Over the years many amazing cases have been presented during the PEMPix presentation at the American Academy of Pediatrics’ annual national Conference and Exhibition during the Section on Emergency Medicine Sessions. PEMPix Classic is a new featured series on PEMBlog that will highlight some of those classic cases.

The Case

An eight year old male with a history of eczema and seasonal allergies presents with “bumps on his eyes.” These bumps developed acutely – over the past couple fo days. Additionally, he has had bilateral watery eye discharge, eye itching and redness for the last 5 days. He denies eye pain, vision changes, purulent drainage and fever. His only daily medicine is Claritin. They tried saline eye drops.

On examination he has normal vitals and is generally well appearing. His Pupils are equal and reactive to light. He has intact extra ocular movements. The conjunctivae are injected in both eyes. His cornea are clear with small white masses circumferentially in the peri-limbic region of the eyes bilaterally. There is normal 20/20 vision bilaterally using short distance Snellen card.

What is the diagnosis?

A. Atopic conjunctivitis

B. Vernal conjunctivitis

C. Seasonal allergic conjunctivitis

D. Viral conjunctivitis

E. Giant papillary conjunctivitis

Click here for the correct answer

B. Vernal conjunctivitis

This type of conjunctivitis is associated with other atopic diseases like asthma and allergic rhinitis and is a distinct entity from seasonal allergic conjunctivitis. It is IgE mediated – but there’s more to the picture. It is more common in males who are dark-skinned and is usually bilateral. Exacerbations are seasonal and typically occur in the spring. Symptoms include puritis, tearing /burning, photophobia, discharge (clear or mucoid), and blurred vision.

On examination you will see giant cobblestone-like papillae on the upper tarsal conjunctiva (Horner-Trantas dots) as well as non-purulent mucus discharge.

Management consists of avoiding triggers and excessive eye rubbing. Medical treatments are offered in conjunction with Ophthalmology follow up including topical antihistamines and topical mast cell stabilizers.