Chapter 97 My baby keeps closing one eye

Introduction

The child who closes one eye can cause considerable anxiety to the parents, and pose a diagnostic conundrum. The presentation could be in the acute clinical setting or as a chronic symptom, and the symptoms may be intermittent.

The approach to a case

The parents often describe the child as “screwing up the eye” or “squinting one eye,” or covering the eye with the hand.

The history includes which eye is involved, duration and frequency of symptoms, aggravating factors such as bright lights,¹ cold windy weather, stressful situations, and relieving factors, if any. Associated symptoms such as redness and watering are relevant. A history of trauma must be sought.

A full eye examination is mandatory until the cause is found, although the approach depends on the mode of presentation.

With the direct ophthalmoscope on +4 D magnification it is useful to assess corneal and media clarity followed by slit lamp examination. A drop of short-acting topical anesthetic such as proxymetacaine 0.5%, with or without fluorescein, may facilitate the examination. If no cause is evident, dilated fundus examination is warranted. Tonometry (see Chapters 7 and 37) can be difficult in the acute setting, but the advent of the I-care tonometer has made this easier. Other useful maneuvers include examining the younger child when feeding or asleep.

If an adequate examination is impossible, and it is important to exclude a foreign body, uveitis or glaucoma in the presence of an unexplained red eye, examination under anesthetic or sedation may be needed.

Acute presentation

The common causes in the acute setting are given in Box 97.1. The child is often distressed, usually seen in the emergency department, and examination might be difficult. The commonest cause is a corneal abrasion or foreign body, less common is infective keratitis (see Chapter 15). Fluorescein staining is very useful in these situations. It is important to evert the lids and look for subtarsal foreign bodies if multiple linear abrasions are seen.

Box 97.1

Causes of unilateral eye closure