A girl whose eyes appear white in photos. What could be the
A 6-year-old girl was referred to pediatric ophthalmology for a white reflex that was seen in photographs by her parents. Initially, the mother only saw the white reflex in the left eye, but then she started to also notice the white reflex in the right eye and in almost every photograph.

The patient's mother was uncertain whether her daughter could see well, but noted that she sat close to the television.
The mother denied misalignment or nystagmus; however, the maternal aunt has nystagmus. There was no history of trauma.

On exam, the patient's visual acuity was 20/60 in the right eye and 20/50 in the left eye. Visual fields to confrontation were full. Pupil, ocular motility, anterior segment, and posterior segment exams were normal. Cycloplegic refraction was plano +3.50 x 095 in the right eye and plano +3.00 x 088 in the left eye.

The patient was diagnosed with high refractive error is the correct diagnosis, given the normal dilated fundus exam and astigmatism found with the cycloplegic refraction.

The patient was prescribed glasses for her refractive error and was asked to wear them full-time. On follow-up exam, the parents noted that the white reflex was no longer seen in photographs when the patient wore the glasses. The patient's vision improved to 20/25 in each eye.

The patient was also subsequently diagnosed with mild bilateral ametropic amblyopia that improved with glasses wear alone. The parents were instructed to have her continue to wear her glasses full time and to have her be monitored for her amblyopia.

Key takeaways:-
- Leukocoria (from the Greek meaning "white eye") is a finding with expansive differential diagnoses. Etiologies of true (pathologic) leukocoria include malignant, inflammatory, vascular, infectious, and embryologic, and nearly any ocular structure may be implicated.

- The finding of leukocoria demands prompt ophthalmologic referral and evaluation for vision- or life-threatening conditions.

- Some patients with observed leukocoria in photographs are found to have an unremarkable dilated funduscopic exam. As such, pseudoleukocoria is yet another entity to consider on the differential diagnosis of leukocoria.

- Pseudoleukocoria, a transient artefactual white pupillary reflex seen on flash-illuminated photography in a clinically normal eye, is seen in the photographs of the patient, owing to this uncorrected high refractive error.

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