This week’s case focuses on a 5-year-old who presents with eye pain. The crux of the discussion centers on strategies to examine an eye in an uncooperative patient. Pediatric cooperation is a key barrier to detailed exams. Strategies such as distraction, anxiolytics, and, if needed, procedural sedation can be employed. Before considering procedural sedation, topical proparacaine eye drops can be highly effective for assessing eye pain caused by surface injuries in uncooperative children. Additionally, assessing for pain in the injured eye when shining a light in the non-injured eye can help identify traumatic iritis, a condition consistent with worsening pain and photophobia days after an injury.

In this case, the patient was given oral midazolam. Ophthalmology was able to do the exam but in their note said “Examination performed with oral midazolam and still very difficult, however, appears to have Seidel positive corneal defect.”

A Seidel positive corneal defect is a clinical finding indicating the presence of a full-thickness corneal injury that allows aqueous humor to leak from the anterior chamber of the eye. It is detected using the Seidel test, which involves the application of fluorescein dye to the surface of the cornea:

The patient went to the operating room and per the Operative note: “The lesion is consistent with a corneal abrasion caused by biologic material, such as paper, cardboard, wood, or a fingernail, with poor epithelial adherence as healing occurred. Another cause for this appearance could be frequent rubbing the eye after the initial injury. The loose epithelium would easily imitate the appearance of a Seidel positive exam suggesting a corneal laceration and mimic an occult open globe.