What to do when an infant has an asymmetrical red reflex?

From the Guidelines

When an infant has an asymmetrical red reflex, immediate referral to a pediatric ophthalmologist is essential, as this finding may indicate serious eye conditions such as congenital cataracts, retinoblastoma, or other vision-threatening disorders that require prompt evaluation 1. The red reflex test is a crucial screening tool for detecting abnormalities in the ocular media, external inspection of ocular and periocular structures, pupillary examination, and assessment of fixation and following behavior.

Key Considerations

• Asymmetry in the red reflex can be an indication of a problem, including opacities in the visual axis, abnormalities of the back of the eye, and amblyogenic conditions 1.
• The red reflex test should be performed by directing an ophthalmoscope light into both eyes simultaneously from approximately 18 to 30 inches away, with the lens power set at “0” and adjusted to ensure that the pupillary reflexes are sharply focused 1.
• Any asymmetry in color, brightness, or size of the red reflex is indicative of a problem and warrants referral to an ophthalmologist experienced in examining children 1.

Recommendations

• Referral to a pediatric ophthalmologist is the most appropriate course of action when an infant has an asymmetrical red reflex, as early intervention is critical for conditions like congenital cataracts, which can cause permanent vision impairment if not treated within the first few months of life 1.
• While waiting for the specialist appointment, document the appearance of both eyes and any other associated symptoms the infant may have.
• Parents should be advised not to delay this referral, as prompt evaluation and treatment can significantly improve visual outcomes for affected infants.

From the Research

Asymmetrical Red Reflex in Infants

The nurse practitioner has noted an asymmetrical red reflex in an infant, with a dark red-brown light reflex in the left eye and a slightly brighter, red-orange light reflex in the right eye. This observation is a cause for concern and requires further evaluation.

Possible Causes and Next Steps

• The asymmetrical red reflex can be an indication of several ocular disorders, including cataract, retinoblastoma, and glaucoma 2, 3, 4.
• The American Academy of Pediatrics recommends that all infants should have their red reflex tested as part of their routine well-child assessment 2.
• If the red reflex is abnormal, the nurse practitioner should dilate the pupils and reassess the red reflex to determine if the abnormality is due to a refractive error or another condition 3.
• Referral to an ophthalmologist is necessary if the abnormal red reflex persists after dilation and reassessment, or if other signs of ocular disease are present 3, 4.

Rationale for Next Steps

• Dilating the pupils and reassessing the red reflex can help to determine if the abnormality is due to a refractive error or another condition, and can help to identify other signs of ocular disease 3.
• Referral to an ophthalmologist is necessary to ensure that the infant receives a comprehensive eye examination and any necessary treatment to prevent vision loss or other complications 3, 4.
• Delaying evaluation and treatment can result in poor outcomes, including vision loss and other complications, especially in cases of retinoblastoma and other serious ocular disorders 5, 6.

Recommended Course of Action

• The nurse practitioner should dilate the pupils and reassess the red reflex to determine if the abnormality is due to a refractive error or another condition.
• If the abnormal red reflex persists after dilation and reassessment, or if other signs of ocular disease are present, the infant should be referred to an ophthalmologist for further evaluation and treatment 3, 4.