What does a normal red reflex test look like in a child?

A brighter reflex in the deviating eye

How is the binocular red reflex (Bruckner) view performed?

Direct ophthalmoscope at zero, both pupils at 40-50 cm In a dim room the ophthalmoscope lens is set to zero and both pupils are viewed together at about 40-50 cm, then each eye separately from closer.

Slit lamp with a 90 D lens at the corneal plane

Indirect ophthalmoscope with scleral depression

Direct ophthalmoscope at +10 D held at 5 cm

On the Bruckner test, what does a brighter reflex in one eye suggest?

That eye deviates or has a refractive error Differences between the eyes point to strabismus, anisometropia or opacity, and the brighter reflex suggests the deviating eye or the one with refractive error.

That eye is the normal fixing eye

That eye has a vitreous haemorrhage

A child has a dark or absent red reflex. What is the appropriate next step?

Repeat with dilation and refer for full examination A dark reflex suggests dense cataract, vitreous haemorrhage or a small pupil; an absent reflex is repeated dilated and the child referred because the cause may be serious.

Reassure, as dark reflexes are always normal

Prescribe spectacles and review in a year

Patch the better eye for amblyopia

When does the American Academy of Pediatrics recommend red reflex testing?

In newborns and at each well-child visit The AAP recommends testing in newborns and at every well-child visit, and repeating it at any age if concerns arise.

Only when parents report a problem

What is a key limitation of the red reflex test?

A normal reflex does not exclude all disease The test misses some small lesions and poor cooperation reduces accuracy, so it is combined with history and other screening tests.

It cannot be performed in newborns

It requires general anaesthesia

It detects only refractive errors

Parents report a white pupil reflex in one eye on flash photographs. How should this be handled?

Take it seriously and examine the child A white reflex in flash photographs can be an early clue and must be taken seriously, so clinicians should ask parents about photographs.

Dismiss it as a camera artefact

Wait for the next routine visit

Advise photographs without flash

Red Reflex Test: Technique and Abnormal Findings

Red reflex test is a simple screening examination that detects media opacities and retinal disease in infants and children.

A normal result shows a bright, symmetric red-orange glow from both pupils.

Therefore, it should be done at every well-child visit and by every clinician who sees children.

What the Red Reflex Test Detects

The test shows whether light passes through the cornea, lens and vitreous to the retina and back.

Opacities in these media change the reflex.

Also, retinal tumors and detachments alter the color.

Because early detection saves vision and life, the test is part of routine care.

Preparing for the Red Reflex Test

Use a dim room and a direct ophthalmoscope.

Set the lens to zero and hold the instrument at arm’s length.

Also, let the child look at a toy or the light.

Therefore, the child stays calm and the eyes stay open.

Test your knowledge 10 questions from this article

Technique of the Red Reflex Test

View both pupils together at about 40 to 50 centimeters.

Then look at each eye separately from a shorter distance.

Also, compare the brightness, color and symmetry.

Because the first view is binocular, it shows differences at once.

The Bruckner Test

Bruckner described the binocular view in 1962.

Differences between the eyes point to strabismus, anisometropia or opacity.

Also, a brighter reflex suggests the eye that deviates or has a refractive error.

Therefore, the test detects amblyopia risk as well as disease.

Normal Findings on the Red Reflex Test

The reflex is red to orange in most children.

Darkly pigmented children show a duller or grayer reflex.

Also, both eyes should match.

Because pigmentation varies, learn the normal for each patient.

Abnormal Findings: Leukocoria

A white or gray reflex is called leukocoria.

Causes include cataract, retinoblastoma, Coats disease, persistent fetal vasculature and retinal detachment (see leukocoria).

Also, retinopathy of prematurity may cause it.

Therefore, refer any child with leukocoria urgently.

Abnormal Findings: Dark or Absent Reflex

A dark reflex suggests a dense cataract, vitreous hemorrhage or other media opacity.

It may also reflect a small pupil.

Also, an absent reflex needs a repeat in dilated conditions.

Because the cause may be serious, refer for a full examination.

Asymmetric Reflex

A brighter reflex in one eye may indicate high refractive error.

A reflex with a crescent suggests anisometropia.

Also, strabismus shows a brighter reflex in the deviated eye.

Therefore, asymmetry deserves a referral for cycloplegic refraction.

Retinoblastoma and the Red Reflex Test

Leukocoria is the most common presenting sign of retinoblastoma.

Abramson and colleagues linked presenting signs with outcomes.

