Examination of the Red Reflex in Pediatric and Adult Patients
Title: Examination of the Red Reflex in Pediatric and Adult Patients
Author (s): Cole Swiston, MSIV, University of Wisconsin School of Medicine and Public Health
Photographer: Ethan Peterson (Videographer), James Gilman CRA/FOPS (Photographer)
- Understand the basic physics and physiology which result in the red reflex
- Learn the purpose of red reflex testing in pediatric and adult patients
- Learn how to perform red reflex testing with the direct ophthalmoscope (see our video on the use of the direct ophthalmoscope for more details on its general use)
- Become familiar with basic etiologies of an abnormal red reflex in pediatric and adult patients
The red reflex is a reflective phenomenon seen when light passes through the pupil and is reflected back off the retina to a viewing aperture, creating a reddish orange glow. You may notice this commonly in pictures with flash. Red reflex testing is a valuable tool for detection of abnormalities in the normally transparent visual axis or in the retina. Loss of transparency in any of these structures can alter the red reflex, including from front to back; the tear film, cornea, aqueous humor, lens, vitreous gel, and retina. In pediatric patients, abnormalities in the red reflex can be the first clue to sight threatening conditions that cause amblyopia, or life-threatening pathologies such as retinoblastoma. Similarly, the red reflex can assist in the diagnosis of conditions causing visual loss in adults.
When examining the red reflex, look first for its presence or absence, the color of the reflex, brightness, and importantly, symmetry between eyes.
How to perform red reflex testing:
- Make sure the lights in the room are turned off, making the red reflex easier to see.
- Align the height of your eyes with the patient’s eyes. If the patient is a child, have them sit on their parent’s lap.
- Set your direct ophthalmoscope diopter power to 0, or to match your refractive error.
- Switch on the ophthalmoscope, hold it close to your eyes and 12-18 inches away from the patient’s eyes, and shine the light towards the patient’s eyes.
- Encourage the patient to look at your light. Toys and hand motions may be helpful.
- Direct your light at each eye individually to evaluate the red reflex of each eye.
- Direct your light over both eyes to evaluate for symmetry of the reflex.
The American Academy of Pediatrics recommends red reflex testing in all patients during the neonatal period and during all subsequent well child and routine health appointments. Any abnormalities discovered, especially leukocoria, require urgent referral to an ophthalmologist.
Leukocoria is a term for whitening of the red reflex. The most common conditions causing this whitening are retinoblastoma (a serious tumor in the back of the eye), cataracts, persistent fetal vasculature and Coat’s disease. Coat’s disease is characterized by abnormal blood vessel development in the retina and can threaten vision if left untreated. Another important aspect of red reflex testing is evaluating for symmetry between eyes. Asymmetry would be considered an abnormal result and is generally evaluated with the Bruckner test, where both eyes are visualized simultaneously with the direct ophthalmoscope. In strabismus, or misalignment of the two eyes, the deviated eye will generally have a lighter and brighter red reflex. If the refractive error is different between the two eyes (termed anisometropia), one reflection also may be brighter than the other. It is especially important to evaluate for these conditions, as they both may lead to amblyopia, which is abnormal development of the normal visual pathways. Similar to a pediatric patient, dimming, dulling, or asymmetry in an adult patient often indicates opacity of structures in the visual axis. The most common cause of this dulling in an adult is a cataract, but an abnormal red reflex may also clue you in to other pathologies in the cornea (abrasion, infection, or scar), vitreous (hemorrhage or inflammation), or retina (retinal detachment).
- Ophthalmology S on. Red Reflex Examination in Infants. Pediatrics. 2002;109(5):980-981. doi:10.1542/peds.109.5.980
- How to test for the red reflex in a child. Community Eye Health. 2014;27(86):36.
- Shafiq A. Seeing red in young children: the importance of the red reflex. Br J Gen Pr. 2015;65(633):209-210. doi:10.3399/bjgp15X684625
- Light Reflex Tests. https://www.aao.org/bcscsnippetdetail.aspx?id=703d090d-b6a0-45d5-a3da-e456c030caec. Accessed September 6, 2018.
Faculty Approval by: Griffin Jardine, MD
Copyright statement: Cole Swiston, ©2018. For further information regarding the rights to this collection, please visit: http://morancore.utah.edu/terms-of-use/