Vision Screening Online Training Program - Retinal Reflex (Red Reflex)

Vision Screening Online Training Program

Module 5: Retinal Reflex (Red Reflex) and Pupillary Light Response
(C&TC: Often performed by the health care provider)

For community settings the following two procedures can be performed by health care personnel. Health care personnel includes:

  • Primary care clinicians (physicians, nurse practitioners, physician assistants).
  • Nurses, including public health and school nurses, after completion of MDH or equivalent training.
  • Ophthalmic or optometric staff.
  • Other trained medical personnel.

These procedures are not included in general mass screenings, but can be performed as an additional screening for children who do not pass any component of the vision screening procedures. These procedures should be performed routinely by nurses approved to perform C&TC screening exams.

The two procedures that are a part of this module use light sources to check the child's pupillary health. The retinal reflex uses an ophthalmoscope and the pupillary light response uses a penlight. These two procedures have separate purposes however. The retinal reflex is primarily checking for disease whereas the pupillary light reflex is screening for muscle or physiological abnormalities. Carry out these procedures together so that the child will be exposed to direct light in two consecutive tests rather than spaced out through the screening process. Since a child's eyes are slightly affected by light shined directly in their eyes, their eyes will need a few seconds to adjust after these tests.

Retinal Red Reflex

The retinal reflex test is normally done by a child's health provider because an ophthalmoscope is needed Ophthalmoscope Directions

This is the best screening test possible when looking for a leukocoria or retinoblastoma. From the reflex given by the eye, obstructions inside the eye may be detected. It is important that the lights in the room are dimmed so that deviations in the eye may be seen clearly.

Post newborn through 20 years.

To check for abnormalities that block light flow within the eye by observing the reflected light from the retina, which is red in color.

Check for symmetrical and equal intensity reflexes from the retina with an ophthalmoscope light.


Screener qualifications
This test should be performed only by trained health care personnel, such as primary care clinicians, ophthalmic or optometric staff, or nurses.

Lower light level/darkened room with a minimum number of light sources (windows, overhead lights, etc.).


  1. With the ophthalmoscope positioned in front of your eye, focus the light on the palm of your hand, which should be positioned about 18 inches away from the child's eyes.
  2. Make sure the lens is focused so you can see the lines of your palm clearly.
  3. Once the ophthalmoscope is properly focused, project the light into both eyes of the child at the same time.
  4. Looking through the ophthalmoscope, you should observe a glow in both pupils simultaneously.
    • Note whether this glow is the same intensity in both eyes or not.

    Vision screener using an ophthalmoscope to observe a glow in both pupils of child.

    Close-up of a vision screener using an ophthalmoscope to observe a glow in both pupils of a child.

Retinal reflexes are equal in symmetry of pattern, color and intensity.

A reflex that is asymmetric, (one eye with a brighter reflex than the other) has dark spots or has obviously decreased reflex. In the presence of a leukocoria, one or both pupils may appear white instead of the normal red color expected and immediate referral is required.

For more information, refer to the American Academy of Pediatrics Policy Statement Red Reflex Examination in Neonates, Infants, and Children, December 2008.

Joey Bergsma: A child with retinal blastoma. Joey Bergsma, a child with retinal blastoma.
Photo courtesy of Pam Bergsma.


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