Checking the red reflexes

6 week check series – The Absent Red Reflex – with thanks to Dr Sarah Prentice

 Importance of red reflex examination at the 6 week check

Early detection of potentially sight and life-threatening eye disease. Due to the early and time-limited plasticity and development of the eye, any blockage of light to the retina interferes with development of optic neural pathways and can have profound effects on later vision.




                High Refractive errors

                Vitreal haemorrhage/opacity

                Corneal scaring (e.g. ocular toxocariasis)

                Retinal tear

                Retinopathy of prematurity

                Persistence of the tunica vasculosa lentis/Persistent hyperplastic primary vitreous (1)

The Examination

                Darkened room

                Ophthalmoscope on +3 dioptres

                Hold 1 foot away

Red reflexes can only be described as normal if they are:                               

Equal in colour, intensity and clarity with no opacities or white spots (2)


Handy hints

                For the child that won’t open his/her eyes: try picking/sitting them up or rocking them from sitting to lying.  Having a parent hold them on their shoulder (as if winding them) and looking from behind often works. A feeding child will often open his/her eyes, although breast feeding then makes looking in the eyes logistically tricky.

Children with darker skin tones may have pale retina.  If retinal vessels can be seen and followed to the disc and the reflex is equal bilaterally then this is reassuring.  Comparison with parents’ red reflexes may also help.


                Normal:   No further follow-up. Will have routine ophthalmology review by school nurse/orthoptist in pre-school years. (5)

                Unable to see red-reflexes or unsure:  Referral to paediatric ophthalmology primary care clinic (if available)

                Absent red reflex:  Urgent referral to paediatric ophthalmologists (should be seen in less than 2 weeks)

                 Family history of neonatal eye disease e.g. retinoblastoma, congenital cataracts:  Routine referral to paediatric  ophthalmologists.

                Low birth-weight/premature infants (at high risk of retinopathy of prematurity):  Should have had ROP screening and follow-up arranged as necessary by neonatal unit.

 References and resources

  1. 1.       Robertson’s Textbook of Neonatology. Fourth Edition. 2005. Edited by Janet M. Rennie.
  2. 2.       American Academy of Pediatrics Policy Statement. Red Reflex Examination in Infants PEDIATRICS Vol. 109 No. 5 May 2002
  3. 3.       Red Reflex Examination in Neonates, Infants, and Children. PEDIATRICS Vol. 122 No. 6 December 2008, pp. 1401-1404 (doi:10.1542/peds.2008-2624)
  4. 4.  – Good pictures of cataracts, retinoblastoma and glaucoma
  5. 5.
  6. 6.  Poster of red reflexes and referral pathway from Bart’s and The London.

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