Basic Eye Examination - Any primary care physician should be able to perform a basic eye

examination, which should be given to all patients as part of a general physical examination. Basic eye
examination:
● History;
● Visual Acuity;
● Eyelids (just a penlight is needed);
● Anterior Segment;
● Pupillary Reflexes;
● Extraocular muscles function: Ocular Alignment/Ocular Motility;
● Direct Ophthalmoscopy: to look at the posterior pole and observe the optic nerve, the retina and its
vessels, and the macula. With the direct ophthalmoscope it is possible to diagnose glaucoma;
● Confrontation Visual Field, which is a basic test of the visual field.

History - At least 50% of a correct diagnosis can be made with a “well-done” medical and ophthalmic
history to assess risk factors for ocular diseases. Symptoms referred by patients are rather typical, and
therefore helpful for the diagnosis.
• Vegetables – broccoli and spinach are the best for the retina.

Family history:
− Glaucoma;
− Age-related macular degeneration (AMD);
− Refractive Errors, Strabismus, Amblyopia;
− Retinal Detachment;
− Ocular Tumors.
These diseases are more common in families à higher risk for the patient when becoming older.

Medical history:
− Age.
− Smoke, Hypertension, Hyperlipidaemia: age and smoke are the major risk factors for AMD;
− Diabetes;
− Carotid Stenosis: the eye is provided with vessels, and in particular it receives its supply from the
internal carotid artery. In some cases, cardiovascular risk factors are also risk factors for
glaucoma;
− Autoimmune Diseases;
− Malignancy;
− Thyroid Diseases.

Ophthalmic history:
− Previous good vision? In both eyes?
− Use of lenses?
− Previous ocular diseases, surgery1, or laser;
− Previous ocular trauma: useful to understand potential consequences on visual function.

Signs and symptoms:

− Burning, stinging, foreign body sensation: burning is referred by patients in case of inflammation
or damage to the anterior segment, e.g. bacterial conjunctivitis, dry eye conjunctivitis, while
stinging and foreign body sensation are typical of more severe cases;
− Itching: found any time there is allergic conjunctivitis;

1
Cataract extraction is a procedure that has been introduced in the 20th century;”retinatio” was performed
before, starting from the Egyptians: It consisted in the use long spike that was inserted inside to eye in order to
push the lens inside the vitreous. In that case, only the patient with ripe cataract were submitted to surgery,
while today microsurgery is performed with positive outcomes without waiting for ripe cataract.
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− Pain: ask the patients if the pain can be translated into burning, stinging, or foreign body sensation,
ask if the pain is superficial or deep inside (and in this case the problem is usually more serious, as
acute neuritis or acute glaucoma). Check also the eye movements and ask the patient if by moving
the eye the pain increases, since in most of the cases this is a sign of retrobulbar neuritis, which in
a young patient can be due to multiple sclerosis.
− Decreased Vision:
1. Deepness;
2. Onset: acute/sudden (hours? days?) or gradual. Acute may suggest pathologies like occlusion
of central retinal artery, optic neuritis and more, while gradual cataract.
3. Monocular/binocular.
4. Distortion (Metamorphopsia): fluid is found under the macula, which in most of the cases is
due to a wet AMD;
5. Double vision (Diplopia): blurred vision can be associated with diplopia. Real diplopia occurs
when both eyes are open. In some cases, patients refer diplopia as symptom, if double vision
occurs when one eye is closed, it cannot be defined as real diplopia, but it is rather blurred
vision, for example, due to astigmatism, and it is a refractive error. Instead, if diplopia occurs
only when both eyes are open, this is due to lack of coordination of the eyes, and therefore
due to strabismus, which may be paralytic strabismus caused by vascular defects located at
the level of the midbrain, where the nucleus of the nerves providing the extraocular muscles
is.

A minimal eye examination should be performed by the general practitioner to examine a patient with
visual problems or with pathologies linked to eyeball or vision. A basic eye examination includes:
● Visual acuity
● Pupillary reflex
● Eye movements
● Direct ophthalmoscopy to look at the posterior pole and observe the optic nerve, the retina and its
vessels, and the macula.
● Direct examination of the lids and anterior segment
● Gross exam of the visual field, called Confrontation or Donders' test

Visual Acuity (VA) - is fundamental in the analysis of visual function. It should be tested whenever
the patient complains of decreased vision, which is the most common symptom referred by the
patients, even though frequently visual acuity is unaltered and only the subjective perception is
decreased.

