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This two-year-old boy was presented by his mother who showed you this picture that she took of her child last week using a flash camera. She was concerned that the eyes looked different and wondered why.

1.	Your initial impression is:
	d -- A thorough eye examination should be done without delay including retina examination using the indirect ophthalmoscope with a dilated pupil. When a photograph of a child shows a “whitish” pupil reflex like the one shown here (also called cat’s eye reflex), it is prudent to consider that this child has retinoblastoma until you rule it out. This phenomenon is called “photoleukocoria”. White pupil in some form is the presenting sign in up to 50% of cases of retinoblastoma. In this case, a thorough eye examination should be done including an examination of the retina through a dilated pupil using the indirect ophthalmoscope.
2.	If on examination of the retina you see a 4 disc diameter raised whitish lesion, a logical plan includes:
	e -- (a) and (d) Both B scan ultrasound and CT scan should be done as the first tests beyond the clinical eye examination. B scan is usually available in the clinic and can be done quickly and easily on a child of this age. This test will give an idea of the size of the lesion and will provide information about whether the retina is detached. More important for confirming the diagnosis is the CT scan looking for calcium. Needle biopsy of the anterior chamber should be avoided.
3.	Vital to making a rapid and accurate diagnosis in this case is:
	d -- seeing calcium on the CT scan Retinoblastoma is the only retinal lesion that produces calcium in a child in the acute phase. A white elevated lesion involving the retina that produces a white pupil reflex and contains calcium confirmed on CT scan is retinoblastoma.