Bucks Montgomery Physician Fall 2020 - 15

One common error ascribed
to pediatricians is the lack of
performing an appropriate "red
reflex test" when examining a child's
eyes during a well-baby visit. The test
should be done in a darkened room
to allow the child's pupils to dilate
[enlarge] to provide a better view of the
lens and retina with the ophthalmoscope. The
standard of care is written in the journals of the AAP,
AAO and AAPOS. Missing a congenital cataract or other
opacity or birth defect of the ocular media can result in
severe vision loss. In unilateral cases, significant amblyopia
can develop if treatment is significantly delayed before
surgical treatment is performed and occlusion amblyopia
therapy started in unilateral case. A serious condition
causing leukocoria is retinoblastoma, a potentially deadly
cancer. Vision and life can be preserved if the cause
of the absent red reflex is found to be retinoblastoma
at an early stage and appropriate chemotherapy,
radiation and surgical therapy instituted promptly.
In children and adults, the onset of acquired strabismus
can be caused by events other than a childhood
nonaccommodative esotropia or untreated intermittent
exotropia. A para lytic strabismus in which there is
lack of movement in one or more directions could be
caused by a fibrotic syndrome (strabismus fixus) or a
third nerve palsy caused by neurofibromatosis [NF-1].
Imaging is needed to confirm the diagnosis. Missing
[NF-1] early on can result in serious consequences.
Surgery may be needed. Strabismus in an individual
[child or adult] accompanied by long tract signs (limb

weakness causing falling, tripping) should alert the
physician that a space occupying brain mass may be
present, and an MRI is need ASAP. Also, acquired variable
eye muscle weakness may be a result of myasthenia
gravis. Testing using tensilon can make the diagnosis.
Congenital nystagmus is usually evident by the age of 2
and is typically a benign condition. Spasmus Nutans is an
idiopathic acquired nystagmus that also manifests during
the first 2 years of life, presenting as a triad of generally
small-amplitude high frequency (shimmering) nystagmus,
head nodding and torticollis. The nystagmus is binocular
but often asymmetric, vertical as well as horizontal or
rotary. Most significant is Spasmus Nutans-Like nystagmus
associated with chiasmal or supra-chiasmal tumors or
retinal dystrophies. It is thus prudent to perform brain
imaging in any child with asymmetric nystagmus to
avoid the devastating result of an untreated brain tumor.
Without neuroimaging, malpractice litigation is inevitable.
Continued on next page.

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