Referral guideline – Abnormal pupil reaction or size

GP management

Please check the following:

  • Visual acuity if child is of an appropriate age (usually older than 3yrs) If the child is too young to check visual acuity, ascertain whether the child can fix and follow – for toddlers try a toy, for infants try a toy or a light.
  • Ocular motility – ask child to look in the direction of gaze of the extraocular muscles. Use a toy or a light for very young children.
  • Attempt fundus examination and note presence/absence of red and white reflex.
  • Pupillary reactions and sizes.

When to refer

  • Asymmetric pupil reactions/afferent pupillary reflex – IMMEDIATE REFERRAL.
  • Greater than 1mm difference between the pupil sizes, especially if this difference is noticed in the dark.
  • Limitation of eye movement (adduction) in the eye with the larger pupil – suggestive of 3rd nerve palsy.

Essential referral info

  • Presenting complaint and the reason for referral.
  • Visual acuity in each eye.
  • Bilateral pupil size and reactivity, presence/ absence of red reflex.
  • Patient details (name, age and gender).
  • Medicare number.
  • Parent/Carer’s name and contact details.
  • Referring clinician details (name, contact details, provider number, date and length of referral).

From 1 May 2019 referral criteria will apply at CHQ. This condition has minimum demographic and essential clinical referral information that is required to be included prior to submission of the referral. Visit the CPC website for the required condition. If you are unable to provide the required “essential information” please state the reason when you submit the referral.

Helpful referral info

  • Ocular history, including other eye problems, injuries, diseases, surgery, treatments including glasses and/ or amblyopia therapy.
  • Other past medical and surgical history.
  • Antenatal and perinatal history that may be relevant – prematurity, birth weight, birth trauma, alcohol/drug use in pregnancy.
  • Family history – of eye conditions or genetic conditions.
  • Current medications and allergies.
  • Examination findings – including any dysmorphic features, full ocular examination.
  • Is the patient of Aboriginal or Torres Strait Islander descent?

Parent service


Contact details

Hospital Switchboard
(Ask for Ophthalmology On-call Registrar)
t: 07 3068 1111


Red Reflex video
List of CHQ aligned optometrists
Emergency Eye Manual
Paediatric Optometry Alignment Program