Visual Acuity Test - is a measurement of the smallest object a person can identify at a given distance
from the eye. The object has to be easily recognized (letter, numbers or drawings can be used). It
depends on the smallest element that enables the letter/number/drawing to be identified at a given
distance.
• Letters are different and some may be more easily recognized than others (e.g. L is easier to
recognize in compare to S).
• Another factor that has to be considered is patient cooperation.
• If a child is admitted to VA test, the examiner has to make sure that the child knows how to read,
otherwise a different (non-letter) type of chart has to be used.
• Cheating has to be considered for driving license and also with reimbursements, for example with
insurances, where the patient may fake a clinical picture worse than the actual one. In this case an
ophthalmologist has several instruments to examine the eye and detect the “real” problem, but for
a general practitioner it is harder.

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The test: Snellen charts -Visual acuity is
tested with the Snellen charts used
worldwide, but with local differences (due to
different alphabet, phonetics, numbers, etc.).
• Pointing at letters improves recognition.
• In Italy VA is the last line seen for at
least half of the letters at a distance of,

usually, 5 meters.
• In the US, Snellen fraction is used Figure SEQ Figure \* ARABIC 1
instead: VA= (Testing distance) /
(distance at which the smallest letter
identified subtends a normal VA) e.g. in a
3m chart a patient with normal vision is
able to read the 10th line when at 3m
distance; the same person when at 30m is
able to read the 1st line.
• Some charts include both 10ths and Snellen ratios.
• If the patient cannot see any letter, the distance of the patient from the chart is reduced. If he still
cannot recognize any letter, he is asked to count fingers, if he cannot do that, he required to
recognize hand motion and then, light.

The test: ETDRS charts - (Early Treatment Diabetic Retinopathy Study)

charts were developed to standardize VA test for the treatment of early
diabetic retinopathy. It is characterized by geometric progression in size
of lines, letters of same difficulty on the same line and lines with same
number of letters. The examiner does not point any letter, the patient
reads all letter in sequence until the last one he can read and the
examiner counts the number of correct letters read.

VA in adults - 10/10 is the apex of the Gaussian in VA distribution in

the population. If monocular VA is 10/10 (or 1) usually binocular VA is above 10.
Reduced VA is the best single criterion for referring a patient to an ophthalmologist. Sometimes
patients may be completely unaware of having VA loss if only one eye is involved and the other eye is
normal, due to normal cortical perception of vision (happens to old patients with cataract).
• A general practitioner should prescribe asymptomatic patients eye examination at 40 years of age
if not previously done, every 2 to 4 years for patients between 40 and 60 years of age and every
year for patients over 60.
• The GP also should refer to an ophthalmologist patient with OUVA2 < 5/10 or at
least 2 lines of difference in VA between the 2 eyes.

VA in children - All children should be submitted to a VA testing with an

ophthalmologist as soon as possible around the age of 3 due to the importance of
early amblyopia 3detection (family history is helpful).
VA testing in children depends on age. In a newborn a simple test could be using an
object (e.g. a pen) and moving it, observing the eyes of the child. With 3 years old
children simple Snellen charts can be used. The “tumbling E” chart is the most
adequate.
Figure SEQ
Figure \* ARABIC


2
Binocular vision
3
Reduced VA, that can be a consequence of child disease; e.g. strabismus, congenital cataract, astigmatism, refractive
errors, hyperopic anisometropia (hyperopia different in the 2 eyes; serious and difficult to recognize)
3

Fovea - Visual Acuity depends on the sharpness of the image on the Fovea and the sensitivity of the
interpretative faculty of the Brain. The image of the object is projected on the retina, especially the
fovea (where the retina is thinner, and there’s the highest cone concentration); this image is converted
into action potential, that travels through the visual pathways to the visual cortex, where the brain
analyzes and perceives vision of the observed object. Visual acuity is a measure of the spatial
resolution of the visual processing system, i.e. the smallest space between 2 points recognizable by the
visual system. The spatial resolution is at maximum in the fovea, so the VA test tests the fovea.
The fovea is the most important part of the retina, but it constitutes only a few millimeters’ area in the
macula. The fovea contains only tightly packed cones. Light gets directly on the cone, a signal is
generated and passes to its corresponding bipolar cell, to its ganglion cells and, through the visual
pathway is projected to the visual cortex. The fovea projects to over 50% of the visual cortex. Only
the fovea is able to reach 10 degrees of vision. The rest of the eye contains only few bigger cones and
rods, that however are not able to see as clearly as cones. The diseases affecting the fovea or the
macula have dramatic effects on the subject’s vision capabilities and its quality of life.

