*2.3.2 Office examination*

The initial examination of the child should occur while history taking, by watching the child's behavior, visual interaction with the world, and evaluating for any abnormalities in size of the child, proportions, or for any facial abnormalities. The external examination of a child with retinoblastoma should be otherwise normal except for the ocular exam unless the child has a 13q deletion syndrome. Before the formal examination, the ability to notice leukocoria, decreased visual function, strabismus, or periorbital swelling should be noted upon gross examination. Assessment of vision is obviously dependent on age of patient, and his or her individual cooperation, but the size and symmetry of each eye should be recorded, as asymmetric size can suggest other diagnoses as well as retinoblastoma. Presence or absence of heterochromia should be noted during this portion of the examination as well [12]. Pupil response should also be documented. Using a direct ophthalmoscope or retinoscope, the pupillary light reflex should be noted in both eyes and leukocoria can be noted at that time.

The next step should be instillation of dilating eyedrops (0.5% tropicamide and 2.5% phenylephrine). Cyclopentolate is not necessary for this examination. If the

child is large enough or a portable slit lamp is available, slit lamp examination should be performed, care to note, presence or absence of cataract, conjunctival or scleral injection, anterior segment shallowing, neovascularization of the iris, iris seeding or iris atrophy. Evaluate for retrolental membranes to assess presence of retinopathy of prematurity or persistent fetal vasculature. Most patients with retinoblastoma have normal anterior segments but may have anterior cells or nodules on the iris. In exophytic tumors, visualization of retinal vasculature behind the lens may be possible as well. Indirect ophthalmoscopy should be performed to evaluate the posterior pole and fundus. Depending on the age of the child, they may cooperate or family members may be needed to help secure the patient in a supine position. Very young children may be swaddled with a blanket to secure their limbs. The indirect exam in the office should be used to rule out simulating lesions when possible and to also increase or decrease suspicion for retinoblastoma, thus determining whether examination under anesthesia (EUA) is needed for full evaluation and diagnosis. An eyelid speculum may be needed for proper dilated examination, and a topical anesthetic such as 0.5 or 1% proparacaine should be instilled prior to speculum insertion. Scleral depression may be indicated, if it can be reserved for examination under anesthesia it is less traumatic but can be done in the office setting.
