Eye Pain in Children

Zenia P. Aguilera, MD,* Pauline L. Chen, BS†

*Ophthalmology Division, Nicklaus Children’s Hospital, Miami, FL.
†
Nova Southeastern University School of Osteopathic Medicine, Ft. Lauderdale, FL.

Abstract
Primary care physicians are often the first to see a child with the
complaint of eye pain. The eye examination in children is not easy, and
the entities that can cause pain in children range from a foreign body in
the cornea to the most serious amblyogenic (inducing decreased vision)
and life-threatening conditions. Eye pain is a red flag for ocular and
systemic conditions, either in a “quiet eye” or “red eye.” A detailed
history of present illness; pertinent review of systems; close attention to
the past medical, family, and social histories; and meticulous physical
examination can help to determine the cause, establish the correct
treatment, and serve as the basis for referral to a pediatric
ophthalmologist if necessary.

Education Gaps
1. Clinicians should know that eye pain is a red flag for a visual and
systemic life-threatening condition.
2. A child complaining of pain in a “quiet eye” needs the same
meticulous approach as a child complaining of pain in a “red eye.”
“Quiet eye” is defined as a painful eye without classic inflammatory
ocular signs.
3. Clinicians should have a high index of suspicion for significant eye
disease in children with systemic, inflammatory, infectious,
autoimmune, and neoplastic conditions who present with eye pain.

Objectives After completing this article, readers should be able to:

1. Recognize the most frequent reasons for eye pain in children.

2. Perform an anterior-to-posterior assessment of the anatomic structures
involving the eye and neighboring structures to avoid missing the
source of the ocular pain.
AUTHOR DISCLOSURE Dr Aguilera and Ms
3. Establish proper treatment and indications for referral to a pediatric Chen have disclosed no financial relationships
relevant to this article. This commentary does
ophthalmologist if necessary.
not contain a discussion of an unapproved/
investigative use of a commercial product/
device.

