An examination of the red reflex of the eyes of all neonates, infants and children should occur prior to discharge from the neonatal nursery and during all subsequent routine health visits, according to a newly updated policy statement published in the December issue of Pediatrics, the journal of the American Academy of Pediatrics.  Red reflex testing is vital for early detection of vision- and potentially life-threatening abnormalities such as cataracts, glaucoma, retinoblastoma, retinal abnormalities, systemic diseases with ocular manifestations, and high refractive errors. 

The new protocol includes the following:

The red reflex test uses transmission of light from an ophthalmoscope through all the normally transparent parts of a subject's eye, including the tear film, cornea, aqueous humor, crystalline lens, and vitreous humor. This light reflects off the ocular fundus, is transmitted back through the optical media and through the aperture of the ophthalmoscope, and is imaged in the eye of the examiner. Any factor that impedes or blocks this optical pathway will result in an abnormality of the red reflex.

All infants and children with a positive family history of retinoblastoma; congenital, infantile, or juvenile cataracts; glaucoma; or retinal abnormalities should be referred to an ophthalmologist who is experienced in the examination of children  for a complete eye examination regardless of the status of the red reflex, because these children are at high risk of vision- and potentially life-threatening eye abnormalities. Age of referral to an ophthalmologist depends on specific risk factors (eg, genetic condition, familial eye disease, etc), which can vary in age of presentation. However, it is still valuable for the pediatrician to perform red reflex testing on these patients to help determine if it is necessary to expedite this referral. Whenever an opacity or tumor is suspected, an expedited referral is indicated. Because of the urgent nature of diagnosis, it is prudent for the pediatrician to contact the ophthalmologist personally about the possible diagnosis and express (and document) the urgency of the appointment to the parent. 

TAKE HOME MESSAGE:  The red reflex is an easy exam to learn and can be preformed by most healthcare personal.  It should be preformed on all children and infants as part of the routine exam.  Any uncertainty should be referred promptly to an ophthalmologist.

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