Picture of the Month—Diagnosis

Subconjunctival hemorrhages are among the most frequent diagnoses in ophthalmology and commonly occur following trauma.¹ Simultaneous periorbital and subconjunctival hemorrhages are reported in a few diseases, including coagulopathic states, thrombocytopenia, trauma (occult or known), metastatic neuroblastoma, rhabdomyosarcoma, and leukemia.² Our patient had no history of trauma, coagulopathy, or blood dyscrasias. His only medical condition was mild persistent asthma, which was controlled with inhaled corticosteroid (400 μg/d). The coughing paroxysms suggested the cause of the subconjunctival hemorrhages and eyelid ecchymosis. Causes of coughing paroxysms are listed in Table 1.³

Although our patient had received all 4 scheduled pertussis vaccinations (diphtheria-pertussis-tetanus) and taken erythromycin for 1 week, we thought pertussis was the probable cause of the coughing paroxysms. The nasopharyngeal culture was negative for Bordetella pertussis; however, previously immunized patients are known to have a lower rate of positive cultures when infected. Patients previously treated with antibiotic agents may also have negative nasopharyngeal cultures for B pertussis. According to the clinical- and laboratory-confirmed case definitions of pertussis recently adopted by the Centers for Disease Control and Prevention in collaboration with the Council of State and Territorial Epidemiolologists (Table 2),³ our patient met the criteria for diagnosis of probable pertussis.

Ophthalmologic complications of coughing paroxysms in pertussis infection include hemorrhages of the subconjunctival space, orbit, and anterior chamber, and, rarely, the retina and ocular adnexa.^2,4-6 The characteristic forceful coughing paroxysms associated with a strong Valsalva maneuver sufficiently explain all of the known associated ocular findings. The unexpected finding in our patient was the localized thinning areas in the periphery of the corneas or dellen. This is a unique case of coughing paroxysms associated with dellen secondary to subconjunctival hemorrhage.

Dellen may be observed as localized thinning in the cornea and the sclera, adjacent to corneal and conjunctival elevations such as subconjunctival hemorrhage, pterygium, limbal tumor, and postsurgical edema. They are thought to be localized in areas of dehydrations, owing to the surfacing abnormalities of the tears. In our patient, the extensive subconjunctival hemorrhage probably led to lack of wetting by the eyelids.

The diagnosis is obvious at slitlamp examination. Rapid onset, location adjacent to elevations, lack of infiltration, and coverage by intact epithelium differentiate these thinning areas from ulcerations. The diagnosis of dellen may also be confirmed during therapy. Just taping the eyelids closed may lead to improvement in 1 to 2 hours, and total disappearance will occur over 24 to 48 hours.⁷ If hydration is not restored, the corneal stroma may undergo secondary degeneration leading to localized scarring and vascularization. Therefore, management should include treatment with artificial tears and lubricant supplements, eye patching, and close follow-up until the subconjunctival hemorrhage subsides. In our patient, dellen resolved in 5 days after supplemental therapy with artificial tears and lubricants. However, unilateral eye patching, with periodic alternation of which eye is patched, is recommended because bilateral eye patching is not easily tolerated. The therapy was continued for 3 weeks until the subconjunctival hemorrhages resolved. Elimination of the cause is mandatory for permanent recovery.⁸

Although dellen is usually innocuous and transient, it may be easily overlooked at penlight examination. Pediatricians should be aware of ocular complications of coughing paroxysm, especially if there is extensive subconjunctival hemorrhage disturbing distribution of the tear film layer.

Correspondence: Sevgi Keles, MD, Selçuk Üniversitesi Meram Tıp Fakültesi, Pediatri AD, 42080 Konya, Turkey (drsevgikeles@yahoo.com).

Accepted for Publication: July 31, 2005.