418 Pediatrics in Review

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INTRODUCTION
The eyes are among the most sensitive organs in the body.
The ophthalmic division of cranial nerve V accounts for
most of the sensorial innervation of the eye. Ocular pain
may be a manifestation of a problem that has an ocular
origin, but it may also have no ocular source. When no cause
of pain is found, eye pain is generally considered to be due
to an idiopathic or functional disorder.
Eye pain can have a variety of sources, ranging from a
foreign body underneath the eyelid to a corneal abrasion or
problem unrelated to the eye but associated with its sur-
roundings. The purpose of this article is to examine the
most frequent reasons for eye pain in children, suggest an
approach to performing an anterior-to-posterior assessment
of the anatomic structures involving the eye and neighbor-
ing structures to avoid missing the source of ocular pain,
and establish proper treatments and appropriate referral to
a pediatric ophthalmologist if necessary.
The first step is to obtain precise clinical information,
particularly the classic questions in reference to pain (Table 1).
A verbal child can be asked the direct question, “Where is the
pain located?” In a nonverbal child, pain may manifest as eye
rubbing, light sensitivity, excessive blinking, and irritability.
(1) Other pertinent questions include: Is the pain monocular
or binocular? What is the intensity of the pain? (Using pain
scales related to the child’s developmental stage may aid in
communicating pain intensity.) How long does the pain last?
Is it acute or chronic? Is the pain constant or intermittent?
Does it appear at a particular time of the day such as in the
morning or at night? Are there any alleviating factors such as
administering analgesics? Are there any aggravating factors?
What, if any, are the associated symptoms (eg, redness, blurry
vision, photophobia, eye discharge, eye swelling, double vision,
headache)? Is there any history of trauma? Is the child taking
any medications? What is the child’s family history?
The physical examination should focus on the eyes and
the neighboring structures, such as the paranasal sinus,
cranium, ears, mouth, and throat. A meticulous exploration
of the eyes starts with documentation of the subjective part
of the eye examination, including visual acuity, color vision,
visual field, pupillary reflexes, refractive power, extraocular
motility, and intraocular pressure. Objectively measuring
intraocular pressure is very difficult in the primary care
setting, but clinical signs such as cloudy cornea, red eye,
buphthalmos (enlargement of the eyeball), and eye tearing
are suggestive of increased intraocular pressure. Objective
eye pain and photophobia should be noted. Gentle digital
palpation of the globe may be used to grossly examine
for elevated intraocular pressure, but this method is not
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TABLE 1. Pertinent Questions About Ocular
Pain
• Where is the pain located?
• Is it monocular or binocular?
• What is the intensity of the pain?
• How long does the pain last? Is the pain acute or chronic?
• Is the pain constant or intermittent?
• Does it appear during a certain time of the day?
• Are there any alleviating/aggravating factors?
• What are the associated symptoms?
• Is there any history of trauma; medications; and past medical,
systemic, or family history?
reliable. Although easy to use, electronic tonometry devices
are not widely available in the primary care setting. Any
suspicion of increased intraocular pressure should prompt
referral to an ophthalmologist.
The objective part of the eye examination begins from the
adnexa: orbits, eyelids (including eyelid margin), eyelashes,
lacrimal system (lacrimal gland, lacrimal punctum, canalic-
ulus, lacrimal sac, and nasolacrimal system), and the caruncle
(small, pink, globular nodule at the medial angle of the eye)
(Figure). Simply everting the eyelids upon examination may
reveal a foreign body or growth behind the lids.
Assessment continues with examination of the anatomic
structures of the eye: conjunctiva, cornea, anterior chamber,
iris, pupils (symmetry, size, and pupillary reflex), and lens.
Evaluating the red reflex is a rapid method of determining
the presence of opacities of the ocular medium. Such eval-
uation involves using the ophthalmoscope in a darkened
room to see if there is a symmetric orange-red light visible
from each fundus. Asymmetry of the red reflex should
raise concerns for retinoblastoma. (2) Ophthalmoscopy
also provides a view of the posterior chamber, which in-
cludes the vitreous humor, retina, choroid, and optic
nerve. Vitreous and retinal conditions are generally not
painful, which is why a diagnosis of retinal disease in
children may be delayed.
Optic nerve lesions are relatively easy to detect with a
magnified view from a direct ophthalmoscope. Direct oph-
thalmoscopy provides a highly magnified image (
15) of
the optic disc. Normally the disc has well-defined margins
around a center cup through which retinal blood vessels
extend, including the central retinal artery and the central
retinal vein. Blurriness to the disc margin with hyperemia of
Vol. 37 No. 10 OCTOBER 2016 419

