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Home , Mydriasis, Red reflex

AMERICAN ACADEMY OF PEDIATRICS

POLICY STATEMENT Organizational Principles to Guide and Define the Child Health Care System and/or Improve the Health of All Children

Section on

Red Reflex Examination in Infants

ABSTRACT. Red reflex examination is recommended sis of serious ocular conditions, including retinoblas- for all infants. This statement describes the indications toma and congenital , in which early treat- for and the technique to perform this examination, in- ment is essential for future ocular and systemic cluding indications for dilation of the before ex- health, often is not made sufficiently early to mini- amination and indications for referral to an ophthalmol- mize potential consequences of those conditions. ogist. This concern has led to consideration of legislation in several statesa mandating early -dilated red re- INTRODUCTION flex examinations in all neonates or very young in- urrent American Academy of Pediatrics pol- fants. icy recommends examinations for infants Although in infants, pupils are easily dilated using and children at specified intervals during various agents, significant complications have been C sporadically reported with all commercially avail- their development, including an examination to take place sometime during the first 2 years of life, stat- able dilating agents, including sympathomimetic ing: “Vision screening and are vital agents like and agents for the detection of conditions that distort or sup- like hydrochloride and . press the normal visual image, which may lead to These complications include elevated blood pressure 2 3 4 inadequate school performance or, at worst, blind- and heart rate, urticaria, cardiac arrhythmias, and 5,6 ness in children. Retinal abnormalities, , contact dermatitis. However, pupillary dilation , , eye muscle imbalances, has been performed routinely for many years in al- and systemic with ocular manifestations may most all new patients seen in most pediatric ophthal- all be identified by careful examination.”1 mology offices, with no complications seen for years The policy further recommends that an eye evalu- at a time, so this procedure appears to be very safe ation for infants and children from birth to 2 years of when performed in an office setting on infants older age include examination of the following: than 2 weeks. Similarly, premature infants’ pupils are often dilated in the neonatal intensive care unit 1. and orbits; without significant complication, so dilation appears 2. External structures of the ; to be relatively safe even in very young infants. 3. Motility; The purpose of this policy statement is to suggest 4. Eye muscle balance; a guideline based on current knowledge and experi- 5. Pupils; and ence for examination of the eyes of young infants to 6. Red reflex. minimize the risk of delay in diagnosis of serious vision-threatening or life-threatening disorders. The red reflex test is used to screen for abnormal- ities of the back of the eye (posterior segment) and opacities in the visual axis, such as a cataract or RECOMMENDATIONS . An ophthalmoscope held close to the 1. All infants should have an examination of the red examiner’s eye and focused on the pupil is used to reflex of the eyes performed during the first 2 view the eyes from 12 to 18 inches away from the months of life by a pediatrician or other primary subject’s eyes. To be considered normal, the red re- care clinician trained in this examination tech- flex of the 2 eyes should be symmetrical. Dark spots nique. This examination should be performed in a in the red reflex, a blunted red reflex on 1 side, lack darkened room on an infant with his or her eyes of a red reflex, or the presence of a white reflex open, preferably voluntarily, using a direct oph- (retinal reflection) are all indications for referral to an thalmoscope held close to the examiner’s eye and ophthalmologist. approximately an arm’s length from the infant’s Concern has been expressed recently that diagno- eyes.

PEDIATRICS (ISSN 0031 4005). Copyright © 2002 by the American Acad- aPassed in California and under consideration in New York, Massachusetts, emy of Pediatrics. South Carolina, Florida, and New Jersey (at the time of publication).

