The test, which is part of the Newborn and Infant Physical Examination (NIPE) in the UK, involves shining a light into an infant’s eyes to observe the reflection from the retina.
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The scientists note that a “normal” result is commonly expected to be red, but that this is based on presentations among white patients, perpetuating racial biases in healthcare.
The paper, published today in the journal Eye Nature, highlights that in those with darker skin tones, the reflex can present in different colours, such as yellow, orange, or less bright hues.
Renaming the test as the ‘Fundal Reflex Test’ would be an “anatomically accurate description that avoids implying a specific colour, thereby reducing misunderstanding and promoting equity and inclusivity”.
The study used reflex videos of six adults reflecting a diverse range of ethnicities – Black, Asian Indian, Asian Afghan, Southeast Asian, White with fair hair, and White with dark hair – which were captured via an Arclight ophthalmoscope attached to a smartphone camera.
The Arclight ophthalmoscope—a low-cost, portable diagnostic tool—has been instrumental in training and equipping healthcare workers in low- and middle-income countries (LMICs) to perform this essential examination.
The researchers asked 27 first-year medical students to record their “subjective” impressions of the colour seen in the pupil space for each video.
An objective analysis was then provided by using an algorithm to calculate the mean objective Red-Green-Blue (RGB) value of all ‘pupil space’ pixels.
Subjectively, yellow, orange, and white were the most commonly recorded colours, while objectively, brown and orange were the most frequent.
“Traditionally the name of this test is the ‘red reflex test’ because the colour looks reasonably red in white European people.
“When performed on different populations of varying skin pigmentation, and therefore different eye pigmentation it does not look red and so it is not an inclusive term.
“It’s not covering the diversity of people that this test is being used on even in the UK let alone when working overseas.
“It’s much important that we describe this test using a word which isn’t related to colour, but instead to the anatomy of the test.
“Language shapes our perceptions and practices. Decolonising terminology has the potential to inspire similar initiatives across healthcare.
“It’s a step toward dismantling long-standing biases, promoting inclusive medical education, and ensuring all patients, regardless of background, receive respectful and equitable care.”
Dr Blaikie leads the Arclight Project, which is run by the university’s School of Medicine to enable those working in low and middle income countries to equip, train and empower local health workers to diagnose and manage eye and ear disease.
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It aims to improve diagnostic accuracy and eye care outcomes for vulnerable populations worldwide, helping to address the very biases highlighted by this research.
The findings also align with the NHS Race and Health Observatory’s review on neonatal assessments, which raised concerns about the use of skin colour in determining the Apgar score and identifying jaundice, highlighting the urgent need for updated, inclusive medical practices.
