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The parents of a 2 year old boy notice a difference in appearance of his two eyes in a recent flash photograph, and they alert their paediatrician.
A white red reflex is ‘leukocoria’—‘leukos’ Greek for white and ‘core’ for pupil. Evaluation of the red reflex is a useful screening test that should not be missed from the routine paediatric examination. It is quick, non-invasive and only needs a bright direct ophthalmoscope. An asymmetrical red reflex—with abnormal colour, size, shape or positioning—can indicate need for urgent ophthalmology referral.
In children, leukocoria can represent a wide range of underlying pathologies, intraocular and systemic. Having the confidence to conduct a thorough history and examination is crucial to reach a differential diagnosis and exclude rare sight and life-threatening conditions.
Swiss ophthalmologist Bruckner in 19621 described the red reflex as a screening tool in infants and children. The beauty of using the red reflex screening tool is that it is non-invasive and can be done rapidly, without even touching an apprehensive child. Furthermore, it can be easily learnt and is not a skill reserved solely for specialists. A study in 1995 by Gole and Douglas2 demonstrated that the transillumination of the red reflex by non-ophthalmologists has a high sensitivity for detecting abnormalities.
How to elicit a red reflex
Anyone who has been behind a flash camera has probably generated a red reflex. The light travels through the cornea, aqueous humour, lens and vitreous body and reflects off the chorio-retinal sheen and vasculature.
To elicit the reflex, darken the room to allow the subject's pupils …
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