Leucocoria Case

Case Presentation

The pediatrician was alarmed when he got a chance to evaluate the 2 weeks-old newborn and was unable to get the usual red reflex in either eye with the indirect ophthalmoscope. The reflection in both eyes was grayish white. The mother remembers having flu-like symptoms in her early pregnancy but attributed it to being a part of normal pregnancy.

Ocular Examination

• Visual Acuity (cc):
  • OD: Reacts to light
  • OS: Reacts to light
• IOP (tonoapplantation):
  • OD: Not tested
  • OS: Not tested
• Pupils: Equal, round and reactive to light, no APD.
• Extraocular Movements: Full OU. No nystagmus.
• External: Normal, both sides
• Fundus: Unable to perform due to poor view

1- What is diagnosis?

Leukocoria (if the case said there’s opacity of lens so Congenital cataract \ if said there’s calcification in US it’s RETINOBLASTOMA )

2- Differential diagnosis

• Congenital cataracts: Can form due to intrauterine infections, metabolic disorders, a malignancy, or a genetic defect. Intrauterine infections that can result in congenital cataracts include rubella (German measles, the most common infectious cause).
• Retinoblastoma: The most prominent intraocular malignancy in children.
• PHPM (Persistent hyperplasic primary mem)
• Toxocariasis
• Retinal Detachment
• Endophthalmitis

3- Clinical Examination & Investigations

Clinical Exam

• Full ophthalmic examination under anesthesia .

• A complete medical history including maternal illness or drug use during pregnancy is very important.

• Family ocular history of congenital blindness, congenital cataracts, strabismus, or amblyopia should also be addressed.

• A complete eye exam including visual assessment of each eye alone and an attempt to determine the visual significance of the cataract is necessary.

• A physical examination to determine signs and/or symptoms of systemic intrauterine-acquired infections is essential.

Investigations

• Ocular US\CT\MRI
• B-scan can be helpful to evaluate the posterior eye to rule out posterior abnormalities.
• Intravenous fluorescein angiogram (Coats disease, ROP, retinoblastoma)

4- Treatments

Treat the cause

• IF Cataract

  • less 18mon surgery only followed by correction of Aphakia .
  • More than 18mon Cataract surgery + IOL .

• If RETINOBLASTOMA

  • If small tumor
    • Photocoagulation\cryotherapy\ radiation therapy
  • large without metastasis:
    • Enucleation
  • large + metastasis : Extraocular stage; Metastases:
    • enucleation + palliative; chemotherapy + radiation

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Patient History Y

• Past Ocular History: None
• Ocular Medications: None
• Past Medical History:
  • Birth history: 38 week gestation, normal spontaneous vaginal delivery, no complications
• Surgical History: None
• Past Family Ocular History: No history of eye disease, blindness or congenital cataracts
• Social History: Will live at home with mother and father. Mother denies smoking, alcohol use or other drug use during pregnancy.
• Medications: None
• Allergies: None

Clinical Features Y

• History
• Retina
• Visual acuity
• Pupil

Fixation and follow = seeing - sweet test - Coin test-Optikienetic Drum