the disc and blurriness of the blood vessels are consistent
with disc edema and increased intracranial pressure (ICP).
Such findings could be due to papilledema, pseudopapille-
dema (optic nerve drusen), papillitis, or optic nerve tumor.
The optic nerve itself does not have sensorial innervation,
but when the optic nerve sheath is affected by such condi-
tions as optic neuritis and increased ICP, eye movements
can stretch the optic nerve layers, which elicits pain.
CAUSES OF OCULAR PAIN
Pain is one of the first basic words children learn as part of
their vocabulary, and children may use the word pain to
describe a variety of feelings. Eye pain that has no obvious
cause, as indicated by normal findings on eye examination,
is unlikely to be related to a serious condition. Richards et al
(3) considered eye pain to be functional in 73 of 80 (91%)
children between ages 2 and 6 years who presented with-
out a red eye or a history of obvious cause for the pain.
According to these researchers, functional pain is an ab-
sence of a preexisting or obvious organic cause for the eye
pain and is a diagnosis of exclusion. (3) However, in children
younger than 8 years, in whom visual function is not fully
developed, ocular pain could be a sign of an amblyogenic
condition, and in rare cases, a sign of a visual and life-
threatening condition. Accordingly, the source of the pain
must be found.
To facilitate the clinical diagnosis, a practical approach
should consider if the eye is “quiet” or “red.” “Quiet eye” is
defined as a painful eye without classic inflammatory oc-
ular signs, such as eyelid swelling, tearing, eye discharge,
eye redness, photophobia, or changes in vision. (4) “Red eye”
420 Pediatrics in Review
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Figure. Anterior surface eye structures of a
toddler.
implies the presence of the previously cited classic inflam-
matory signs. There are multiple causes of pain in a “quiet
eye” and “red eye” (Table 2).
PAIN IN A “QUIET EYE”
Refractive Errors
Refractive errors can result in asthenopic (“eye strain”)
symptoms after prolonged visual activities. (1) When refrac-
tive errors are large, the presenting symptom of pain is
reduced. Large measurement errors do not usually present
as pain because the refractive mechanism of the eye cannot
accommodate the imaging. However, when the refractive
errors are small, the eye makes an effort to accommodate
the images. Symptoms can vary. After long periods of work,
defined as prolonged visual activity, the eyes may feel hot,
tired, and uncomfortable (asthenopic symptoms). If the
work continues, severe pain may develop in the eyes. (1)
Sustained excessive accommodation-convergence associa-
tion can give rise to strain in the effort to maintain binocu-
lar single vision.
Binocular Function Disorders
Disorders of binocular function, such as convergence in-
sufficiency, exophoria, and accommodative spasm, can elicit
eye pain, double vision, blurry vision, and headaches. Con-
vergence insufficiency is characterized by an inability of the
eye to converge at near distances. Exophoria is latent out-
ward deviation of the eye. Patients may develop an accom-
modating spasm, in which the ciliary muscle remains in a
constant state of contraction, which can lead to the pre-
viously cited symptoms. (1)
TABLE 2. Differential Diagnosis of a “Quiet Eye” Versus “Red Eye”
“QUIET EYE” DIAGNOSIS
• Eye strain due to refractive errors
• Convergence insufficiency
• Acute optic neuropathy
• Cranial neuralgias
• Intracranial processes (headaches with or without
increased ICP)
• Orbital tumor
• Facial processes (sinus infections)
• Diagnosis of exclusion: functional or idiopathic pain
ICP¼intracranial pressure.
Optic Neuropathy
Typical optic neuritis can present with pain upon eye
movement. Optic neuritis is associated with abnormal
optic nerve function (decreased visual acuity, abnormal
color vision, visual field defects, and/or afferent pupillary
defect). During eye examination, the optic nerve may show
disc edema, hyperemia, exudates, and hemorrhage or may
have a normal appearance if the retrobulbar portion is
affected.
Orbital, Periorbital, Retro-orbital, Cranial, or Facial Pain
Vascular abnormalities of the orbit, including orbital
varices, lymphangiomas, arteriovenous malformations, ve-
nous anomalies, and low-flow dural-cavernous venous fistu-
las, can cause eye pain with minimal eye redness. (4)
Important findings in the eye examination beyond elicited
eye pain are proptosis that can vary with Valsalva maneu-
ver, diplopia, and/or orbital bruits.
Ischemic lesions of cranial nerve III are more frequent
in adults, but compression by internal carotid-posterior
communicating artery aneurysms can be seen in children
and can elicit eye pain. The eye examination reveals ptosis,
a lateral and inferior eye position, and a dilated pupil.
Cavernous sinus lesions can cause deficits in multiple
cranial nerves.
Of note, when several cranial nerves are affected, includ-
ing the optic nerve, Tolosa-Hunt syndrome should be
included in the differential diagnosis. This very rare idio-
pathic inflammatory condition involves the superior orbital
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“RED EYE” DIAGNOSIS
