A full-term 2-month-old baby girl is referred to the pediatric ophthalmology clinic by the patient’s primary care provider for “poor fixation”. History of present illness: The patient's mother noticed that her right eye wandered out significantly at birth but reported that this had improved.
The mother is uncertain if the girl can see clearly or not. Past ocular history: Unremarkable Past medical history: Full-term, normal spontaneous vaginal delivery, no pregnancy complications Medications: None Allergies: No known drug allergies Family history: No known eye diseases Physical examination: General: well-appearing, the well-developed infant in no acute distress External exam with mild telecanthus Winces inconsistently to light OU IOP soft by palpation OU Normal alignment for age No obvious nystagmus but possibly a few beats noted on bundled exam Slit-lamp exam within normal limits OU…
