Chapter 96 My child keeps blinking and closing his eye
This is a relatively common referral to the pediatric ophthalmologist. In the vast majority of cases the diagnosis will be evident from a targeted history and a standard ophthalmological examination. Tic disorder and ocular surface disease are the two common causes.
1. Enquire about associated symptoms and signs. Redness, tearing, discharge, mucus, and clouding of the cornea indicate an ocular surface disorder. There may be a history of atopy, or recent eye lid vesicles suggesting primary herpes simplex virus infection. Potentially significant ocular trauma or foreign body exposure is often unreported by children unless specifically asked about.
2. Ask about the circumstances in which the blinking or unilateral eye closure is most evident. There are characteristic factors that exacerbate or ameliorate tics (see below). Previous episodes of self-limiting unilateral or bilateral increased blinking at the appropriate age also suggest tic disorder.
3. Slit-lamp examination should include exclusion of lid margin malposition, lash abnormalities, and a foreign body (including subtarsal). Superior limbal vernal keratoconjunctivitis may be missed unless specifically looked for; look also for signs suggesting corneal anesthesia such as opacity and superficial vascularization.
Simple motor tics are sudden brief repetitive stereotyped motor movements involving discrete muscle groups. Eye winking (one eye) or eye blinking (both eyes) tics are the commonest and affect boys more than girls (3 to 10 times more frequent) at an average age of 6 years. In 12% the onset is before the age of 4 years and development after the end of the first decade is very unusual. 10% to 15% of boys between school starting age and 10 years will have a simple motor tic at some stage. Tics may be triggered by minor focal trauma, e.g. in the case of eye winking a lash in the eye.