• Preseptal cellulitis
• Dacryocystitis
• Blepharitis, internal and external hordeolum
• Conjunctivitis (follicular, bacterial, viral, allergic, or
traumatic)
• Dry eye syndrome
• Corneal abrasion, corneal ulceration, corneal foreign body
• Primary congenital glaucoma
• Episcleritis, scleritis, and uveitis associated with systemic
conditions
• Eye contusion
fissure. Inflammatory processes respond dramatically well
to corticosteroid treatment. Immediate referral to a pedi-
atric ophthalmologist and brain magnetic resonance
imaging (MRI)/magnetic resonance angiography should
be performed without delay to rule out infectious and
inflammatory conditions, vascular malformations, and
tumors in this area.
Intracranial Processes
Frequently, patients who have headaches also complain of
eye pain, a pain that is referred. The cause of headaches can
range from a migraine headache to a tumor that increases
ICP. With increased ICP, papilledema may be present upon
eye examination. In this situation, brain MRI of the orbit
is recommended. Of note, the absence of disc edema does
not rule out increased ICP. If brain MRI does not reveal
any ocular condition, lumbar puncture is the most appro-
priate next step to rule out idiopathic increased intracranial
hypertension.
Facial Processes
Chronic paranasal sinus disease should be considered
in patients complaining of facial or eye pain. Disease
processes affecting the teeth, jaw, and related structures can
have referral symptoms such as eye pain. (4)
If thorough examination and imaging yields no clinical
explanation for eye pain in the “quiet eye,” the pain can be
defined as idiopathic or functional.
Vol. 37 No. 10 OCTOBER 2016 421
 PAIN IN A “RED EYE”
Adnexa
Inflammatory, infectious, vascular, and traumatic orbital
conditions as well as orbital tumors can present with eye
pain and other signs such as eyelid edema, hyperemia,
double vision, and pain with eye movement.
Idiopathic orbital inflammation can simulate an orbital
tumor. This inflammatory process presents with the classic
signs of headache, severe ocular pain, double vision, pain
with eye movement, blurry vision, eyelid and conjunctiva
inflammation, and posterior scleritis. All of these signs and
symptoms respond dramatically to corticosteroids. MRI of
the orbit can help diagnose an inflammatory condition. On
rare occasions, biopsy of the orbit is necessary to confirm the
diagnosis.
Preseptal cellulitis due to trauma such as skin lacera-
tions, infected insect bites, or sinus diseases can present
with eyelid swelling and erythema. Preseptal cellulitis is
one of the most common ocular conditions the pediatrician
encounters. From the anatomic point of view, preseptal
cellulitis is infection of the soft tissue anterior to the or-
bital septum and does not involve the orbit or other ocular
structures. Preseptal cellulitis is generally a mild condition
that rarely leads to a complication requiring surgical inter-
vention. The most common predisposing causes are trauma
or bacteremia. The most frequent bacterial cause is Staph-
ylococcus aureus; community-acquired methicillin-resistant
Staphylococcus species are becoming increasingly common
pathogens. (5) Patients may complain of pain with eye move-
ment, but when the pain with eye movement is severe and
accompanied by decreased vision, double vision due to ex-
ternal ophthalmoplegia, proptosis, and abnormal pupillary
reflexes, the most likely diagnosis is orbital cellulitis. Orbital
cellulitis is an invasive bacterial infection, typically due to
underlying ethmoid sinusitis. (6) The most common bac-
terial causes include Streptococcus pneumoniae, Moraxella
catarrhalis, Haemophilus species, S aureus, group A Strepto-
coccus, and upper respiratory tract anaerobes. (6) The pres-
ence of an afferent pupillary defect in orbital cellulitis
suggests serious compromise of the optic nerve that re-
quires prompt evaluation and management. Complications
from orbital cellulitis, such as subperiosteal abscess, cav-
ernous sinus venous thrombosis, or intracranial extension,
can cause blindness or death.
“Red eye” can also be a manifestation of a vascular
malformation, which includes lymphangiomas, hemangi-
omas, arteriovenous fistulas, and varices of the orbit. When
there is a spontaneous or traumatic rupture of these vascular
malformations, a retrobulbar hematoma can appear, leading
422 Pediatrics in Review
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to orbital compartment syndrome, which requires emergent
lateral canthotomy (incision of the lateral canthal tendon).
When examining the eyelids, clinicians should pay close
attention to the skin surrounding the eyelids, which can
reveal blepharitis, a condition that is very symptomatic in
children. Blepharitis describes inflammation of the eyelash
roots in the lid margin. Anterior lid margin inflammation
suggests seborrheic or staphylococcal blepharitis. Posterior
lid margin inflammation is caused by meibomitis, inflam-
mation of the meibomian glands. Angular blepharitis is
associated with Moraxella species infection. Symptoms of
blepharitis include burning, itching, redness, foreign body
sensation, decreased vision, red eyes, tearing, and most
