The newborn evaluation should include noting eye color; pupil size; appearance of the conjunctiva, sclera, and eyelid; eye movement; and spacing between the eyes. Genetic syndromes often cause unusual eye shape, such as epicanthal folds (excess skin over the medial aspect of the eye) and upslanting of palpebral fissures associated with Down syndrome. Colobomas (a gap or defect in the structure of the eye, primarily the iris) may occur with many syndromes, including CHARGE (coloboma of the eye, heart defects, choanal atresia, retraction of growth and/or development, genital and/or urinary abnormalities, and ear abnormalities and deafness). Infants with colobomas need a formal ophthalmology evaluation. Hypertelorism (increased space between the eyes) and hypotelorism (decreased space between the eyes) are
often associated with a genetic disorder. 14 The visual acuity of newborns is approximately 20/400, and a dysconjugate gaze is normal in the first two to three months of life. Subconjunctival hemorrhages from blood vessel rupture are also a common benign finding that may take weeks to resolve. The red reflex test is performed by using an ophthalmoscope, with the lens power set at 0 and the examiner standing approximately 18 inches away. Light should project onto both eyes simultaneously. A red reflex result is normal if there is symmetry in both eyes without opacities, white spots, or dark spots ( Figure 3 15 ) . The color of the reflex may be different among ethnic groups because of varying amounts of pigmentation in the ocular fundus; however, the reflex should not be white. 14 , 16 Table 2 gives a differential diagnosis of leukokoria. 14 , 16 An abnormal red reflex result warrants urgent referral to an ophthalmologist. Regardless of red reflex findings, all newborns with a family history of retinoblastoma, cataracts, glaucoma, or retinal abnormalities should be referred to an ophthalmologist experienced in the examination of children because of the high risk of serious eye abnormalities. 17 Figure 3. Interpretation of red reflex test results in a newborn. (A) Normal, symmetric red reflex. (B) Normal red reflex in the right eye, and abnormal, diminished red reflex in the left eye, which is most commonly caused by refractive error between the eyes, but can also be caused by a more serious pathology (e.g., retinoblastoma). (C) Normal red reflex in the right eye and no reflex in the left eye, which occurs when the reflection is blocked by an opacity such as a cataract. Reprinted with permission from Bell AL, Rodes ME, Collier Kellar L. Childhood eye examination [published correction appears in Am Fam Physician. 2014;89(2):76] . Am Fam Physician. 2013;88(4):246 . Table 2. Common Causes of Leukokoria in the Newborn CAUSE DESCRIPTION Cataract Opacity or clouding of the lens, often due to a genetic or systemic disorder Chorioretinitis Inflammation of the retina and choroid, may be due to cytomegalovirus or toxoplasmosis Coats disease Congenital disorder caused by abnormal blood vessels behind the retina, leads to progressive deterioration of vision Coloboma Full-thickness defect of the eye
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- Fall '14
- Pediatrics, MMR vaccine, Pertussis