Endgames Picture Quiz

White pupillary reflex in a 3 year old boy

BMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g6081 (Published 21 October 2014) Cite this as: BMJ 2014;349:g6081
  1. Panos Masaoutis, consultant ophthalmic surgeon,
  2. Chryssanthi Koutsandrea, professor, ophthalmology,
  3. Theodore Paraskevopoulos, consultant ophthalmic surgeon,
  4. Ilias Georgalas, assistant professor, ophthalmology
  1. 1Department of Ophthalmology, University of Athens, Athens, Greece
  1. Correspondence to: P Masaoutis, 154 Mesogeion Ave, 15400 Athens, Greece lekiat37{at}gmail.com

A 3 year old boy was referred to our department by his general practitioner because of a “white reflex of his right eye” that had been noted in recent family photos. Direct ophthalmoscopy performed by his GP reported clear optical media (cornea, aqueous humour, crystalline lens, and vitreous) and a possible white retinal lesion in the right posterior pole.

He had no medical history of note. His best corrected visual acuity after refraction was 20/100 in the right eye and 20/20 in the left eye. Cycloplegic refraction—a procedure used to determine the refractive error after temporarily paralysing the ciliary body with cycloplegic eye drops—showed a 4.00 dioptre difference in hypermetropia between his eyes (more pronounced in the right eye than in the left). Slit lamp examination showed a white pupillary reflex (leucocoria) in the right eye, but no inflammatory cells or proteins in the anterior chamber (no anterior chamber reaction). Gonioscopy was used to visualise the iridocorneal angle and applanation tonometry (Perkins tonometer) was used to determine intraocular pressure under general anaesthesia. Intraocular pressure was 12 mm Hg in both eyes and the iridocorneal angle was within normal limits in both eyes.

Fundoscopic examination showed a yellow-white round mass, 5 mm in diameter and temporal to the fovea, in the right eye, with a clear vitreous (figure). There were no pathological features in the left eye. B scan ultrasonography showed a right hyperechogenic mass with areas of calcification. The poor vision in his right eye was mainly attributed to his previously undetected hypermetropic anisometropia (the condition in which the hypermetropic refractive error differs greatly between the two eyes). However, subtle macular changes (slit subretinal fluid or atrophic changes of the outer layers) as a result of the nearby tumour could not be excluded.


  • 1. What is the most probable …

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