Return to Scenario ListShow Learning Points most relevant to Phase 1:

Infant with an altered light reflex and watery eye

Clinical Discipline(s)/Organ System(s)
Ophthalmology, Paediatrics
Progress Test Topic(s)
Child health, Eyes
During the 6 week check of a term Pakeha baby, the parents report watering of the child’s left eye for 2 weeks.  On examination, the GP notes both eyes are white, with symmetrical corneal reflexes and the eyes are the same size. The corneas are clear and the irides and pupils well visualised. However the red reflex is absent in the left eye.  The child is alert and has no objection to occlusion of the right eye, but he gets upset when his left eye is occluded. He has a full range of extraocular motility
Progress Test-Type Questions:   Question 1
Applied Science for Medicine 
   - Ocular anatomy relevant to possible site of the opacity: cornea, lens, vitreous, retina
   - Pathogenesis of congenital cataract, congenital corneal opacity, retinopathy of prematurity
   - Pathogenesis of retinoblastoma
   - Describe the genetic basis of cancer; oncogenes, tumour suppressor genes, genes that control cell death, DNA repair genes
   - Anatomy and physiology of tear production and drainage
   - Pathogenesis of congenital tear duct obstruction
   - Anatomy and pathology of intraocular pressure
   - Pathogenesis of 
congenital glaucoma
   - Pathogenesis and microbiology/virology of 

   - Pharmacology of chloramphenicol
Clinical and Communication Skills 
   - Obtain an appropriate history; consider duration, history of prematurity, birth weight, ocular injury, evidence of maternal infection, other systemic conditions, family history of eye problem/operations
   - Examination including visual acuity,
pupil response; assess for strabismus and nystagmus; dilate pupil and assess for lens opacities; compare ocular status of eyes
   - Differential diagnosis of strabismus
   - Additional investigations that may be required:
slit lamp examination (portable), ultrasound if the media is opaque and Retcam (fundus camera), neuroimaging for retinoblastoma, general paediatric assessment (for systemic causes), genetic/other laboratory investigations

   - Outline the management of congenital cataract and of congenital glaucoma
   - Long-term visual prognosis and rehabilitation following congenital
cataract surgery; resources for children with visual impairment

   - Communicate with parents/family/whānau to establish relationship that will assist in adherence to management plan (postoperative correction of residual refractive error)
   - Management of amblyopia (patching or atropine); consider effect on school performance of visual disability/hospital attendance
   - Obtain history relevant to prior watery eye establishing onset and if improvement (relevant to congenital tear duct obstruction (common), infective conjunctivitis and  congenital glaucoma (rare))
   - Indications for microbiology/virology swabs if persisting watery eye or investigation for congenital infection (congenital cataracts)
   - Recognition of globe enlargement (buphthalmos), corneal haze, photophobia
   - Recognising need for urgent referral plus general physical examination and risk of congenital infections
   - Management of congenital tear duct obstruction: indications for surgical intervention, advice to family/whanau on supportive treatment if persistent watery eye
   - Management of infective conjunctivitis: risks of transmission, role of antibiotics

Personal and Professional Skills 
   - Empathetic communication with family/whānau and sensitivity to parental anxiety which ensues when the possibility of an abnormality is raised
Hauora Māori 
   - Appropriate engagement and consultation with whānau
Population Health 
   - Epidemiology of congenital cataract
   - Prevention of congenital infections (rubella immunisation programme)
   - Notification requirements relating to epidemics of viral conjuncitvities and public health systems around outbreak management 
Conditions to be considered relating to this scenario
Opacity in infant: Congenital cataract, retinoblastoma, retinopathy of prematurity and its stages, persistent hyperplastic primary vitreous, vitreous hemorrhage, toxocariasis, Coats disease Watery eye: congenital nasolacrimal duct obstruction, bacterial conjunctivitis, viral conjunctivitis, allergic conjunctivitis, corneal or sub-tarsal foreign body
Opacity in infant: Chorioretinal colobomas, other tumours e.g. choroidal haemangioma, congenital rubella syndrome Watery eye: congenital glaucoma, corneal dystrophies