*2.4 Exam under anesthesia (EUA) considerations*

If EUA is warranted, general anesthesia will be needed to conduct detailed examination and ancillary testing at one time. Preparation of the room for EUA should consist of examination materials including: external photography, portable slit lamp, tonometry, indirect ophthalmoscope with condensing lens and scleral

#### **Figure 1.**

*10 mHz ultrasound in A and B scan mode showing a large intraocular retinoblastoma with irregular mass and intrinsic calcification with acoustic shadowing.*

**31**

*Retinoblastoma: Presentation, Evaluation, and Diagnosis DOI: http://dx.doi.org/10.5772/intechopen.85744*

pinealoblastoma in trilateral disease.

successfully without long term sequelae [16].

hypoplastic thumbs, cleft palate, or microcephaly [17].

buphthalmos and increased corneal diameter.

**2.6 Examination under anesthesia**

*2.6.1 External examination*

*2.6.2 Anterior examination*

disease [18].

**2.5 Anesthesia**

depressor, wide-angle hand-held fundus camera, intravenous fluorescein dye, high resolution ophthalmic ultrasound, ultrasound biomicroscopy, electroretinography. When retinoblastoma is confirmed, an MRI of the brain and orbits with and without contrast should be ordered at the time of the EUA to assess for extrascleral extension, orbital anatomy, posterior portion of the optic nerve, and presence of

The type of general anesthetic and airway support varies depending on institution and available resources. Safe anesthesia methods range from mask anesthesia, to laryngeal mask airway (LMA), to complete endotracheal intubation. Both inhaled anesthetics and intravenous anesthetics, or a combination of the two, are suitable for examination. General guidelines recommend that heavy fatty meals be discontinued 8 h prior to procedure, light meals, formula, and nonhuman milk 6 h prior to surgery, human milk 4 h prior to anesthesia, and clear liquids 2 h prior to anesthesia [15]. These recommendations will vary by location and anesthesiologist, and type of anesthesia administered. Recently there has been literature support for use of LMA without placement of intravenous lines, which reduces total time under anesthesia without increased anesthesia complications, all of which were managed

An orderly approach to the exam should be taken to efficiently access and treat the patient to avoid prolonged anesthesia exposure. The overall features of the child should be assessed, evaluating for any abnormalities that are consistent with retinoblastoma and a 13Q deletion syndrome which is strongly associated with retinoblastoma risk (**Figure 2**). Patient's with 13Q deletion syndrome may have hypotelorism, micrognathia, hypoplasia of midface, absent nasal bones, large ears,

Intraocular pressures should be measured using Schiotz tonometer, tonopen, Perkins tonometer, or pneumotonometer. Elevated intraocular pressure in patients with retinoblastoma can be secondary to iris neovascularization or angle closure, and has been associated with increased risk of optic nerve invasion and metastatic

After intraocular pressure is checked, corneal diameter should be measured with a caliper both in horizontal and vertical directions. Conditions such as persistent fetal vasculature (PFV) is associated with asymmetric corneal diameter size as well as eyes with congenitally elevated intraocular pressures can be associated with

A portable slit lamp should be used to assess the anterior segment. The clinician should evaluate anterior depth, clarity of the lens, neovascularization of the iris or atrophy, retrolental membrane, anterior chamber cells, nodules of the iris, or anterior vitreous seeds seen behind the lens. Presence of a pseudohypopyon should raise suspicion for endophytic tumor and anterior chamber seeing of cancer. It may be possible to visualize retinal vascular, retrolental masses, or retrolental membranes. Retrolental retinal tissue should reveal blood vessel branching patterns depressor, wide-angle hand-held fundus camera, intravenous fluorescein dye, high resolution ophthalmic ultrasound, ultrasound biomicroscopy, electroretinography. When retinoblastoma is confirmed, an MRI of the brain and orbits with and without contrast should be ordered at the time of the EUA to assess for extrascleral extension, orbital anatomy, posterior portion of the optic nerve, and presence of pinealoblastoma in trilateral disease.