importantly, eye pain. If not treated properly, it can lead
to recurrent external or internal hordeolum and chalazion.
Of note, these terms are frequently used interchangeably,
which is incorrect. External hordeolum, also known as a
stye, is an infection of the Zeiss glands, located in the lid
margin. Acute inflammation of the meibomian glands is
an internal hordeolum that often evolves into a chalazion (a
localized bump in the eyelid of varying sizes). Both internal
and external hordeolum can be very painful and can present
with eyelid edema and erythema.
Viral inflammation of the lacrimal gland, as seen in
mononucleosis, can also cause eye pain. Acute dacryocys-
titis, a bacterial infection of the nasolacrimal sac due to
congenital or acquired nasolacrimal canal obstruction, can
present with eyelid swelling, redness, and eye discharge.
Although rare, a lacrimal tumor can cause swelling and have
similar manifestations.
Acute conjunctivitis can have a bacterial, viral, allergic, or
traumatic cause. In all cases, it can present with red eye,
foreign body sensation, and eye discomfort. Differentiating
the causes of acute conjunctivitis can be difficult. If a child
presents with watery eyes, redness, follicular conjunctiva
reaction, and/or sick contacts, a viral process is most likely.
On the other hand, bacterial conjunctivitis is associated
with yellowish-greenish discharge.
Viral conditions of the skin such as molluscum conta-
giosum can present with a chronic red eye due to a follicular
conjunctivitis. Removal of molluscum contagiosum from
the eyelids is only necessary if the patient develops follicular
conjunctivitis of the eyelids that does not resolve.
Dry eyes in children are rare and usually associated with
systemic conditions such as immunologic diseases, graft-
versus-host disease, meibomian gland dysfunction, and use
of medications that can dry the eyes, such as antihistamines,
anticholinergics, antimuscarinics, antihypertensives, decon-
gestants, and opioids. The decreased blinking time associated
with use of electronic devices also can lead to dry eyes. (7)
Patients may have symptoms such as a foreign body sensa-
tion, burning sensation, reflex tearing, or pain related to
corneal irritation. Another reason for eye discomfort during
the morning is keeping the eyes open throughout the night
while sleeping. In this case, simple eye moisturizer drops or
ointment can alleviate the symptoms.
Cornea
Children can accidently induce a corneal abrasion, which is
extremely painful. The differential diagnosis for the signs
and symptoms of a corneal abrasion include corneal foreign
bodies, infections, and rarely corneal degeneration. Fluo-
rescein stain with slit-lamp examination is helpful to iden-
tify damage to the epithelium.
Glaucoma
Primary congenital glaucoma can present with the classic
triad of lacrimation, blepharospasm, and photophobia due
to corneal edema from elevated intraocular pressure (IOP).
(1) Juvenile open angle glaucoma usually is not painful, but
secondary causes of increased IOP, such as inflammatory
glaucoma, seen in acute or chronic uveitis, can manifest
with eye pain, redness, decreased vision, and elevated IOP.
SYSTEMIC CONDITIONS ASSOCIATED WITH A
“RED EYE”
Among the numerous systemic conditions associated with a
“red eye” are juvenile idiopathic arthritis, Kawasaki disease,
inflammatory bowel disease, Stevens-Johnson syndrome,
vitamin A deficiency, collagen vascular diseases, and viral
exanthemas. (8) Episcleritis, scleritis, and uveitis are pain-
ful conditions that have classic ocular inflammatory signs
such as eye pain, eye redness, and photophobia and can be
associated with systemic autoimmune conditions. Identifi-
cation of the multiple systemic signs and symptoms associ-
ated with red eyes allows the clinician to choose appropriate
diagnostic tests.
Parent Resources from the AAP at HealthyChildren.org
Eye Pain in Children
• Eye Infections in Infants & Children: https://www.healthychildren.org/English/health-issues/conditions/eyes/Pages/Eye-Infections.aspx.
• Specific Eye Problems in Children: https://www.healthychildren.org/English/health-issues/conditions/eyes/Pages/Specific-Eye-
Problems.aspx.
• Sties: https://www.healthychildren.org/English/health-issues/conditions/eyes/Pages/Sties.aspx.
Downloaded from http://pedsinreview.aappublications.org/ by guest on October 1, 2016
ACKNOWLEDGMENT
We acknowledge Michal and Emily Trcalek for providing an
image of their child for this publication.
Summary
• On the basis of research evidence (evidence quality B), eye pain in
a child without obvious reasons revealed in an eye examination is
unlikely due to a serious condition. However, in children younger
than 8 years, in whom visual function is not fully developed,
ocular pain could be a sign of an amblyogenic condition that, in
rare cases, may be a visual and life-threatening condition. (3)
• On the basis of studies (evidence quality B and D), “quiet eye” is
defined as a painful eye without classic inflammatory ocular signs,
such as eyelid swelling, tearing, eye discharge, eye redness,
photophobia, or changes in vision. “Red eye” implies a painful eye
with the previously cited classic inflammatory signs. (4)
