Melissa Valdellon

Patient case for September 15, 2023

We have a 5 year old Hispanic male we’ll talk about today. His parents brought him in because they’ve noticed his eyes getting really red for the past month. There aren’t any vision concerns and no other ocular complaints at this time. It is the kid’s first eye exam ever.

The patient is systemically healthy with some seasonal allergies for which he’s taking Claritin. Otherwise, he has no other drug allergies.

Incoming visual acuity is 20/20 in each eye, confrontation pupils, EOMs, color, and fields are full in both eyes, cover test shows ortho in the distance. Dry retinoscopy shows +1.00 DS in each eye.

Eyes are white in office, but he does have about 1+ papillae in both eyes. The rest of his anterior segment findings are normal.

What allergy drops would you recommend for this pediatric patient? At what age can you start prescribing allergy drops for kids? If the parents ask, should the patient continue the Claritin? Doesn’t it cover the ocular signs and symptoms too?

Would you want to cycloplege this patient or not? He has no headaches, no eyestrain, and no eso posture.

We ended up just using tropicamide and phenylephrine for his patient. Damp retinoscopy results showed +1.25 DS in each eye.

What is your recommendation for glasses for this child? And their follow up?

Any general thoughts or questions on this case?

Skip to content