Approach to

White Pupil
Mohammed Bader Al –Jaryan
CABOpht, FICMS(Ophth), FICO
MRCS Glas.(Ophth),MRCS Ed (Ophth)
 Objectives

At the end of the lecture, students should be

able to:
• Define leukocoria
• Outline the cuases of leukocoria
• Outline management principles.
• Define cataract
• Outline causes, types and managment
 Leukocoria
• Is the reflection of white light seen upon direct
illumination of the fundus through the pupil, in
contrast to the usual red glow.
• Results from opacities and abnormalities
occurring anywhere from the crystalline lens
through to the posterior pole can create the
leukocoric reflex.
• Usually first noticed by family or on flash
photography.
 Causes of Leukocoria
• Tumors
– Retinoblastoma
– Medilloepithelioma
– Combined Hamartoma of Retina and Retinal Pigment
Epithelium
– Retinal astrocytic hamartoma (tuberous sclerosis)
• Congenital malformations
– Persistent Fetal Vasculature
– Chorioretinal or optic nerve coloboma
– Myelinated retinal nerve fiber layer
– Morning Glory Anomaly
– Norrie disease
• Media opacities
– Cataract
– Organizing vitreous hemorrhage
• Retinal detachment
• Vascular diseases
– Retinopathy of prematurity
– Coats disease (xanthocoria)
– Familial exudative vitreoretinopathy
• Inflammatory diseases
– Ocular toxocariasis
– Congenital toxoplasmosis
– Cytomegalovirus retinitis
– Herpes simplex retinitis
• Trauma
– Commotio retinae
• Refractive
– High myopia or anisometropia
• Miscellaneous
– Strabismus (Brückner’s phenomenon)
– Photographic artifact
– Pseudoleukocoria due to optic nerve reflex
PFV
Retinoblastoma
Cataract
Organized Vitreous Hemorrhge
Retinal detachment
Retinopathy of Prematurity
Coats disease
Ocular Toxoplasmosis
 How to Deal with It?
• History
– Age of onset
– Duration and other ocular symptoms.
– Past ocular history and past medical history:
• prematurity
• Retinopathy of prematurity
• Trauma
• Arthritis
• Prenatal infection
– Family history of ocular diseases
• Retinoblastoma
• Familial exudative vitreoretinopathy
• Examination:
– Red reflex:
• performed during the first 2 months
• Requires to be performed in a darkened room with the
infant opens both eyes voluntarily.
• Normal reflex should be symmetrical
• Refer to ophthalmologist if there is:
– Dark spots in the red reflex
– Blunted red reflex on 1 side
– Lack of a red reflex
– The presence of a white reflex
– Ophthalmic Examination
– Ancillary Testing
• Ultrasonography ( calcification in retinoblastoma)
• Fluorescein angiography
 Cataract
• clouding of the natural intraocular crystalline
lens
• Results in blurred vision and even blindness if
untreated.
• Is number one cause of preventable blindness.
• There is NO medical treatment to prevent the
development or progression of cataracts.
• Surgery is the only definitive treatment of
cataract.
 Causes
• In adults:
– Diabetes.
– Steroid use (oral, IV, or inhaled).
– Ultraviolet exposure.
– Smoking.
– Ocular diseases: Retinitis Pigmentosa, Uveitis.
– Ocular Trauma.
– Prior ocular surgery.
– Genetic predisposition.
– cataracts associated with dermatologic diseases.
– Radiation or chemo therapy.
• In pediatric age group:
– Bilateral cataract:
• Sporadic
• Familial (mostly AD)
• Systemic diseases:
– Metebolic:
» Galactosemia
» Wilson disease
» Ghypocalcemia
» Diabetes
– Syndromes: e.g. trisomy 21
– TORCHS
• Trauma : if there is no history of trauma to explain acquired
cataract in this age group, then suspect child abuse.
• Symptoms
– In adults:
• Blurred vision at distance or near
• Glare (halos or streaks around lights)
• Difficulty seeing in low light situations
• Loss of contrast sensitivity
• Loss of ability to discern colors
• Increasing near-sightedness or change in refractive status
– In pediatric age group:
• Asymptomatic
• Poor reaction to light
• Strabismus
• Delayed development or failure to react to toys
• Photophobia in bright light
• Nystagmus
• Investigation :may be needed for bilateral
cataracts and may include:
– Urine test for reducing sugars
– TORCHS (toxoplasmosis, rubella, cytomegalovirus,
varicella)
– blood test for
• Calcium
• Phosphorus
• Glucose
• Galactokinase levels.
– Dysmorphic features may suggest the need for
involvement of a geneticist.
• Treatment
– For adults :
• Non surgical :
– Correction of refractive errors
– Eat a balanced diet
– Prevent excessive exposure to UV radiation by using
good quality UV blocking sunglasses
– Avoiding injuries by using protective eyewear
– If diabetic closely control blood sugar levels.
• Surgical: removal of cataractous lens and implantation of
intraocular lens, by various procedures including:
– Intra-capsular extraction
– Extra-capsular extraction
– Small-incision cataract surgery
– Phacoemulsification cataract surgery
 ?When to operate
• Visually significant lens opacity (for patient and
doctor)
• Cataract is the main cause of visual loss.
• Removal of the cataract is likely to lead to
improved vision and improved level of
functioning
• The potential improvement is enough to warrant
the risks of surgery.
• The patient can tolerate the operation is able to
follow postoperative instructions and follow up
• Treatment:
– For pediatric age group:
• Observation
• Pupillary dilatation
• Occlusion (unilateral cataract)
• These options are non surgical treatment suitable for:
– Cataract < 3mm in diameter
– Peripheral or paracentral cataract not obscuring the visual axis
– Blue-dot cataract which is not afftecting the vision
– Presence of good red reflex viewed with direct ophthalmoscope
or retinoscope
– Absence of strabismus or nystagmus
• Surgery : removal of cataractous lens ± lens implantation
(depending on the age of the patient)
– For >3mm central opacity, centrally obscuring posterior pole ,
with strabismus or nystagmus
Thank You for Attendance