|“My child’s eye reflex looks white.”|
|Retinopathy of prematurity|
|When first noticed?|
|Does the eye wander?|
|Does the child appear to see?|
|Family history of childhood cataracts|
|Other systemic/developmental problems|
|Family history of retinoblastoma|
|Only noticed in photographs when taken from the
|Family history of retinal disease|
|Assessment of red reflex with direct ophthalmoscope|
|Clouding of lens|
|White mass posterior to lens|
|Grey mass posterior to lens|
|Red reflex appears normal when viewed from straight
|Abnormal when viewed from side|
Almost all patients whose parents report an abnormal red reflex
should be referred to a pediatric ophthalmologist due to the potential
serious implications of the possible diagnoses. Similarly, if the
red reflex cannot be adequately visualized during a well-child examination,
referral is indicated.
Retinoblastoma is highly curable if it is identified while confined
to the eye, but is potentially lethal if it spreads. Therefore,
early diagnosis is very important.
The visual prognosis for infantile cataracts is directly related
to the age at which they are detected and treated. Unilateral congenital
cataracts should be removed by 6 weeks of age to maximize the potential
- 1. Cataracts. Cataracts in
infants are most commonly identified by an abnormal red reflex (Figure
19–1). Due to the high risk of amblyopia in unilateral
cataracts, prompt referral to a pediatric ophthalmologist is indicated.
Bilateral cataracts may occur in association with several syndromes
or diseases, and these children require evaluation for these systemic
disorders (see Chapter 30).
- 2. Retinoblastoma. Retinoblastoma
is rare, but it is the most common primary intraocular tumor in
children. It most frequently presents due to an abnormal red reflex
(Figure 19–2A and B). It is one of the few life-threatening
disorders encountered in pediatric ophthalmology. Intraocular retinoblastoma
is very treatable, but the mortality for metastatic disease is high.
Identification of tumors before systemic spread is critical. Most
children with large unilateral tumors will require enucleation (surgical removal
of the eye), but the eye and vision may sometimes be preserved if
the tumors are identified when they are small.
- 3. Pseudoleukocoria. The optic
nerve head at the back of the eye is white. If a light is shined
into the eye from an oblique angle temporally, the reflection from
the optic nerve head may fill the pupillary opening, producing pseudoleukocoria
(Figure 19–3). This usually requires evaluation by a pediatric
ophthalmologist to verify.
- 4. Retinal disorders. Retinal
disorders that cause detachments are rare in children. They most
commonly occur in infants with retinopathy of prematurity and may
also occur following trauma or due to rare familial ...