Visual Acuity: Driving License in Italy - The visual acuity needed for a driving license in Italy is of
at least 10/10 totally (at least 8+2); this is not so high, and most individuals fulfill this requirement.
The acuity must be at least 2/10 in the worse eye (8/10 in the other) with or
without glasses. In case of glasses, the difference between the two lenses
should be ≤ 3D (diopters). Otherwise, there could be difficulties in merging
the two images formed from the lenses at the level of the cortex, resulting in
double vision.

Eyelids and Anterior Segment

The anterior segment of the eye is easily observable with a penlight or a
Figure 1: Cornea, Sclera,
smartphone flashlight. Firstly, the surface of this segment is observed,
Conjunctiva and Limbus of the Eye
starting from the eyelids. Characteristics that should be noted are the

color of the skin, redness, swelling of the upper or lower eyelids, and
the position (ptosis, dermatochalasis etc.). Ptosis and dermatochalasis rarely occur in younger patients.
The cornea is a good anatomical reference point to compare the position of the eyelid margin. The
inferior eyelid passes at the level of the limbus, which is a tissue between the cornea and the sclera
(figure 1). The inferior eyelid is at the level of the inferior limbus. The superior eyelid covers the
superior limbus by 1-2mm, so less than 2mm. The sclera is the white of the anterior segment of the
eyeball and is covered by the conjunctiva.4

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• In figure 2, the superior eyelid is inflamed, and there is localized swelling
possibly due to a chalazion or even a stye.

• In figure 3, the right eye is normal while the left one is not. In the left
eye there is swelling in both the inferior and superior eyelids (edema). Figure 2: Chalazion or a Stye
The vessels that reach the anterior segment also reach the eyelids, so the
inflammation of the anterior segment, such as in conjunctivitis, usually
involves also the eyelids. The eyelids are composed of loose connective
tissue, so they swell easily and there is some exudation. Thus, if there is a
slight swelling of the eyelids, it is usually not a direct inflammation.

Figure 3: Conjunctivitis of Left

Eye
3
Eye
• In figure 4, the cornea is abnormal with a whitish ring around it.
Normally, the cornea is transparent. Here, the cornea is not completely transparent due to the
presence of lipid depositions forming a ring around the cornea. This deposition,
called gerontoxon, is formed close to the limbus with an empty space between
the limbus and the deposition. It is a typical sign of physiological process of
aging. However, the cornea is not damaged, and vision is not impaired.
Specifically, the area of the cornea responsible for vision is only the central one,
that corresponds to the pupil in which light enters to reach the posterior segment,
retina and the fovea. This is the corneal part that must be transparent with a Figure 4: Lipid Deposition
regular curvature to allow normal vision. The white of the eye is given by the around the Cornea
underlying sclera which is covered by a wet, thin layer of mucosa called the
conjunctiva. Being a mucosa, the conjunctiva contains vessels, so it is not entirely correct to call
the sclera as “white of the eye”.

• In figure 5, there is a fold of the skin and ptosis of the upper eyelid; the upper eyelids
cover more than 2mm of the upper cornea. This is due to aging. The patient does not
have any visual problems unless the eyelids droop until they cover the central part of
the cornea, the visual axis.
Figure 5: Drooping and Ptosis
of the Upper Eyelids

• In figure 6, the eye is red but there is no swelling of the conjunctiva. At the level of the
conjunctiva, there is an inflammatory reaction with neutrophilic infiltration against a
foreign body which penetrated the eye. The cornea is completely avascular since it
must be completely transparent, so when inflamed, there is hyperemia and
vasodilation around the cornea.

Figure 6: Foreign Body- Induced

Inflammation
• In figure 7, there is no hyperemia around the cornea and just something on the
cornea. This is called a pterygium, tissue coming from the conjunctiva, growing
on the surface of the cornea. It is often caused by chronic exposure to UV light
and wind, so it is typically found in fishermen, countrymen or farmers. This is
not a cancer, but it has a high rate of recurrence after removal. A growing
pterygium has to be removed before it reaches the visual axis (center of the Figure 7: Pterygium
cornea), because the cornea under the pterygium is not any longer transparent
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 once the pterygium is removed, thus impairing vision. In some cases, the pterygium is stable and
does not grow.

