A boy aged 6 years presented with redness in the left eye associated with foreign body (FB) sensation of eight hours’ duration. The patient reported exposure to strong winds the day before. The physical examination at the primary care center evinced small dark spots in the temporal, nasal, and superior bulbar conjunctiva of the left eye and conjunctival hyperemia (Fig. 1). The eye was irrigated with physiological saline and extraction of a potential FB attempted with gauze, a procedure that was painful and unsuccessful. The patient was referred to the pediatric ophthalmology clinic, where slit lamp biomicroscopy showed a clear and transparent cornea, mild conjunctival hyperemia that was attributed, most likely, to manipulation, and immobile pigmented nodular lesions under the bulbar conjunctiva located 3 to 4 mm from the corneal limbus. The lesions were diagnosed as Axenfeld loops, normal anatomical variants consisting of loops of the long posterior ciliary nerves within the sclera.1 Symptomatic treatment with artificial tears was prescribed, and the family was informed of the benign nature of the lesions.2

Figure 1.

Clinical image of the left eye of a male patient aged 6 years. Presence of small pigmented lesions in the temporal, nasal and superior bulbar conjunctiva (yellow arrow), corresponding to Axenfeld loops (intrascleral loops of the long posterior ciliary nerve), recognizable by their typical location 3 to 4 mm from the corneal limbus and their nodular gray or pigmented appearance.

The recognition of these structures as a common and benign anatomical variant is essential in order to avoid iatrogenic interventions involving painful manipulation (as the loops are nerve endings), reduce the use of health care resources and improve diagnostic accuracy.3