• On the basis of studies (evidence quality C), the decreased
blinking time associated with use of electronic devices can lead to
dry eyes. Patients may have symptoms such as foreign body
sensation, burning sensation, reflex tearing, or pain due to
corneal irritation. (7)
• On the basis of studies (evidence quality C), systemic conditions
associated with a “red eye” can include juvenile idiopathic
arthritis, Kawasaki disease, inflammatory bowel disease, Stevens-
Johnson syndrome, vitamin A deficiency, collagen vascular
diseases, and viral exanthemas. (8)
• On the basis of studies (evidence quality D), eye pain is a red flag
for ocular and systemic conditions either in a “quiet eye” or “red
eye.” A detailed history of present illness; pertinent review of
systems; close attention to the past medical, family, and social
histories; and meticulous physical examination can aid in
determining the cause, establishing the correct treatment, and
suggesting appropriate referral to a pediatric ophthalmologist if
necessary. (4)(8)
References and CME quiz for this article are at http://pedsinre-
view.aappublications.org/content/37/10/418.
Vol. 37 No. 10 OCTOBER 2016 423
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1. A 4-year-old African American boy with no significant past medical history is brought to his REQUIREMENTS: Learners
pediatrician by his parents with pain in his left eye. There is no photophobia, eye discharge, can take Pediatrics in
or systemic complaints. A basic visual examination shows visual acuity to be 20/20 in the Review quizzes and claim
right eye and 20/25 in the left eye. All extraocular eye muscles are intact. Pupillary reflexes credit online only at:
are present and reactive to light bilaterally and red reflexes are normal bilaterally. http://pedsinreview.org.
Intraocular pressure by digital palpation eye feels soft bilaterally. Which if the following is
the most likely diagnosis in this patient?
To successfully complete
A. Conjunctivitis. 2016 Pediatrics in Review
B. Functional/idiopathic eye pain. articles for AMA PRA
C. No ocular origin. Category 1 CreditTM,
D. Refractive error. learners must
E. Scleritis. demonstrate a minimum
2. A 9-year-old girl is brought to the pediatrician with a 3-week history of worsening performance level of 60%
headaches. She is known to have migraines and is taking nonsteroidal anti-inflammatory or higher on this
drugs when necessary with relatively good control. Her headaches recently became assessment, which
“different than the usual migraines,” occur almost daily, radiate to her eyes, and are measures achievement of
associated with blurry vision. A few episodes occurred in the early morning and woke her the educational purpose
up from sleep to vomit. There is no associated fever or diarrhea. Family history is significant and/or objectives of this
for migraines. Her neurologic examination results are nonfocal and ophthalmoscopic activity. If you score less
examination shows blurred disc margins. In addition to an ophthalmologic evaluation, than 60% on the
which of the following is the most appropriate next step? assessment, you will be
A. Computed tomography scan of the sinuses. given additional
B. Migraine prophylaxis with propranolol. opportunities to answer
C. Magnetic resonance imaging of the brain and orbits. questions until an overall
D. Reassurance. 60% or greater score is
E. Trial of systemic corticosteroids. achieved.
3. A 6-year-old boy with allergic rhinitis is brought to you for evaluation of left eyelid swelling
and redness of a few days’ duration. The patient has had 6 weeks of chronic clear This journal-based CME
rhinorrhea associated with itchy, watery eyes and has been treated with loratadine. Over activity is available
the past 10 days, he developed fever, increased rhinorrhea with thick yellowish-greenish through Dec. 31, 2018,
mucus, and nighttime coughing. He woke up this morning with a swollen left eyelid and however, credit will be
left eye discharge. Physical examination reveals an erythematous and edematous left recorded in the year in
eyelid. Extraocular movements and proptosis are difficult to assess fully because the eye is which the learner
swollen shut. Significant left eye pain is reported with eye movement. There are no completes the quiz.
meningeal signs. Immunizations are up to date. Which of the following is the most
appropriate next step in management?
A. Oral antibiotics.
B. Oral decongestants.
C. Magnetic resonance imaging of the brain and orbits.
D. Sinus surgery.
E. Topical antimicrobial ophthalmic solution.
4. A 6-month-old boy is brought to his pediatrician for a health supervision visit. His mother
reports that for the past few weeks, the child has been having eye blinking and excessive
tearing in both eyes and seems to cry and have light sensitivity when she takes him
outside. Over the past few weeks, she noted redness of both eyes. There are no upper
respiratory tract infection symptoms, no fever, and no change in appetite or activity.
Although he started rolling over and pulling to stand, he is reaching less for toys when he is
in bright light. With this triad of lacrimation, blepharospasm, and photophobia, which of
the following is the most likely diagnosis?

