From the Guidelines
The red reflex is not always red and can vary in color depending on a patient's ethnicity and pigmentation, and retinoblastoma can be either unilateral or bilateral, with approximately 60-70% of cases being unilateral and 30-40% being bilateral. In individuals with darker skin tones or more heavily pigmented retinas, the red reflex may appear more orange, yellow, or even pale due to increased melanin in the retinal pigment epithelium, as noted in the pediatric eye evaluations preferred practice pattern 1. This variation is normal and should not be confused with pathology.
When examining the red reflex in children, clinicians should look for symmetry between both eyes rather than focusing solely on the color, as emphasized in the pediatric eye evaluations preferred practice pattern 1 and the amblyopia preferred practice pattern 1. Any white, opaque, or asymmetric reflex (leukocoria) should raise concern for retinoblastoma or other serious ocular conditions and warrants immediate referral to an ophthalmologist. The appearance of the red reflex varies based on retinal pigmentation and, thus, varies by race and ethnicity, as highlighted in the pediatric eye evaluations preferred practice pattern 1.
Key points to consider when evaluating the red reflex include:
- The red reflex can vary in color depending on ethnicity and pigmentation
- Symmetry between both eyes is more important than the color of the reflex
- Any white, opaque, or asymmetric reflex should raise concern for retinoblastoma or other serious ocular conditions
- Retinoblastoma can be either unilateral or bilateral, with approximately 60-70% of cases being unilateral and 30-40% being bilateral, as noted in the recommendations for long-term follow-up of adults with heritable retinoblastoma 1 and 1.
In clinical practice, it is essential to prioritize the detection of retinoblastoma and other serious ocular conditions, and to refer patients with suspicious findings to an ophthalmologist for further evaluation and management, as emphasized in the American Academy of Pediatrics policy statement on eye examinations 1.
From the Research
Red Reflex in Different Ethnicities
- The red reflex test is a simple, non-invasive method that can be performed easily by pediatricians during the clinical examination in neonatal period, infancy, and childhood 2.
- Abnormal reflexes can lead to prompt diagnosis of several ocular disorders, with potentially severe consequences on patient's vision, cognitive function, and even life 2.
- The color of the red reflex can vary in patients with different ethnicities, but there is no specific study mentioned in the provided evidence that discusses this topic in detail.
- However, it is known that the red reflex can appear white or yellow in cases of retinoblastoma or other ocular disorders, which can be detected through the red reflex test 2, 3.
Retinoblastoma Laterality
- Retinoblastoma may be unilateral (60%) or bilateral (40%) 4, 5.
- Bilateral cases are always heritable and present at an earlier age compared to unilateral ones 4, 5.
- Unilateral cases are mostly non-heritable, but 15% can be heritable, and the median age of presentation is 2 years 4.
- The laterality of retinoblastoma is an important factor in determining the treatment and prognosis of the disease 4, 6, 5.