department were listed by six sites. A medical studentophthalmology club was listed by two.

Faculty information was listed on 73 sites. Photographsof faculty members were posted on 37 sites. Faculty e-mailaddresses were listed on 18 sites. Biographical informationon specific faculty members was listed on 34 sites.

A section of the departmental website dedicated topatient care was found on 70 sites. This included maps tothe various hospitals and clinics at which EyeMDs (oph-thalmologists with medical doctorates) worked on 51 sites.Text directions were listed on 51 sites as well. A descrip-tion of clinical facilities was present on 62 sites. Videocontent was found on only two websites. In both cases, thevideo content consisted of surgical demonstration videos.

Links to other web-based resources were present on 71sites. Intrainstitutional links were present on 69 sites, and47 sites had interinstitutional links. Links to other websitesproviding academic resources were found on 40 sites. Linksto patient care resources were found on 32 sites. Links toophthalmology publications were found on 25 sites. A linkto the American Academy of Ophthalmology website(http://www.aao.org/) was found on 25 sites.

Whereas most ophthalmology programs do have a web-site, there exists only a small cohort that effectively utilizethe internet in each of the areas evaluated in this study.The websites of these programs are easily accessible. Thevast majority of programs have extremely limited internetpostings, many of which are not easily accessible. Medicalstudent resource postings appear to be particularly scarce.In the interests of each program and to optimize all aspectof medical education, current and comprehensive websitesmust become standard across the board for our specialty.

REFERENCES

1. Rozental TD, Lonner JH, Parekh SG. The internet as acommunication tool for academic orthopaedic surgery depart-ments in the United States. J Bone Joint Surg Am 2001;83-A:987–991.

2. Brazin LR. Sources of information on postgraduate medicaltraining programs—2002 update. Med Ref Serv Q 2002;21:1–14.

3. Huot SJ, Wong JG, Luzzi K, Fortin AH VI. Developing andimplementing web-based communications for a residencyprogram. Workshop presented at the APDIM Annual Meet-ing, Philadelphia, PA, April 2000.

4. Zucker S, White JA, Fabri PJ, Khonsari LS. Instructionalintranets in graduate medical education. Acad Med 1998;73:1072–1075.

Unilateral Leukocoria in Off AxisFlash Photographs of Normal EyesJodie Marshall, MBBS, andGlen A. Gole, MD, FRANZCO

PURPOSE: To describe an optical phenomenon producingleukocoria in off axis flash photographs of children whohave a normal ophthalmic examination.DESIGN: Observational case series.METHODS: Description of three otherwise well childrenwho presented to a pediatric ophthalmologist with uni-lateral leukocoria seen in flash photographs. The childrenunderwent a full ophthalmic examination, including di-lated fundus examination.RESULTS: All ophthalmic examinations were normal. Thephotographs were all found to be approximately 15degrees off axis with the leukocoria seen in the eyeswhere the flash illuminated the nasal retina.CONCLUSIONS: Leukocoria can be seen in normal eyeswhen the child is not fixing directly on the camera. Thatis due to reflection off the optic nerve head. (Am JOphthalmol 2003;135:709–711. © 2003 by ElsevierInc. All rights reserved.)

LEUKOCORIA IS THE PRESENTING SIGN IN AT LEAST 50%

of patients with retinoblastoma and necessitates anurgent diagnostic workup.1 We present an observationalcase series of three children who presented with unilateralleukocoria seen in flash photographs, all of whom hadnormal ocular examinations.

● CASE 1: A 4-year-old girl presented with two off axisflash photographs showing leukocoria in the left eye whenlooking to the right of the camera (Figure 1, top left).Unaided visual acuity was 20/30 in both eyes. No strabis-mus was detected. The pupils reacted normally. Fullcycloplegic reaction was �1.75 in both eyes. Dilatedfundus examination showed no abnormality.

● CASE 2: A 15-month-old boy presented with an off axisflash photograph showing leukocoria in the left eye whenlooking to the right of the camera (Figure 1, top right).Fixation was equal, and no strabismus was detected. Thepupils reacted normally. Full cycloplegic refraction was�1.25 in both eyes. Dilated fundus examination showedno abnormality.

● CASE 3: A 10-month-old girl presented with two offaxis flash photographs showing unilateral leukocoria. Inone photograph the child was looking to the left of thecamera and the leukocoria was in the right eye, and inthe other photograph the child was looking to the rightof the camera and the leukocoria was in the left eye(Figure 1, bottom left and right). Fixation was equal andno strabismus was detected. The pupils reacted nor-mally. Full cycloplegic refraction was �1.25 in both

Accepted for publication Oct 25, 2002.From the Royal Children’s Hospital, Brisbane, Queensland, Australia.Inquiries to Glen A. Gole, MD, Department of Paediatrics and Child

Health, Royal Children’s Hospital, Herston Rd, Brisbane, Queensland4029, Australia; fax: (�61) 7-3870-0060; e-mail: g.gole@uq.edu.au

BRIEF REPORTSVOL. 135, NO. 5 709

eyes. Dilated fundus examination showed no abnormal-ity in either eye.

