Leukocoria Diagnosis and Referral

Introduction to Leukocoria

A white pupillary reflex indicates interference with the normal red reflex pathway, suggesting abnormality anywhere from the cornea through the retina, according to the American Academy of Family Physicians 1
The white reflex specifically indicates possible retinoblastoma when detected on red reflex examination, as stated by the American Academy of Family Physicians 1
Media opacities, including lens abnormalities or vitreous pathology, can block or diminish the normal red reflex, as noted by the American Academy of Ophthalmology 2

Perform red reflex testing using direct ophthalmoscope in a darkened room from 12-18 inches distance, viewing each eye separately, as recommended by the American Academy of Family Physicians 1
Assess for asymmetry using the Brückner test (simultaneous binocular red reflex) from 18-30 inches, as suggested by the American Academy of Ophthalmology 2 and the American Academy of Ophthalmology 3
Document whether the reflex is white, absent, has dark spots, or shows opacities, as advised by the American Academy of Family Physicians 1
Examine both eyes separately, as ocular pathology may be asymmetric, according to the Journal for ImmunoTherapy of Cancer 4

Assess pupil size, shape, symmetry, and light reactivity, as recommended by the American Academy of Ophthalmology 2
Perform swinging-light test to detect relative afferent pupillary defect, which may indicate optic nerve or extensive retinal disease, as suggested by the American Academy of Ophthalmology 2 and the Journal for ImmunoTherapy of Cancer is not preferred over American Academy of Ophthalmology, however Praxis Medical Insights: Practical Summaries of Clinical Guidelines 5 is not the best source, American Academy of Ophthalmology is preferred
External inspection for orbital abnormalities, proptosis, or eyelid changes, as noted by the American Academy of Ophthalmology 2

All cases of leukocoria require immediate evaluation by a pediatric ophthalmologist experienced in examining children, as stated by the American Academy of Family Physicians 1 and the American Academy of Ophthalmology 2
A transient opacity from mucus in the tear film that completely disappears with blinking is the only exception that does not require referral, according to the American Academy of Ophthalmology 2
Avoid starting corticosteroid treatment before ophthalmologic examination, as this may worsen infectious conditions or mask accurate diagnosis, as advised by the Journal for ImmunoTherapy of Cancer 4