Peds Ophtho Case 1: Additional History & Physical Exam

Peds Ophtho Case 1 Index

Additional History: 

On further questioning, the father reports that the white glare appears whenever she is in a dimly lit room, and is always in the right eye. He also reports that the patient will occasionally bump into furniture while walking. The patient was born at 37 weeks under a Cesarean section, but otherwise there were no pregnancy complications. The patient has no medical conditions and does not take any medications. For developmental history, the patient can say sentences containing 2 to 4 words. She can kick a ball and can sort shapes and colors. Family history for congenital eye diseases and malignancy are negative. The patient lives with her parents and puppy in an apartment. The patient’s vaccinations are up-to-date. Review of systems is negative.

Physical Exam: 

General appearance: Well-appearing and in no apparent distress. No dysmorphic features
Vitals: Temp: 37C, BP: 100/65, HR: 102 bpm, RR 24, O2 sat: 99%, Weight: 12,000g (birth weight 3500g, 50th percentile), Height: 84 cm
Visual acuity: Does not fix or follow OD, Fixes and follows OS
Pupillary reflex: OD white pupillary reflex, OS red pupillary reflex
Pupils: Pupils equal and reactive to light OU, 2+rAPD OD
EOM: full OU, no nystagmus, no gaze deviation OU
Intraocular pressures (IOP): Soft to palpation OU
Hearing: Intact bilaterally

Below is an external photo of the patient’s eyes:

Leukocoria OD
Above Image Credit

How would you describe the external exam above?

Based on the physical exam findings, the pediatrician refers the patient to a pediatric ophthalmologist.  

Click here for the ophthalmology exam!

Peds ophtho Case 1 Index
Peds Ophtho Case 1 Introduction