• In figure 8, there is no inflammation, but the transparency of the cornea is altered due
to a whitish scar formation, called leukoma, which makes the iris behind the cornea
unclear. If the scar affects the visual axis, visual acuity is reduced. Scarring could be
due to a foreign body, an infiltration, or an ulcer of the cornea.

Figure 8: Corneal Scar

• In figure 9, the cornea is not transparent, and there is a green-yellow area on its
surface. The corneal epithelium has been lost for various reasons, a trauma being the
most frequent one. It is not always easy to detect a corneal lesion especially if the
lesion is small. However, the lesion can be pointed out using a piece of sterile paper
containing a sodium fluorescein dye, which is applied on the surface of the eye where
it coats the tear film. The fluorescein highlights any area of epithelial damage and
corneal loss. Symptoms of corneal damage are pain and very annoying foreign body
sensation, as if there was sand in the eye. This is because epithelial loss exposes the
nerve terminations, which are located just under the epithelium.
Figure 9: Fluorescein

• The eye is examined layer by layer: eyelid, cornea, epithelium, stroma, anterior
chamber, iris, lens, which is the furthest level of observation possible with a penlight. Using a
mydriatic drop, the pupils can be dilated to observe the lens at the posterior pole.
Here in figure 10, the eyelids are normal, and the sclera is white, so there is no
inflammation of the conjunctiva. The cornea is transparent with no lesion. The
iris is normal; the pupil is dilated due to the drops. If a penlight is shined through
the pupil, the posterior pole is lit and the red reflex of the pupil can be seen.
However, if the penlight is not directed towards the pupil, the pupil will normally
appear black. Here, there is a grey reflex inside the pupil. This is due to the
presence of an opaque lens, which can be defined as cataract. Figure 10: Cataract

Pupillary Reflexes - can be induced with an illumination from a penlight or

flashlight from a smartphone. The purpose is to check whether the reaction to
light is normal and the same in both eyes: whether the pupils have the same
size and shape. Normally, there is a direct and consensual pupillary reaction
to light, as depicted in figure 11. Recall that there is decussation at the level
of the optic chiasm, as seen in figure 12. The afferent part of this arc is
formed by the fibers coming from the retina. At the level of the midbrain, Figure 11: Direct and Consensual
there are collateral fibers reaching the pretectal area and the Edinger- Pupillary Reflexes
Westphal nucleus, giving a free synaptic parasympathetic fiber inside the
third cranial nerve (oculomotor), reaching the ciliary ganglion which reaches
the pupillary sphincter. Thus, when light is shined into one pupil, there is
both a direct and a consensual reflex of light since the stimulation of one side
reaches also the other side. Can give important information about
diseases of the anterior eye segment, such as anterior uveitis, which is the
inflammation in the anterior part of the uvea, iris and ciliary body.

Figure 12: Pupillary Light

Reflex Pathway

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• Figure 13a depicts pupillary miosis (small pupil) which is
typical of anterior uveitis; the eyes are red, no exudation and
no swelling of the conjunctiva (excluding conjunctivitis), pain
inside the eye, no foreign body sensation, no burning, acutely
reduced vision.
• Inside the anterior chamber, there are leukocytes and proteins, Figure 13a: Miosis in Figure 13b: Adhesion in
which lead to the formation of adhesions between the pupil and anterior uveitis anterior uveitis
the lens. Thus, when examining an eye with a history of uveitis,
the shape of the pupil can be irregular and not round due to the presence of the adhesion. Here,
there is also a complete gerontoxon (lipid deposition) around the cornea. A
typical gerontoxon is whitish and there is a free small area of cornea between the
cornea and limbus.

• In figure 14, pupil size is bigger than in uveitis: mydriasis. In this case there is
severe pain, loss of vision, red eye (but not conjunctivitis since no swelling and
no exudation are present), no reaction to light. This is a typical acute glaucoma.
• The iris is not clearly visible due to corneal edema; water is inside the cornea
increasing the intraocular pressure and consequently pushing the water Figure 14: Acute glaucoma
through the corneal endothelium inside the corneal stroma. The corneal edema
reduces the visual acuity.
• The difference between acute glaucoma and anterior uveitis is mainly the dimension of the pupil:
in anterior uveitis, the pupil is restricted and in the acute glaucoma the pupil is dilated and thick.

