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Red Eye and White Eye

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The most easily recognised sign of retinoblastoma is an abnormal appearance of the pupil, which reflects light as a white reflex, like a cat's eye at night. "Leukocoria" is usually only visible in dim light, or in photographs where a flash has been used.

Flash photography can cause the eye to appear red.  Although some people prefer to take photographs with a camera that has “red eye reduction”, checking for a red eye in photography is actually an important way to determine if the eye is healthy. In dim light, the pupil expands to allow more light through for clearer vision.  When you take a photograph with a flash, the pupil does not have time to contract, allowing the camera to pick up a red reflection from retinal pigment epithelium and vascular layers supporting the retina.  This red reflex is more pronounced in light coloured eyes.

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Most modern cameras have feature called red eye reduction, which makes the flash bulb light up twice, milliseconds apart.  The pupil contracts following the first flash, and the actual photograph is taken with the second flash, significantly reducing the appearance of red eye. However, taking flash photographs without using red eye reduction is very important.   If the red eye glow is naturally absent in a photograph, it could indicate a serious eye problem, such as a cataract or retinoblastoma eye cancer. Bear in mind that children with darker coloured eyes are likely to have a less pronounced red eye reflex.  Taking flash photographs without red-eye reduction will also help to check a child’s eyes for the typical white “cat’s-eye reflex” symptom of retinoblastoma.

When we take a photograph, we usually see a tiny white dot in the middle of the pupil.  This occurs because the retina, at the point of the optic disc, contains no rod or cone cells, and therefore cannot process light.  So the light is reflected back as a perfectly normal white dot.  When a flash hits the optic disc head on, this dot will be more pronounced. Cats, and many other nocturnal animals, have a special reflective layer on the retina called the tapetum lucidum.  This acts as a mirror, reflecting the light back outside the eye, so that it can be reabsorbed by the cone cells of the retina, creating clearer night vision.   This is why a cat’s pupil looks white when it is caught in bright light.  When a retinoblastoma tumour develops, it acts like the cat’s tapetum lucidum. Light is reflected off the white surface of the tumour, giving the appearence of a white glow in the pupil.  Hence the term “cat’s-eye reflex”. The medical term for this reflex in humans is Leukocoria.  Leukocoria is not necessarily a sign of retinoblastoma.  It is also a symptom of several other eye conditions such as Coat's Disease, or the result of a normal optic nerve reflex. A harmless reflex called pseudo-leukocoria can be captured in flash photography.  This occurs when the child's eye is turned 15 degrees towards the nose, and the flash light hits the optic disc directly.  However, this can only be confirmed with a thorough eye examination by an experienced ophthalmologist.

Can you tell which of the four children below has retinoblastoma?  Move your mouse over the image to find out.

As you can see from the two pictures on the right, photographs of a child who has retinoblastoma do not necessarily catch the leukocoria every time.   This depends on the amount of ambient lighting, the angle from which the photograph was taken, and the position of tumour(s) within the eye. Similarly, if a child has tumours in both eyes, a single photo may catch leukocoria in only one eye. You can see this in the following three photos of the same child, who has bilateral retinoblastoma.

Retinoblastoma specialists recommended that a child's picture be taken once a month in a dimly lit room, without the use of red-eye reduction, for the purpose of checking for a normal red-eye reflex in children under six years of age. Technique: Turn the lights down so that your camera uses the auto-flash.  Make sure the red-eye reduction setting Is turned off (refer to your camera’s instruction manual if you are not sure how to do this). Position yourself close enough to your child that the frame includes the child's entire head, but not so close that the child is focusing on the camera.  You may consider using a zoom feature to achieve this. Take a series of photographs of the child from different angles, so that the child is not looking directly at the camera.  If this is difficult, consider asking another person to stand behind you, holding a favourite toy or treat for the child to focus on.  Check each photograph carefully for any abnormality such as a white reflex, absent red reflex, or reflexes that do not look the same in both eyes..

If you see white reflex in a photograph of your child, compare it to other photos in the same set, and use the technique described above to check for normal red reflex.  Look at previous photos of your child too.  If the reflex appears in a single picture, or in several pictures taken from the same position when the child is looking directly at the camera, while all other photos show normal red reflex, the reflex is likely to be the result of the angle of the flash light.

If you ever see a white reflex or unequal red reflex in your child's photographs, like the photos on this page, It is essential that both eyes be thoroughly examined by a paediatric ophthalmologist (a children's eye doctor) in a darkened room, as soon as possible.  This could save your child's life and vision.

Ensure your child's eyes are examined with an ophthalmoscope in a darkened room at every well child visit. This simply involves shining the ophthalmoscope in the child's eyes. If a white reflection is seen in the pupil of the eye, something that does not belong in the eye is reflecting back light.

Retinoblastoma should be considered the most likely diagnosis in young children, and eyes should be examined by a specialist as a matter of urgency. Retinoblastoma is potentially fatal.  However, it is also entirely treatable.  Children do not die from primary tumours in the eye, but from cancer which has spread beyond the eye due to late diagnosis.  Correct monitoring at regular paediatric exams, and prompt investigation of any leukocoria should ensure that retinoblastoma never remains undetected.

Please print our poster which explains about photographing retinoblastoma, and the importance of checking a child's eyes, and share this vital information with your friends and family.

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