424 Pediatrics in Review

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 A. Acute optic neuropathy.
B. Corneal abrasion.
C. Primary congenital glaucoma.
D. Refractive error.
E. Tolosa-Hunt syndrome.
5. A 7-year-old girl is brought to the clinic for evaluation of a 6-week history of left knee and
ankle pain, redness, and swelling associated with intermittent fevers, generalized malaise,
and feeling tired. She reports no rashes, no urinary tract infection symptoms, and no sore
throat. Blood testing for antinuclear antibody is positive. She describes eye pain, redness,
and light sensitivity lately. Among the following findings, which is the most likely to be
seen on follow-up ophthalmologic evaluation?
A. Acute optic neuropathy.
B. Anterior uveitis.
C. Corneal abrasion.
D. Papilledema.
E. Preseptal cellulitis.

Vol. 37 No. 10 OCTOBER 2016 425

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 Eye Pain in Children
Zenia P. Aguilera and Pauline L. Chen
Pediatrics in Review 2016;37;418
DOI: 10.1542/pir.2015-0096

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 Eye Pain in Children
Zenia P. Aguilera and Pauline L. Chen
Pediatrics in Review 2016;37;418
DOI: 10.1542/pir.2015-0096

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Pediatrics in Review is the official journal of the American Academy of Pediatrics. A monthly
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