Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
2 min synopsisUK scopeSources checked 7 Sept 2026Clinical review pending
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A white pupil requires urgent investigation
Leukocoria can arise from retinoblastoma, cataract or significant retinal disease. A child may appear entirely well and have useful vision from the other eye.
Action: Contact the paediatric ophthalmology service promptly to arrange urgent assessment of an abnormal reflex. New-onset squint with an absent red reflex requires immediate ophthalmology referral under NICE NG127; do not await community imaging or blood tests.
Synopsis
Recognise a white or abnormal pupillary reflex, organise urgent ophthalmic assessment and distinguish the principal childhood causes without delaying exclusion of retinoblastoma.
Leukocoria describes an appearance and does not establish its underlying diagnosis.
Retinoblastoma is a retinal malignancy whose early recognition protects life and vision.
Cataract, persistent fetal vasculature and Coats disease are important alternative explanations.
Key red flags
A white or absent reflex on direct ophthalmoscopy, especially when asymmetric.
Investigation priorities
01
Direct ophthalmoscopy and visual assessmentFirst step
Confirm and describe the presenting abnormality without delaying referral.
Management branches
Initial recognitionEscalate an abnormal pupillary reflex
A child has an abnormal red reflex or a credible persisting white-pupil concern.
Assess visual behaviour and both eyes, documenting the reflex and any new squint.
Contact paediatric ophthalmology urgently and describe the findings directly to support appropriate triage.
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 7 Sept 2026; clinical approval remains outstanding.
NHS England: retinoblastoma service for childrenNational service specification supporting specialist referral without prior community investigations and avoidance of diagnostic intraocular biopsy.
AAPOS: leukocoriaSpecialist society explanation of pupillary appearance and the range of serious ocular causes.