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Fifteen minutes consultation: a structured approach to the child with a white red reflex
  1. Rachel Varughese1,
  2. Peggy Frith2
  1. 1Department of Neurosurgery, Queen's Medical Centre, Nottingham University Hospitals Trust, Nottingham, UK
  2. 2Department of Ophthalmology, University College London Hospitals NHS Trust, London
  1. Correspondence to Dr Rachel Varughese, Postgraduate Centre, Queen's Medical Centre, Derby Road, Nottingham NG72UH, UK; rachel.varughese{at}

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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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  • Competing interests None.

  • Provenance and peer review Commissioned; externally peer reviewed.