A 2-year-old boy is brought to the office for a health supervision visit. His mother has noticed that the patient looks cross-eyed at times, but she otherwise has no concerns. The patient was born at full term without pregnancy complications. He has no medical conditions, but family history is significant for glaucoma in his father. Examination shows the right eye is mildly deviated toward the nose, and pupillary red reflexes are asymmetric. There is no proptosis, and extraocular movements are intact and nonpainful. Which of the following is the best next step in management of this patient?

Question

A 2-year-old boy is brought to the office for a health supervision visit.  His mother has noticed that the patient looks cross-eyed at times, but she otherwise has no concerns.  The patient was born at full term without pregnancy complications.  He has no medical conditions, but family history is significant for glaucoma in his father.  Examination shows the right eye is mildly deviated toward the nose, and pupillary red reflexes are asymmetric.  There is no proptosis, and extraocular movements are intact and nonpainful.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d604_8522_bc81_2d5d088c036b_MD0003_00 Normal ocular alignment results in symmetric corneal light reflexes in the center of the eye and bilateral red reflexes that are equal in color and brightness. In contrast, this patient's right eye esotropia (nasal deviation) and abnormal red reflexes are findings consistent with strabismus, or ocular misalignment. Untreated strabismus can lead to amblyopia, or decreased visual acuity of the improperly aligned eye. Examination findings in strabismus include asymmetric corneal light reflexes and asymmetric red reflexes (more intense in the deviated eye). Strabismus can also be identified by the cover test, in which a patient focuses on an object while one eye is covered to assess for movement in the uncovered eye. A misaligned eye shifts to refixate on the object; an unaffected eye maintains the same position without moving. Although most cases of strabismus are idiopathic or related to convergence insufficiency, the underlying condition can be life-threatening (eg, intraorbital mass, increased intracranial pressure). Therefore, the first step in evaluation is a dilated funduscopic examination to assess for secondary causes, particularly retinoblastoma, an intraocular malignancy that can often be visualized on funduscopy as a nodular, cream-colored retinal mass. Esotropia due to central vision loss is the second most common presentation of retinoblastoma, after leukocoria. leukocoria (Choice B) Fluorescein stains epithelial defects of the eye, and drops are applied to the eye to evaluate for a corneal abrasion. Symptoms include eye pain, tearing, and photophobia; eye deviation does not occur with this condition. (Choice C) Intraocular pressure is measured if funduscopic examination reveals optic nerve cupping indicative of glaucoma. Presenting symptoms may include tearing, corneal enlargement, and strabismus (which is rare and due to vision loss). (Choice D) MRI of the brain and orbits can confirm a diagnosis of retinoblastoma if a retinal mass is seen on dilated funduscopic examination. In addition, MRI of the brain to assess for an intracranial mass is warranted for abducens nerve palsy, which presents with an inability to abduct the eye. This patient's extraocular movements are intact. (Choice E) Visual evoked potential testing may be performed for optic neuritis, which presents with vision loss and eye pain that is worse with movement (not seen in this patient). Optic neuritis is not associated with strabismus. Educational objective: Strabismus (ocular misalignment) presents with eye deviation, asymmetric corneal light and red reflexes, and an abnormal cover test. Dilated funduscopic examination is performed to detect retinoblastoma, a life-threatening cause of strabismus. References: Retinoblastoma. (http://www.ncbi.nlm.nih.gov/pubmed/28620731) Retinoblastoma for pediatric ophthalmologists. (http://www.ncbi.nlm.nih.gov/pubmed/29737052)

A 2-Year-Old Boy Is Brought to the Office for a Health