Jeremy Root, Children’s National Medical Center

The Case
18yo F presents with acute R sided vision loss. This case challenged readers to determine the urgency of working up this relatively rare pediatric complaint.

Here’s How You Answered Our Questions

Denouement:
The patient was discharged home after neurology consult. Her symptoms slightly improved and she followed up with ophthalmology the next day. At ophtho clinic, dilated funduscopic exam of the right eye showed inferior hemispheric whitening adjacent to fovea arcades, consistent with retinal artery occlusion. Given the age of patient without significant medical history or risk factors for occlusion, she underwent a hypercoagulability work-up with lipid panel, ANA, RF, RPR, HgB electrophoresis, APA panel and recommended cardiology consult for an echo. She did not follow up in cardiology clinic and her hypercoagulability work-up was unremarkable.

Discussion:

We had a lively discussion about both what we thought this kid had, and how we would manage it.  On our differential was optic neuritis (possibly as a sign of MS), retinal artery or vein occlusion, retinal detachment or retinal detachment.   Haroon brought up the good thought that this could be a pituitary mass, and maybe her migraines have been pain from the mass all along, which would lead us to consider head imaging early in the course.

We all agreed that we would want to talk to ophthalmology, and have them see this patient.  We also discussed that we would need their input on what diagnoses could safely wait to be seen in clinic the next day.  Jennifer Chapman brought up that we often do not know the answer to this question, and should ask our consultants to help with this, but, with the caveat that if we do not feel comfortable sending a child home, even after discussion with the consultant, we should never feel pressured to do so.  Pavan also made the good point that if a family has transportation concerns, that is a reason to require an in person consult in the ED, or, you can keep the patient in the ED until the morning to be seen in clinic.