Marcus Gunn Pupil - is a widespread unilateral retinal or optic nerve disease detectable via the
pupillary reflex examination. With a penlight, light is shined into a normal pupil and there will be a
direct and consensual reflex to light. The light is moved from right to left side and again there will be
a direct and consensual constriction of the left and right pupils respectively. Thus, Marcus Gunn Pupil
is tested by moving the light from the normal to the pathological pupil. In the pathological pupil,
there will be pupillary dilation (both direct and consensual pupillary reflex) instead of constriction.
This means there is a serious, widespread damage of the optic nerve and/or of the retina of the
damaged side. For example, an occlusion of the central retinal artery results in afferent pupillary
defect. In unilateral damage, the light stimulus is not transmitted to the visual pathway of both sides.
When light is shined in the affected pupil, there is no visual stimulus at the level of the retina or
travelling to the optic nerve. Thus, there is a consequent pupillary dilation.

Anterior Chamber Depth - When shining the light from the temporal
side of the patient, if the iris looks completely lit, it means that the iris is
flat and the anterior chamber is deep, while if only half of the iris is lit the
anterior chamber is shallow and the iris has a curved shape, as in fig. 1.
The reason for checking for anterior chamber depth is that closed angle
glaucoma (a disease predominantly affecting middle aged
hyperopicfemales) is due a shallow anterior chamber. This disease is
otherwise rather difficult to recognize. A confirmed closed angle glaucoma Fig. 1
patient must be referred to a glaucoma specialist.
• Hyperopia – shorter eye than normal, the opposite of myopia. To
confirm it, you should measure the depth of the anteroposterior axis with echography.

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Ocular Alignment - In a normal subject the eyes must be Fig. 2: In the middle
aligned in the primary position. If the eyes are aligned the
picture, the reflex is
corneal reflex, i.e. the reflex of a pen light flashed in the eye of
the patient, falls inside the pupil, and is located in its center located more temporally
slightly on the nasal side. It must be symmetrical in both eyes. than expected, hence the
If this is not the case, the patient has a strabismus. Esodeviation eye is nasally deviated. The
is defined as a movement of the eye towards the nose, opposite is true in the
exodeviation as a deviation toward the temporal bone.
bottom picture.

Ocular Motility - A check for ocular motility is performed with a

finger or a pen. The patient is asked to follow an object in 6 directions
– primary position, right, left, up right, up left, down right, down left.
These are called primary or cardinal fields of action, and allow to
check for the correct function of the 6 extraocular muscles: the 4 recti
(superior rectus, lateral rectus, inferior rectus and medial rectus) and
the 2 oblique (superior and inferior oblique).

• The only muscles that have aligned axes to the anteroposterior

axis of the eye bulb are the lateral and medial recti muscles. So,
when the doctor asks the patient to move his eyes laterally, he is
checking for the function of the two horizontal muscles.
• The anteroposterior axes of the other muscles are not parallel to
the one of the eye bulb, so the patient must be asked to move the eye so that
the anteroposterior axis of the eye bulb is in the same direction as the axis of
each muscle. For example, moving the eye bulb laterally brings the axis of
the bulb in the same direction as the axis of the vertical recti muscles, hence
when the patient is asked to shift the gaze laterally and to look up, the doctor
checks for the function of the superior rectus muscle, and when he is asked
to look laterally and down, the inferior rectus is being investigated.
• The origin of the oblique muscles is lateral and in front of the eye, so the eye
bulb must be moved to the nose to have the same direction of the axes.
Therefore, when the patient is asked to look to the nose and up, the inferior
oblique is being checked, when to the nose and down, the superior oblique is under investigation.

Ocular motility gives information about extra-ocular muscles function and innervation. If the eyes are moving
in a coordinated manner, their function is normal.

● Cranial nerve III (CNIII), the oculomotor nerve, innervates

the 3 of 4 recti muscles, medial, inferior and superior recti,
and the inferior oblique.
● CN IV (trochlear nerve) innervates the superior oblique.
● CN VI (abducens) innervates the lateral rectus.

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Ocular motility is checked in the first place when the patient complains about diplopia. This can be caused,
among others, by muscular weakness or paralysis, by brain stem ischemia or tumors.

