A 'Gleam' in the Left Eye of a 5-Year-Old Boy

Mauricio E. Pons, MD; Maria Silvana Horenstein, MD


July 22, 2016

Physical Examination and Workup

The physical examination reveals a well-nourished child in no distress. The patient's height and weight are at the 60th and 50th percentiles, respectively. His oral temperature is 98.6°F. His pulse is regular, with a rate of 80 beats/min, and his blood pressure is 110/65 mm Hg. His lungs are clear to auscultation, with normal respiratory effort. The S1 and S2 heart sounds are normal. The abdomen is soft and nontender. The peripheral arterial pulses in the upper and lower extremities are normal.


Figure 1

Figure 2

Examination of the patient's head and neck shows mild esotropia, normal lids, clear corneas, and moderate conjunctival congestion in the left eye. The left eye is tender to the touch and, as a result, the child does not cooperate with a complete examination of the eye. He is scheduled for another examination under anesthesia by a pediatric ophthalmologist.

During the second examination, the eyes are noted to have anisocoric pupils that are round and regular, with an afferent pupillary defect in the left eye. The red reflex is normal in the right eye, but absent in the left. Funduscopic examination with dilated pupils reveals normal fundus in the right eye; in the left eye, a yellowish mass with dilated vessels and total retinal detachment are noted. The crystalline lens is clear in both eyes.

Fluorescein angiography is performed, which shows fluorescein leakage from neovascularization of the iris. Gonioscopy reveals a closed anterior chamber angle, with no view of any angle landmarks. The retina exhibits telangiectatic vessels, microaneurysms, and irregular and dilated vessels.

Intraocular pressure is measured at 15 mm Hg in the right eye, which is within the reference range, and 50 mm Hg in the left eye, which is elevated. B-scan ultrasonography is performed, which shows total serous retinal detachment in the left eye.

A review of family photographs reveals that the abnormal red reflex has been present for several months.

Figures 1 and 2 show the patient's dilated left eye and the fluorescein angiography.


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