980 PEDIATRICS Vol. 109Downloaded No. 5 May from 2002www.aappublications.org/news by guest on September 30, 2021 2. The result of a red reflex examination is to be Howard L. Freedman, MD rated as negative or normal when the reflections Harold P. Koller, MD of the 2 eyes are equivalent in color, intensity, and Section on Ophthalmology, clarity and there are no opacities or white spots 2001–2002 (leukokoria) within the area of either or both red Gary T. Denslow, MD, MPH, reflexes. Chairperson 3. A positive or abnormal result of a red reflex ex- Steven J. Lichtenstein, MD, amination (inequality in color, intensity or clarity Chairperson-Elect of the reflection, or the presence of opacities or Jay Bernstein, MD white spots) should be followed, in a timely fash- Edward G. Buckley, MD ion, by 1 of 2 actions: George S. Ellis, Jr, MD Gregg T. Lueder, MD a. A red reflex examination preceded by pupil James B. Ruben, MD dilation with Յ1% tropicamide or a Յ1% tropi- camide/2.5% phenylephrine mixture or a 0.25% Consultant cyclopentolate/2.5% phenylephrine (eyedrop or Michael Redmond, MD spray), administered to each eye approxi- Staff mately 15 minutes before this examination. Stephanie M. Mucha, MPH b. Examination by an ophthalmologist experi- enced in the examination and treatment of the *Lead author eyes of young infants, including ocular examination, using indirect after pupil dilation. 4. Infants in high-risk categories, including relatives REFERENCES of patients with retinoblastoma, congenital cata- 1. American Academy of Pediatrics, Committee on Practice and Ambula- ract, congenital retinal dysplasia, and other con- tory and Section on Ophthalmology. Eye examination and genital retinal and lenticular disorders should ini- vision screening in infants, children, and young adults. Pediatrics. 1996; 98:153–157 tially have a dilated red reflex examination or 2. Ogut MS, Bozkurt N, Ozek E, Birgen H, Kazokoglu H, Ogut M. Effects examination by an ophthalmologist experienced and side effects of mydriatic eyedrops in neonates. Eur J Ophthalmol. in the examination and treatment of the eyes of 1996;6:192–196 young infants, as described previously (3b). 3. Fraunfelder FT. Pupil dilation using phenylephrine alone or in combi- nation with tropicamide. Ophthalmology. 1999;106:4 5. Infants with a history of leukokoria (a white pu- 4. Gaynes BI. Monitoring safety; cardiac events in routine mydriasis. pillary reflex) in 1 or both eyes noted by parents Optom Vis Sci. 1998;75:245–246 or other observers or on any physical examina- 5. Resano A, Esteve C, Fernandex Benitez M. Allergic contact blepharo- tion, and those with absence of a red reflex should due to phenylephrine eye drops. J Investig Allergol Clin have an examination by an ophthalmologist expe- Immunol. 1999;9:55–57 6. Boukhman MP, Maibach HI. Allergic contact dermatitis from tropicam- rienced in the examination and treatment of the ide ophthalmic solution. Contact Dermatitis. 1999;41:47–48 eyes of young infants, as described previously (3b).

Red Reflex Subcommittee All policy statements from the American Academy of *Walter M. Fierson, MD, Chairperson Pediatrics automatically expire 5 years after publication unless Allan M. Eisenbaum, MD reaffirmed, revised, or retired at or before that time.

Downloaded from www.aappublications.org/news by AMERICANguest on September ACADEMY 30, 2021 OF PEDIATRICS 981 Red Reflex Examination in Infants Section on Ophthalmology Pediatrics 2002;109;980 DOI: 10.1542/peds.109.5.980

Updated Information & including high resolution figures, can be found at: Services http://pediatrics.aappublications.org/content/109/5/980 References This article cites 6 articles, 1 of which you can access for free at: http://pediatrics.aappublications.org/content/109/5/980#BIBL Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Fetus/Newborn Infant http://www.aappublications.org/cgi/collection/fetus:newborn_infant_ sub Ophthalmology http://www.aappublications.org/cgi/collection/ophthalmology_sub Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.aappublications.org/site/misc/Permissions.xhtml Reprints Information about ordering reprints can be found online: http://www.aappublications.org/site/misc/reprints.xhtml

Downloaded from www.aappublications.org/news by guest on September 30, 2021 Red Reflex Examination in Infants Section on Ophthalmology Pediatrics 2002;109;980 DOI: 10.1542/peds.109.5.980

The online version of this article, along with updated information and services, is located on the World Wide Web at: http://pediatrics.aappublications.org/content/109/5/980

Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. Pediatrics is owned, published, and trademarked by the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2002 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

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