Also, Li and colleagues studied the detection of simulated tumors by red reflex testing.

Because delay worsens outcome, act without hesitation (see retinoblastoma).

Clinical image illustrating Red Reflex Test (figure 2)

Photographs and Flash Reflexes

Parents may notice a white reflex in flash photographs.

This can be an early clue and should be taken seriously.

Also, a different color in one eye in photographs deserves an examination.

Therefore, ask parents about photographs.

Frequency of Red Reflex Test Screening

The American Academy of Pediatrics recommends red reflex testing in newborns and at each well-child visit.

Also, the test should be repeated at any age if concerns arise.

Because disease may appear later, repeat screening matters.

Limitations of the Red Reflex Test

The test misses some small lesions.

A normal reflex does not exclude all disease.

Also, poor cooperation reduces accuracy.

Therefore, combine it with history and other screening tests.

Documentation and Referral

Record the result for each eye and the method.

Also, refer abnormal results promptly to a pediatric ophthalmologist.

Because parents need clear steps, give written information.

Special Situations

In premature infants, the reflex may be dull and the eyes small.

Also, in children with dark irises, the reflex is paler and may look gray.

Because skin and iris color affect the glow, compare both eyes and do not judge a single color.

Pupil Size and Lighting

A dilated pupil gives a stronger reflex and makes subtle opacities easier to see.

Also, bright room lights shrink the pupil and reduce the view.

Therefore, dim the room and use the same setting each time.

Common Mistakes

Do not use too much light, since glare can mask a defect.

Also, do not assume that a single glance is enough.

Because small tumors can sit at the periphery, refer when you are in doubt.

Parent Education

Explain that the test is quick and painless.

Also, tell parents to report a white reflex in photographs.

Because parents often notice changes first, involve them.

References

American Academy of Pediatrics, Section on Ophthalmology; American Association for Pediatric Ophthalmology and Strabismus; American Academy of Ophthalmology. Red reflex examination in neonates, infants, and children. Pediatrics. 2008;122:1401-1404.
Bruckner R. Exakte Strabismusdiagnostik bei 1/2-3jahrigen Kindern mit einem einfachen Fundusreflextest. Ophthalmologica. 1962;144:184-198.
Roe LD, Guyton DL. The light that leaks: Bruckner and the red reflex. Surv Ophthalmol. 1984;28:665-670.
Abramson DH, Beaverson K, Sangani P, et al. Screening for retinoblastoma: presenting signs as prognosticators of patient and ocular survival. Pediatrics. 2003;112:1248-1255.

Test yourself

A few questions straight from this article.

1 / 10 0 correct

What does a normal red reflex test look like in a child?
A normal result shows a bright, symmetric red-orange glow from both pupils, and both eyes should match.
How is the binocular red reflex (Bruckner) view performed?
In a dim room the ophthalmoscope lens is set to zero and both pupils are viewed together at about 40-50 cm, then each eye separately from closer.
On the Bruckner test, what does a brighter reflex in one eye suggest?
Differences between the eyes point to strabismus, anisometropia or opacity, and the brighter reflex suggests the deviating eye or the one with refractive error.
What is the most common presenting sign of retinoblastoma?
Leukocoria is the most common presenting sign of retinoblastoma, and because delay worsens outcome, any child with it is referred urgently.
Which condition is a recognised cause of leukocoria on the red reflex test?
Causes of a white or grey reflex include cataract, retinoblastoma, Coats disease, persistent fetal vasculature, retinal detachment and retinopathy of prematurity.
A child has a dark or absent red reflex. What is the appropriate next step?
A dark reflex suggests dense cataract, vitreous haemorrhage or a small pupil; an absent reflex is repeated dilated and the child referred because the cause may be serious.
An asymmetric red reflex with a crescent suggests anisometropia. What should follow?
A brighter reflex may indicate high refractive error and a crescent suggests anisometropia, so asymmetry deserves referral for cycloplegic refraction.
When does the American Academy of Pediatrics recommend red reflex testing?
The AAP recommends testing in newborns and at every well-child visit, and repeating it at any age if concerns arise.
What is a key limitation of the red reflex test?
The test misses some small lesions and poor cooperation reduces accuracy, so it is combined with history and other screening tests.
Parents report a white pupil reflex in one eye on flash photographs. How should this be handled?
A white reflex in flash photographs can be an early clue and must be taken seriously, so clinicians should ask parents about photographs.

Ahmed Ophthalmologist

Writes and reviews the clinical articles on Educate. Every post is checked against peer-reviewed sources before it goes live.