Abnormal red reflex

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Abnormal red reflex
• Red reflexes unequal in color, brightness, or size
• No strabismus, cloudy or enlarged cornea, tearing or light sensitivity, or poor fixation or tracking
• Referred to pediatric ophthalmology for a dilated eye exam given an abnormal red reflex
• Follow up after the specialist visit

An unequal or dull red reflex can come from a difference in focusing between the eyes or a misaligned eye, and less often from a cloudy lens (cataract) or a problem at the back of the eye, so a dilated exam by the eye doctor is needed. Caregiver expressed understanding and agreement with plan. Answered all questions.

What the sources cover

Unequal color, brightness or size
Dull reflex; dark spots
Absent reflex (possible cataract); white reflex (possible retinoblastoma)
White pupil in flash photos
Recheck in a darkened room
Associated: strabismus, cloudy or enlarged cornea, tearing or light sensitivity, poor fixation
Family history of retinoblastoma or congenital cataract; prematurity
Urgent ophthalmology evaluation
Follow-up after specialist, well check, as needed
Causes (refractive, strabismus, cataract, retinoblastoma) and urgency

Sources

Cribsiders #38 Ophthalmology in Pediatrics (Nov 10, 2021)
Cribsiders #153 Say Cheese! Eye Spy Retinoblastoma (Sept 24, 2025)
AAP Policy Statement, Visual System Assessment in Infants, Children, and Young Adults by Pediatricians. Donahue SP, Baker CN; COPAM, Section on Ophthalmology, AAPOS,…
AAP Clinical Report, Procedures for the Evaluation of the Visual System by Pediatricians. Donahue SP, Baker CN. Pediatrics 2016;137(1):e20153597. Reaffirmed February…