In fig. 8, the right eye cannot move temporally: In fig.9, the patient presents a ptosis of the left
the involved muscle is the right lateral rectus, eye. Innervation of the upper eyelid muscles
innervated by the 6th CN. The hypothesis is CN (levator palpebrae superioris and superior
VI palsy. tarsal muscles) comes from the CN III and from
the sympathetic nervous system, which keeps
the eyes open when the person is awake. It is
Direct Ophthalmoscopy - is an easy test that allows to look a case of CN III palsy.
through the pupil and directly see the blood vessels (arterioles and venules) in the retina, which is the only
tissue where it is possible to do so, by using the ophthalmoscope. If the patient has a vascular problem
(hypertension, diabetes, hypercholesterolemia) an eye examination shows how well the disease is controlled. - -

Instructions for the Use of The Ophthalmoscope

● Turn on the light using the wheel on the front of the device.
● Look through the viewing window.
● A wheel on the side can change the lens of the device (positive
lens – green numbers, negative – red numbers, neutral). A positive
lens creates a convergence of the light behind the lens itself: use of
a positive lens allows to look at the anterior segment of the eye
and investigate diseases of the lens, e.g. cataract. Another use of
the lens is to compensate defects in refraction of the patient. If the
patient is hyperopic, the doctor must use a positive lens, while if
he is myopic, a negative lens will be more appropriate.
● In the Heine ophthalmoscope there is also a blue light that helps to
highlight the fluorescein at the level of the cornea.

Examination of the Posterior Pole

● The margins of the optic nerve head must be checked first –
they should be sharp, not swollen.
● Examine all 4 couples of vein/artery (superior temporal,
inferior temporal, superior nasal and inferior nasal) that
originate from the head of the optic nerve. Starting from the
origin of the optic nerve, which is located quite nasally and is
whitish in color, the doctor moves the ophthalmoscope far
from it along the course of the vessel and back again. Veins
can be distinguished from arteries because they are thicker
and darker.
● Afterwards it is possible to examine the macula moving the
ophthalmoscope temporally.
● It must be kept in mind that the pigmentation of the posterior pole varies in different people.

9

The examination is easier if one drop of a mydriatic drug, i.e. a drug that dilates the pupil, is used. The only
problem is when dilating the pupil in a patient that has a shallow anterior chamber, because this would crowd
the angle, block the aqueous humor outflow, which may cause a sudden increase in intraocular pressure,
possibly causing an acute glaucoma.

In fig. 14, hemorrhages can be observed. The optic nerve head does not have sharp margins, because it is
swollen, with exudate and hemorrhage. Veins are enlarged and tortuous, signaling that the patient has
an occlusion of the central retinal vein. There is also probably an edema at the level of the macula, even
though in this image it cannot be visualized clearly. The green spot on the left is a choroid nevus.

10

 Fig. 15. Veins are not dilated but there is Fig. 16. The posterior pole has an opaque color, due to
hemorrhage and ‘hard exudates’ (made up of an occlusion of the central retinal artery (the tissue is
lipoproteins, caused by the fact that vessels are ischemic). The appearance of the retina is defined as
leaky), visible as whitish inside the retina. ‘white with a cherry red macula’. The fovea is able to
Diabetes is a systemic disease that increases the retain its naturally red color because it is not
permeability of the vessels, so the patient has vascularized (it is made of very packed cones) and
diabetic retinopathy. Possible macular edema. receives nourishment from the choroid, hence is not
affected.

Fig. 18. The optic nerve head normally has 1

Fig. 17. The optic nerve head is swollen: it could be million fibers. When a disease causes a
due to ischemia, infarction of optic nerve head, degeneration of nerve fibers, it reduces the
hypertension in the skull, neuritis (even though in number of fibers in the optic nerve, the “cup”,
this case it should be redder). i.e. the center of the optic nerve head that is
devoid of fibers, looks larger: this is a case of
glaucoma.

Red Reflex - A red reflex in a child is normal. Any change can be significant for a
disease. Leukocoria (“white pupil”) may indicate a congenital problem, a congenital
cataract, a neuroblastoma, Retrolental fibroplasia (ROP).

Fig. 19. Normal red reflex.

Fig. 20. Dislocation of the Fig. 21. Leukocoria.

lens, possibly due to
Marfan syndrome. Fig. 22. Cataract

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