The single commonest route to a late retinoblastoma is a referral written for refraction. A parent notices a turning eye or an odd flash in a photograph, the child is booked for a cycloplegic refraction in six weeks, and the tumour buys six weeks.
Any unilateral strabismus in a child, and any report of leukocoria however casual, earns a dilated fundus examination at the earliest appointment you can make, not the next convenient one. If the view is inadequate because the child will not cooperate, that is an indication for examination under anaesthesia, not for a repeat attempt in the outpatient clinic. Photograph the red reflex if you can, because a parent's phone image is often better than anything you obtain in a bright room.
The cost of over-referring is a normal fundus and a reassured family. The cost of under-referring is a stage that no chemotherapy route will salvage.
- Treat new unilateral strabismus in a child as a fundus problem until the fundus has been seen.
- Ask the parent to show you the photograph; leukocoria is often first seen on a phone.
- Book examination under anaesthesia rather than a second clinic attempt when the view is poor.
- Check both eyes and record the family history, since bilateral disease changes the counselling entirely.
- Give the family a named contact and a date before they leave the room.
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