Question

An 18 month old male presents for a well-child examination. While observing the child playing in his mother's lap, it appears that the child has a wandering right eye. The patient's mother denies any family history of visual disorders or cancer, and says that the child has appeared completely healthy lately. On physical examination, there is no tenderness to mild pressure on either eye. Sclera are non-injected. A white pupillary reflex is present on the right. With the child visually fixed on a toy, each of his eyes are separately covered and then uncovered. There is no eye movement when the patient's right eye is covered and rapidly uncovered, but the patient's right eye refixates on the toy when the left eye is covered and then uncovered. What is the most appropriate next step in the management of this patient?

A. MRI of head
B. Occlusion of left eye with patch
C. Occlusion of right eye with patch
D. Atropine eye drops
E. Reassurance

Answer 1

The most appropriate next step in the management of the 18-month-old male with a wandering right eye and a white pupillary reflex is to occlude the better-seeing eye with a patch to promote visual development in the weaker eye.

Step-by-step explanation:

The case described involves an 18-month-old male with a wandering right eye, a white pupillary reflex, and no movement of the right eye upon covering and uncovering while fixating on a toy. This clinical presentation suggests a possible visual pathway issue, particularly strabismus, where the affected eye is not aligned properly. The absence of the red reflex, which would appear white in this instance, is known as leukocoria and can be an indicator of serious ocular conditions such as retinoblastoma, cataract, or retinal detachment. Therefore, prompt evaluation by an ophthalmologist is crucial. However, since there is no report of acute changes in vision or signs of distress, an MRI is not the immediate next step. Instead, the next appropriate step in management would be occlusion of the better-seeing eye with a patch (Option B), which is part of the treatment for amblyopia and will encourage the use of the weaker eye to promote visual development.