Leukocoria can be detected in photoscreens, where it isa secondary finding or it may be seen incidentally in candidphotographs. In photoscreens the pupil may or may not bedilated.2 The child is instructed to look directly at thecamera. In 14,075 children screened in 1992 to 1993 withan eccentric photoscreener there were no cases of leuko-coria reported in normal eyes.3

In the cases presented, all photographs were candidindoor flash photographs of children with undilated pupilstaken with a range of amateur cameras. These had flashillumination sources coaxial with the lens; film and meth-ods of processing were those commonly available. The

children were at varying distances from the camera andhad not been asked to focus on a specific object or at aspecific distance. All were fixing approximately 15 degreesoff axis. Leukocoria was always unilateral and observedonly in the eye in which the nasal retina was illuminated.The third case presented with photographs showing leu-kocoria in the right eye when fixation was to the right ofthe camera and in the left eye when fixation was to the leftof the camera. In all cases refraction was unremarkable andthe fundi were normal.

Incident light approximately 15 degrees off axis tempo-rally illuminates the optic disk. The optic nerve headbehaves as a diffuse reflector, scattering light, but if itreflected light as a perfect mirror, an illuminated area with

FIGURE 1. Off axis flash photographs of children with undilated pupils showing leukocoria in the eye in which the nasal retinais photographed. Photographs of Case 1 (top left), Case 2 (top right), and Case 3 (bottom left and right) were taken at variousdistances and are cropped to show subject’s face. Note Case 3 has leukocoria in the right eye when fixation is to the left, and in theleft eye when fixation is to the right.

AMERICAN JOURNAL OF OPHTHALMOLOGY710 MAY 2003

diameter 1/30th of the disk diameter would be sufficient toproduce leukocoria filling the pupil (Figure 2).

Leukocoria in normal eyes has not been previouslyreported in the literature to our knowledge. These cases arepresented to add reflection from a normal optic nerve headto the differential diagnosis of leukocoria when childrenpresent with off axis photographs showing a unilateralwhite pupil reflex in the eye with the nasal retina illumi-nated by the flash.

REFERENCES

1. Abramson DH, Frank CM, Susman M, Whalen MP, DunkelIJ, Boyd NW. Presenting signs of retinoblastoma. J Pediatr1998;132:505–508.

2. Kennedy R, Sheps S. A comparison of photoscreening tech-niques for amblyogenic factors in children. Can J Ophthalmol1989;24:259–264.

3. Morgan KS, Kennemer JC. Off axis photorefractive eyescreening in children. J Cataract Refract Surg 1997;23:423–428.

Camera Artifacts Producing theFalse Impression of Growth ofChoroidal Melanocytic LesionsRobert N. Johnson, MD,H. Richard McDonald, MD, Everett Ai, MD, andJ. Michael Jumper, MD

PURPOSE: To report a camera artifact that masks portionsof pigmented lesions while preserving overlying retinaldetails.DESIGN: Case report.METHODS: Cases collected from the authors’ clinicalpractice were identified during review of fundus photos.An attempt was made to reproduce the artifact in anormal eye.RESULTS: Three cases were identified that demonstratedthis artifact.CONCLUSION: Off-axis color photos can produce a reddishartifact that may blend imperceptibly with the surround-ing retinal appearance and filter visualization of melano-cytic pigment. This can mask a portion of a pigmentedlesion and later may create a false impression of a largerlesion. (Am J Ophthalmol 2003;135:711–713.© 2003 by Elsevier Inc. All rights reserved.)

THE MANAGEMENT OF SUSPICIOUS, LARGE NEVI TYPI-cally involves periodic observation for evidence of

growth.1,2 Careful baseline documentation of tumor sizewith fundus photography and ultrasonography is essential.Similar studies are done following treatment of a mela-noma. We recently encountered three cases of fundusphoto artifacts that could suggest possible growth of amelanocytic lesion. This artifact filtered the darker pig-ment from the melanocytic lesion along one edge butpreserved the overlying retinal detail.

● CASE 1: A 45-year-old man was noted to have apigmented choroidal melanocytic lesion measuring 3 mm� 3.5 mm. The lesion appeared to be only slightlythickened. Baseline fundus photography was done. Subse-quent review of the photos revealed a peculiar artifact. Thetemporal portion of the lesion was absent on one (Figure1B) but not another photo (Figure 1A) done the same day.Curiously, the overlying details of the retina and retinalvessels was present in the area overlying the lesion that wasabsent in one of the photos.

● CASE 2: A 67-year-old man returned for follow-up of achoroidal nevus. Review of fundus photographs revealed

Accepted for publication Nov 21, 2002.The authors are in private practice in San Francisco, California.Supported by the Retina Research Fund, St. Mary’s Medical Center,

San Francisco, California.Inquiries to Robert N. Johnson, MD, 1 Daniel Burnham Court, Suite

#210-C, San Francisco, CA 94109; fax: (415) 441-0421; e-mail:retinasf@aol.com

FIGURE 2. Ray diagram showing that for a schematic eye,with a nodal point 17 mm and a camera 1 m away with anentrance pupil 3 mm diameter, an illuminated area with diam-eter 1/30th of the disk diameter will be sufficient to produce awhite reflex filling the pupil. As the entrance pupil at thecamera remains fixed at any distance, the area requiring illumi-nation will vary with the distance from the camera.

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