By Kate Marino 

Snapping photos with smartphones has become second nature – but the quick act can provide more than family memories. 

You’ve likely noticed “red eyes” in photos, caused by a reflection of light from the camera flash off a person’s – or even the family pet’s – eyes. This happens regularly and doesn’t cause most people to think twice. A white reflection from the eye, however, can be a sign that something isn’t quite right. 

The white reflection in photographs is called photoleukocoria and it can be a sign of other eye conditions, according to Evan Silverstein, M.D., an ophthalmologist at Children’s Hospital of Richmond at VCU and associate professor in the Department of Ophthalmology at Virginia Commonwealth University School of Medicine. 

Silverstein authored a case study, “Smartphone-Detected Physiologic Photoleukocoria with Visible Optic Nerve Details,” about this matter, along with Elizabeth Ransone, MS, a medical student from Virginia Commonwealth University’s School of Medicine, and Carolyn May, M.D., a resident in the VCU Department of Ophthalmology. It was published in the March 2025 Pediatrics.  

Silverstein spoke with VCU Health News about the study and what’s important for parents to know if they see abnormal reflections in their children’s eyes.   

What is photoleukocoria? How is it different than leukocoria?  

Leukocoria is an abnormal white or gray reflection from the eye’s pupil with direct illumination. It is typically first discovered by a pediatrician or family doctor. Photoleukocoria refers to leukocoria detected in photographs taken with a flash. 

What eye conditions can leukocoria signal? 

Leukocoria can be a sign of cataracts, congenital malformations, retinal detachments, vascular and inflammatory diseases, or retinoblastoma, a form of eye cancer. It can also be a normal finding, as in these two children. 

How do you determine if leukocoria is a sign of a more serious eye condition?  

The pediatrician will first examine the eye with a direct ophthalmoscope. That’s the tool used to shine light into the eye, providing a good light reflex.  

If they notice anything that may signal a problem, they’ll make a referral to a pediatric ophthalmologist so we can conduct a more thorough dilated exam, make a specific diagnosis and develop a treatment plan if needed. Most commonly, the cause is cataracts, which is treatable by surgically removing the affected, blurred lens. The second most common cause is retinoblastoma. In this case, we would collaborate with our oncology team for the best course of treatment.  

Is leukocoria always a sign of something serious? 

No, leukocoria is not always related to a serious eye condition and I really want to stress this point. For example, both children we examined in for our case study had normal results with no signs of cataracts, retinoblastoma, or other conditions. 

Speaking of your case study, what did it entail?  

We studied the presentation of leukocoria in two pediatric patients – a 13-month-old girl and a 3-year-old boy – whose families noticed unusual reflections coming from their children’s eyes in photographs. Their pediatricians referred them to the pediatric ophthalmology department at CHoR.  

Both photos revealed one eye with an abnormal white reflex and the other eye with a normal red reflex. We began by zooming in on the photos to view clear details of the optic nerve, which is responsible for transmitting signals from the retina to the brain to process what the eye sees. We then conducted a standard ophthalmic examination and a dilated fundus exam. The fundus is the inside surface of the back of the eye and includes key parts of the eye that make vision possible, including the retina, macula, fovea and optic disc. The dilated examination was normal and did not show any worrisome findings.  

The photoluekocoria in these children was a normal finding — it was just picking up the optic nerve based on the alignment of the eye. The eye with the abnormal light reflex was turned in slightly towards the nose, which aligned the optic nerve with the pupil and the camera.  

What should parents do if they notice a white or gray reflection in eyes on photos? 

As smartphone usage increases, families may see more cases of photoleukocoria noted in home photography. Because leukocoria is the most frequent first sign of retinoblastoma, it should be taken seriously. I urge families to check in with their pediatricians right away. They can then make a referral to a pediatric ophthalmologist to perform a full dilated examination. We’ll be able to rule out any worrisome causes of the leukocoria. In the event that we do find a sign of ocular disease, we can develop and begin a treatment plan to address it. 

A version of this story was published by Children’s Hospital of Richmond at VCU

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