December 22, 2013 | POSTED BY | Clinical Optometry, News, Retina
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Age/Sex/Race

2 year old Caucasian female

Chief Complaint

“My granddaughter’s pediatrician thinks her eyes aren’t working together and wants her checked for a lazy eye. It only happens sometimes in the left eye.”

Medical History / Ocular History / Family History

Unremarkable

Medications

None

NKDA

Pediatric ScreeningDiagnosis and initial plan of action

I thought it might be an eye turn or a refractive error.

Applicable Testing & Results of Testing

Distance visual acuity (uncorrected): Unable to obtain OU

Near visual acuity (uncorrected) 20/80 with Lea chart OU

Cover test: ortho at distance and near

Extraocular muscles: grossly full

Pupils: PERRLA OU, (+) APD OD

Angle Kappa: +0.5mm nasal with white reflex OD, +0.0 mm red reflex OS

MEM:

OD: No reflex

OS: +0.50 -0.50 X 180

Slit lamp examination

Anterior segment: unremarkable

Lens: clear OD with white structure right behind it, clear OS

Dilated Fundus Examination:

OD: White structure with vasculature

Unable to see past the structure with BIO, Fundus lens or o-scope

OS: Glimpse of ONH with O-scope

Pediatric ScreeningAssessment and Plan

We diagnosed our patient with retinoblastoma OD. We had them go see a pediatric ophthalmologist within a week. It was so large that we assumed that she would need an enucleation. A pediatric ophthalmologist confirmed that it was a retinoblastoma and she will need enucleation. However, we did not find out whether it metastasized anywhere else. There was no family history of retinoblastoma. If the pediatrician didn’t recommend her to come in, she would have never discovered it until it was too late.

Here’s some more information about retinoblastoma:

It is the most common primary, intraocular malignancy in children. It accounts for about 3% of all childhood cancers. Retinoblastoma occurs due to mutation in RB1, a tumor suppressor gene, in retinal cells. If one sibling is affected, there is a 2% risk that another sibling will be affected. If parents are affected, there is 40% risk that a child will inherit it. About 60% of cases are heritable and unilateral. A child will often present with leukocoria, strabismus, secondary glaucoma, poor vision, pain or redness around the eyes. In severe cases, orbital inflammation, proptosis and retinal detachment can occur. Ultrasound, CT or MRI can be used to aid in diagnosis of retinoblastoma. Depending on the size of the tumor, different treatment options can be used such as photocoagulation, cryotherapy, brachytherapy, external beam radiotherapy, chemotherapy or enucleation.

**Picture courtesy of Nicholai Perez of OS.***

References:

http://radiopaedia.org/articles/retinoblastoma

Tasman, W. & Jaeger, E.A. Atlas of Clinical Ophthalmology , 2nd edition. Lippincott, Williams & Wilkins, 2001.

Kanski, J. Clinical Ophthalmology A Systematic Approach. Elsevier, 6th edition, 2011.