Why would white reflex be seen in a photo but not during an eye exam?

Don’t assume something is wrong just because a white pupil is seen in a photograph, but don’t ignore it either. A white pupil in a photograph is most commonly not a sign of serious eye disease, but should nevertheless not be ignored.

The most common causes of a white pupil in a photograph include reflected light off the optic nerve (which is white) in the back of the eye and photographic angles that cause the light to be reflected in an unusual, asymmetric way between the two eyes. However, a white pupil in a photograph can occasionally be a sign of retinoblastoma, a cataract, or another serious eye disease.

An examination by an ophthalmologist is a reasonable consideration when a white pupil has been detected in a photograph. An eye examination that includes dilation of the pupil is optimal to rule out serious problems. Pediatricians will usually evaluate the red reflex (the reddish-orange light which should reflect back from a healthy eye) using a light source that projects light into the eye while the pediatrician evaluates the quality and color of the light that is reflected back through the pupils. This examination technique will readily detect serious eye abnormalities that cause the pupil to appear white when the pupil is viewed from all directions. Unfortunately, this screening test may not detect smaller lesions within the eye and may not detect lesions that are not directly in line with the direction that the pediatrician is projecting the light into the eye. In these cases, the pupillary red reflex may look normal when viewed from some directions and appear white when viewed from other directions. For this reason, when a pediatrician is suspicious that a serious eye disease may be present, a referral to an ophthalmologist is important even if this screening test appears normal.