts her head to one side nearly constantly. However, you note that when 1 eye is occluded, the torticollis disappears. A common cause of ocular torticollis with a head tilt is

(A) exotropia

(B) esotropia

(C) unilateral ptosis

(D) fourth cranial nerve palsy

(E) sixth cranial nerve palsy

8.
Which of the following suggests that headaches in a child may have an ophthalmologic basis?

(A) headaches routinely develop in the area of the eyes (eyestrain) after reading for 10 minutes

(B) headaches are preceded by a visual aura

(C) headaches are located in the parietal areas

(D) headaches occur only in the dark

(E) B and D

9.
A young child has unilateral ptosis and is commonly noted to manifest chin-up head posturing. Which statement is true?

(A) the parents should encourage their child to hold the head straight

(B) the sound eye probably has a small esotropia

(C) physical therapy will be useful for proper positioning of the head

(D) substantial amblyopia is probably absent from the ptotic eye

(E) A and C

10.
A father is anxious because his 5-year-old child has been blinking both eyes frequently and firmly for the past week. The child seems to be unaware of this, and there is no redness, tearing, discharge, itching, pain, photophobia, or blurred vision. The most likely diagnosis is

(A) allergy

(B) sinusitis

(C) dry eye

(D) tic disorder

(E) intracranial mass

11.
A neonate has an acute purulent conjunctivitis. This is best treated by

(A) systemic antibiotic

(B) topical antibiotic

(C) systemic antiviral

(D) topical antiviral

(E) systemic antifungal

12.
A child has a red eye. You instill fluorescein in the eye. Using a cobalt blue light, you note a small lesion with a tree branch pattern (dendrite). The most likely diagnosis is

(A)
Neisseria gonorrhoeae
(B) fungus

(C)
Haemophilus influenzae
(D) herpes

(E) adenovirus

13.
A child has cellulitis around one eye. Which sign(s) is/are helpful in confirming that this is an orbital process?