Correspondence

Case 5-2006: Loss of Vision in the Right Eye

N Engl J Med 2006; 354:2078-2079May 11, 2006

Article

To the Editor:

In the Case Records, Walton at al. (Feb. 16 issue)1 elegantly discuss retinoblastoma, but their definition of leukokoria is inaccurate. Leukokoria is taken directly from the Greek and means simply “white pupil.” When the normal pupil is observed with a flashlight, it appears black because little light from the eye's interior is reflected back to the examiner. If a white object, such as a mature cataract or intraocular tumor, is sufficiently anterior in the eye, it reflects enough light to make the pupil appear white. When observed coaxially, as with an ophthalmoscope, light reflected from the choroid produces a red reflex in the normal eye. States that produce leukokoria on flashlight examination may produce a light or dark coaxial reflex, depending on pupillary diameter and the position, size, and reflectivity of the abnormal structure. Accordingly, a family's first sign of childhood retinoblastoma may be the white reflex in a coaxial flash photograph. Leukokoria thus distinguishes an abnormal white pupil from the normal black pupil, not a white coaxial reflex from a red one.

David J. Harris, Jr., M.D.
University of Tennessee Graduate School of Medicine, Knoxville, TN 37920
djh2020@aol.com

1 References

1. 1

   Case Records of the Massachusetts General Hospital (Case 5-2006). N Engl J Med 2006;354:741-748
   Full Text | Web of Science | Medline

Author/Editor Response

We agree with Dr. Harris that our explanation of leukokoria was ambiguous. When the pupil appears white in room light or when examined with a flashlight or an ophthalmoscope, the importance of this abnormality must be appreciated; a complete eye examination should be performed.

David S. Walton, M.D.
Massachusetts Eye and Ear Infirmary, Boston, MA 02114