Disclosures: Canestraro and Sherman report no relevant financial disclosures.
August 09, 2021
2 min read

Some refractive errors may suggest retinoblastoma in infants

Disclosures: Canestraro and Sherman report no relevant financial disclosures.
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The American Optometric Association- sponsored InfantSee program resulted in an increase in the number of infants between 6 and 12 months old evaluated by optometrists. These free exams have uncovered a myriad of disorders including strabismus, high refractive error, amblyopia and occasionally pathologies such as congenital cataracts and even retinoblastoma.

There are two refractive error clues that may go unrecognized by some clinicians but may suggest possible retinoblastoma.

Watch for increasing hyperopia

The first is increasing hyperopia in the first years of life, which contradicts the anticipated decrease in hyperopia expected in most normal infants (Atkinson et al). Even a small retinoblastoma in the macula will decrease the axial length and hence increase hyperopia. It has been reported that a 1 mm change in axial length can alter the refractive error by 2.5 D to 3 D (Hyeong-Su et al). While we rarely measure axial length in infants, we do perform retinoscopy on almost every exam.

For example, a +3.00 D refractive error at 6 months but a +6.00 D in the same eye at 12 months almost never occurs; hence, this error should alert the clinician to a possible retrobulbar, choroidal or retinal mass. Even if a dilated fundus examination fails to detect a lesion, B-scan ultrasound through a closed lid is easy to perform on an infant in a minute or so and may detect an early mass missed by binocular indirect ophthalmoscopy. In select cases, a concerned clinician who does not have a B-scan should consider referring to a facility with this noninvasive technology.

Anisometropia could suggest mass

In addition to an increase in hyperopia, anisometropia suggests a possible mass. In a recent study of more than 12,000 newborns, the researchers conclude that “anisometropia is present in a very limited number of cases, reported as 0.01%,” (Semeraro et al). This of course would be most applicable in cases of unilateral retinoblastoma, but refractive error may shift similarly in both eyes if there are tumors located centrally in both eyes.

Knowledge of the scientifically proven concept of emmetropization in both animal models and humans (Troilo et al) is quite useful for providing optimal patient care.

When your refractive error findings disagree with the expected norms, consider a mass such as a retinoblastoma and follow up with a careful dilated exam and possibly specialty referral. You may save an eye or even a life.


  • Atkinson J, et al. Invest Ophthalmol Vis Sci. 2000;41,3726-3731.
  • Hyeong-Su K, et al. PLOS One. 2019;doi:10.1371/journal.pone.0210387.
  • Semeraro F, et al. Front Pediatr. 2020;doi:10.3389/fped.2019.00539.
  • Troilo D, et al. Invest Ophthalmol Vis Sci. 2019;doi:10.1167/iovs.18-25967.

Julia Canestraro, OD, FAAO, is an instructor at Memorial Sloan Kettering Cancer Center, Ophthalmic Oncology Service. She has experience in the diagnosis and nonsurgical management of ocular disease, including ocular tumors. She also specializes in treating the ocular consequences of cancer.

Jerome Sherman, OD, FAAO, is a Distinguished Teaching Professor at SUNY College of Optometry, in private practice at Omni Eye Surgery in New York and a member of the Primary Care Optometry News Editorial Board.