PhotoRED: Know the Glow and Check for Normal Fundal Reflex in Children.
Monday April 21, 2014, updated April 10, 2024 | Abby White, WE C Hope CEO
Know the Glow and PhotoRED – if you have concerns, request an eye exam!
Visit our White Eye section for detailed information about this key early sign of childhood eye cancer.
See Red – or Orange, Yellow, White, or Blue!
In dim light, pupils expand to absorb more light for clearer vision. Flash photos capture a distinct colour of pigment epithelium and vascular layers supporting the retina, seen through the expanded pupil. In white people, which glow is usually red or red-orange. It varies with ethnicity, and may appear yellow, orange, or even blue or off-white in dark eyes.
Traditionally called the “red reflex”, this glow is increasingly called the “Fundal (Red) Reflex”. This acknowledges the range of reflex appearances, and supports effective training and inclusive eye exams to diagnose children early.
The ‘red’ reflex is not red in non-white babies. All three sets of eyes above show normal fundal reflex, with no variation in appearance between the two eyes.
Most Common Early Sign of Childhood Eye Cancer
When retinoblastoma prevents the retina from absorbing the light from a camera’s flash, it is reflected back out of the eye, appearing in the photograph as a white glow. This white reflex is the most common early sign of retinoblastoma. The glow may also be seen with the naked eye.
When parents are unaware of white pupil as an early sign of retinoblastoma, they may see the glow in photos for weeks, months, or even several years, before realizing there could be something wrong with their child’s eyes.
Obsession With “Evil” Red Eyes Threatens Children
Eyes are described as “the window to the soul”, and in fiction, eye colour is often used to define personal nature. Characters with red eyes are almost always villains, sinister, dangerous or downright evil.
Think of vampires like Jerry Dandridge in Fright Night and Jane in Twilight, Voldemort in the Harry Potter books, Sauron, the Mûmak, Wormtongue and the black horses of the Ringwraiths in The Lord of the Rings, Grendel from the poem Beowulf, Judge Doom in Who Framed Roger Rabbit, The Grinch in How the Grinch Stole Christmas!, and Emperor Zurg in Toy Story 2.
Consequently, the ability to remove red eye from photographs has become desirable. This is made possible by means of both technologies within the camera, and image-editing software.
This article from The Lancet shows how red-eye and pet-eye correction tools enable unsuspecting parents to remove white reflex from their child’s photos.
This child’s unsuspecting parents used photoshop to edit out the early warning sign of retinoblastoma.
Modern cameras now have a Red Eye Reduction feature that lights up the flash bulb twice, milliseconds apart. Pupils contract in response to the first flash, and the photograph is taken with the second, significantly reducing the appearance of the fundal (red) reflex in the photograph.
However, Red Eye Reduction limits the camera’s ability to detect white pupil, so taking flash photographs without Red Eye Reduction is very important. Seeing clear fundal (red) reflexes in flash photography is very good because each reflex indicates the eye is healthy. If the fundal reflex is naturally absent in a photograph, it could alert you to a serious eye problem requiring urgent medical attention.
Cameras Are Key to Early Diagnosis
While Red Eye Reduction has previously been a facility the user must manually turn on, some cameras are now produced with Red Eye Reduction auto-set to ON. If users do not know the significance of turning this function OFF, the camera will likely not detect the early signs of retinoblastoma. Parents may only see the white pupil with their naked eye in dim light.
Unless the child is a very young infant with a centrally located tumour, cancer is usually only visible with the naked eye when it already fills the eye. At this stage, removing the eye is likely to be the only curative option, and the child’s life may already be at risk.
The retina is not confined to the back of the eye, as is often described. It forms about 72% of the eye’s inner lining, from the optic nerve at the back to the ciliary body surrounding the iris (coloured ring) at the front.
Retinoblastoma forms when errors occur on the RB1 gene during normal cell division as the retina continues to grow from its centre at the back of the eye outwards towards the front of the eye. Tumours can arise in newly formed retinal cells until the eye is fully developed at around age 6-8 years. The older the child is when tumours form, the more peripheral they will be.
Retinoblastoma is usually only visible to the naked eye when it invades retina at the back of the eye or central parts of the eye, either because the baby is very young or because the tumour is already very large.
So cameras play a key role in the early detection of retinoblastoma at home. Parent awareness of white pupil as an early warning sign of serious eye disease is gradually increasing. However, as technology evolves, it becomes ever more important that families also know how to take photographs correctly to check for healthy fundal reflex and the white reflex sign.
PhotoRED to Check for Red Eye Reflex
Retinoblastoma specialists advise parents take photos once a month to check for a normal fundal (red) reflex in children under six years of age. If possible, photos should be taken with a regular camera rather than a smartphone, in a dimly lit room, without red-eye reduction.
The PhotoRED Technique was developed by a doctor experienced in the diagnosis and treatment of children with retinoblastoma. Research using the technique is ongoing to establish the camera’s value as an early detection tool.
The PhotoRED Technique
- Use a regular camera – smartphone flash is unreliable.
- Turn the lights down so that your camera uses the auto-flash.
- Ensure any light sources – such as table lamps – are behind your child so they don’t reflect in the eyes.
- Check your camera’s red-eye reduction setting Is turned OFF (refer to the instruction manual if you are not sure how to do this). The red eye reduction symbol is usually a diagonal line through an eye. Make sure this is NOT showing as the flash setting.
- Position yourself about four metres from your child and use the zoom to capture the child’s entire head.
- Take a series of photographs from different angles – see the examples below. Ask another person to help you by playing with your child while you take the photographs so her eyes don’t follow the camera.
- Check each photograph carefully for abnormalities such as a white reflex, no fundal (red) reflex, or reflexes that do not look the same in both eyes.
If you have any concerns about the photographs and / or the appearance of your child’s eyes, stay calm and follow our Next Steps guide.
All the photos in the above series show healthy red reflex.
Empower Photographers to Save Life and Sight
Up to 90% of children with eye cancer are diagnosed because a parent sees white pupil in photos and raises concerns with a doctor, but lack of awareness often delays this process by months. If the camera’s ability to detect white pupil is hampered by Red Eye Reduction being auto-ON, children may be increasingly diagnosed at a later stage, with less opportunity to save sight and higher threat to life, requiring more intensive treatments.
Please join us now in calling on the photoimaging industry to commit to the following three permanent sustainable actions to aid earlier diagnosis and life and sight saving opportunities for babies and young children:
- In all cameras: red eye reduction set to OFF as standard.
- In camera user manuals: information about the value of fundal (red) eye photography and the potentially serious nature of white eye reflex.
- In red/pet eye correction software and Help guides: white pupil detection that prompts the user to check for repeated white reflex and links to further information.
That’s really different
Is the photo sample of the PhotoRED technique showing a normal eye, or a concerning sign?
Thanks for asking Kristin. All the photos in the red reflex test set show healthy red reflex. We’ve added a note below the image to clarify this.
Been searching around curiously but can a baby monitor also be a sign? Newborn infant eyes aren’t just white with night vision, they literally are glowing white.
Hi MecKenzie. Yes, if you are seeing white in your baby’s eyes. it is very important to have both eyes examined carefully, preferably by an ophthalmologist who is familiar with young children’s eyes. There are many causes of white reflex, and it may not be cancer, but having a prompt eye exam is important. Please let us know how you go!
Thanks for sharing informative article.