⚠️ Leukocoria is a red-flag sign in children. A white pupillary reflex may indicate life-threatening pathology such as retinoblastoma. Any suspected leukocoria warrants urgent same-day ophthalmology referral.

📖 Definition

Leukocoria (“white pupil”) refers to a white, cream, or yellow reflex seen through the pupil instead of the normal red reflex.
It is a clinical sign, not a diagnosis.
Often first noticed in flash photography (“cat’s eye reflex”).

🧬 Pathophysiology

Normal red reflex occurs when light reflects from the vascular retina and choroid.
Leukocoria occurs when light is reflected from abnormal intraocular tissue or opacity.
Mechanisms include:

🔴 Intraocular mass (e.g. tumour)
💧 Media opacity (cornea, lens, vitreous)
🧫 Retinal pathology with abnormal reflection

🚨 Differential Diagnosis of Leukocoria (White Pupillary Reflex)

Cause	Typical Age	Pathology	Key Clues	Urgency
Retinoblastoma 🔴	<5 years	Malignant retinal tumour	Strabismus, calcification on imaging, family history	🚨 Emergency
Congenital Cataract 💎	Neonate / infancy	Lens opacity	Absent red reflex, TORCH/metabolic association	Urgent
Persistent Fetal Vasculature (PHPV) 🧬	Infancy	Failure of regression of hyaloid system	Unilateral, microphthalmia	Urgent
Retinopathy of Prematurity (ROP) 👶	Premature infants	Abnormal retinal vascular proliferation ± detachment	History of prematurity, oxygen therapy	Urgent
Coats Disease 🟡	Childhood (boys)	Retinal telangiectasia with lipid exudation	Unilateral, exudative detachment	Urgent
Retinal Detachment 🌊	Any age	Separation of neurosensory retina	Reduced vision, trauma history	Urgent
Ocular Toxocariasis 🪱	Childhood	Granulomatous inflammation	Exposure to dogs, eosinophilia	Urgent
Vitreous Haemorrhage 🩸	Any age	Blood within vitreous cavity	Trauma, diabetes, sickle cell disease	Urgent
Coloboma 🌙	Congenital	Failure of embryonic fissure closure	Keyhole-shaped pupil ± systemic anomalies	Routine / Urgent (case dependent)
Severe Uveitis 🔥	Any age	Intraocular inflammation	Photophobia, painful red eye	Urgent

🔍 Clinical Assessment

History: age of onset, prematurity, family history, systemic features.
Examination: red reflex test, visual behaviour, strabismus.
Investigations: urgent dilated fundoscopy, ocular ultrasound, MRI orbit if tumour suspected.

🏥 Management Principles (UK)

Leukocoria in a child = same-day urgent referral.
Exclude retinoblastoma first.
Do not delay referral for community investigations.

📊 Summary Table

Cause	Typical Age	Key Feature	Urgency
Retinoblastoma	<5 years	Calcified retinal tumour	🚨 Emergency
Congenital cataract	Neonate	Lens opacity	Urgent
ROP	Premature infant	Retinal detachment	Urgent
Coats disease	Childhood	Unilateral exudation	Urgent
Persistent fetal vasculature	Infancy	Microphthalmia ± cataract	Urgent

🔑 Bottom Line

Leukocoria is a medical emergency until proven otherwise. The priority is to exclude retinoblastoma. Early detection improves survival and visual outcomes.

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Leukocoria (White Pupillary Reflex) 👁️