Screening of pediatric eye disease at home by using camera of mobile phone

1. Gary L. Rogers, MD 2. Catherine Olson Jordan, MD 1. Department of Ophthalmology, Nationwide Children’s Hospital, Columbus, OH. Although early detection of visual disorders can lead to therapy that will prevent permanent blindness, compliance with screening guidelines of the American Academy of Pediatrics is low. After completing this article, readers should be able to: 1. Be aware of common vision-threatening conditions that can be detected by using basic screening examinations. 2. Become familiar with techniques and findings used in vision screening examinations. 3. Understand the role of commercial screening tools. Early detection of ocular conditions can allow for assessment and treatment of a vision-threatening or life-threatening condition. Amblyopia, or “lazy eye,” can develop if a clear visual image is not projected onto the retina. Amblyopia can be caused by deprivation, strabismus, high refractive error (hyperopia, myopia, or astigmatism), or anisometropia (significant difference in the refractive error between eyes) and can be unilateral or bilateral. The prevalence of amblyopia is estimated to be 1% to 4%. (1) Many factors may prevent the achievement of universal vision screening, including lack of education of families; language, financial, and state legislative barriers; and a lack of available providers. (2) Primary care physicians are crucial providers for detecting and referring vision-threatening ocular conditions. From the newborn examination, through subsequent health supervision visits, and throughout a child’s life, the pediatrician and family physician can perform effective examinations to screen for common and uncommon conditions that may be vision-threatening or even potentially life-threatening. (3) However, vision screening in the primary care office should not take the place of a full eye examination. If a patient cannot be screened effectively after two attempts, a referral should be made to an eye care professional who is comfortable examining children. …

Eye injuries are the leading cause of monocular blindness in children and are challenging to manage. However, limited follow-up studies currently exist. We describe the clinical characteristics and outcomes of open globe injuries presenting to a major UK centre and discuss factors affecting long-term prognosis. Identification of (1) demographic features, (2) causes, types and location of injuries, (3) initial clinical features and correlation with visual outcome, and (4) predictors of poor visual outcome. Retrospective study by reviewing and analysing records of 20 patients, aged 16 years and below, who had undergone repair of an open globe injuries at the Manchester Royal Eye Hospital, UK. Data recorded included demographic data, mechanisms and location of injury, visual acuity, clinical signs on presentation, surgical procedures, postoperative complications, and final visual acuity. The study group comprised of 85% male subjects, 15% female subjects. The average age was 9.8 years (range: 1-15). Average follow-up was 16.3 months (range: 3-48 months). Sharp objects (mainly glass or knife) accounted for the majority (65%) of injuries. Initial clinical signs associated with poor visual outcomes included poor initial visual acuity, cataract, RAPD, and no initial red reflex. Younger patients and blunt injuries (especially BB gun injuries) had worse visual outcomes. Factors suggesting unfavourable final visual acuity after open globe injuries in children are (1) young age at presentation, (2) poor initial visual acuity, (3) presence of a relative afferent papillary defect, (4) absence of red reflex, (5) cataract, and (6) types and number of surgeries performed.Awareness and education with regard to prevention of paediatric injuries need to be actively implemented.

The study analyzes the frequency of acute endophthalmitis occurrence after cataract surgery, the risk factors, characteristic symptoms, and the effectiveness of peri-operative prevention measures. The study retrospectively analyzed 59 670 cases of patients operated for cataract in 2017-2021. To prevent infections, patients received four instillations of third generation fluoroquinolone (quinolone antibiotic) in the course of two days prior to cataract phacoemulsification (PE), and two instillations immediately (1 hour and 30 minutes) before the surgery; three-minutes treatment of the cornea, conjunctival sac and periocular skin with 5% povidone iodine before the surgery; and as the last step of surgery, patients received subconjunctival injection of 0.05 g cefazolin with 2 mg dexamethasone. Follow-up after surgery included four injections of 0.5% levofloxacin in the course of 7-10 days, and 0.1% dexamethasone for two weeks, or fixed combination of tobramycin and dexamethasone four times per day for two weeks. The criteria for acute endophthalmitis are: loss of spatial vision, absence of red reflex, pronounced thickening of the choroid, suspended particulates in the retrovitreal space and the vitreous observed with ultrasonography in the early postoperative period (day 4-7 after surgery). There were 32 patients (0.054%) diagnosed with acute endophthalmitis. Posterior capsule rupture was the main complicative risk factor of endophthalmitis development (OR=11.75, p=0.026). Main diagnostic criteria of acute endophthalmitis were hypopyon (OR=22.5, p=0.001) and absence of red reflex (OR=19.59, p<0.001). The use of the fixed combination of tobramycin and dexamethasone was associated with 5.8-times higher risk of acute endophthalmitis than separate application of levofloxacin and dexamethasone (p=0.042). Povidone iodine and third generation fluoroquinolone as a method of acute endophthalmitis prevention after cataract surgery demonstrate comparable efficacy to intracameral antibiotic injections.

Background: Red reflex is a simple test that can detect potentially life-threatening ocular abnormalities. In 2012, a red reflex screening campaign started in Umbria, central Italy. In the present study, we report the results of eye examination in the routine first visit of newborns in a private hospital within 2014-2016.Methods: The red reflex test was carried out as a part of the first health visit of newborns in a private hospital for 2 years. The eyes of all newborns were examined on the first day of life by a handheld ophthalmoscope. The suspected cases with cataract were referred to the Ophthalmologic Department of Mashhad University of Medical Sciences, Mashhad, Iran, for the confirmation of the diagnosis.Results: During the 2 years of the study, a total of 10,484 neonates were delivered in this hospital 10 of whom were referred for ophthalmology consultation due to suspected abnormal red reflex. In 2 cases (0.019%), the diagnosis of congenital cataract was confirmed by an ophthalmologist.Conclusion: The results of the current study are consistent with the findings of previous studies, although the reports on red reflex screening are sporadic in the literature. Due to low cost and easy performance and in spite of high false-positive red reflex test, it appears to be useful for the early diagnosis of congenital low-vision disease for the prevention of vision impairment. In addition, the present study confirmed that the red reflex test should become a part of the first newborn examination immediately after birth.

Cataracts

Cataracts

Objective:Red reflex test is an effective screening tool in the early diagnosis of neonatal eye abnormalities. The aim of this study was to detect the sensitivity and specificity of red reflex assessment in neonates, performed by pediatricians (or other care providers) in comparison with ophthalmologists. Also association between red reflex findings and neonatal variables is evaluated.Methods:By a prospective study all neonates born from July 2011 until March 2012 in Mustafa Hospital, a general teaching hospital in Ilam city, Iran, were evaluated. Neonates were firstly investigated by pediatrician in substandard conditions at the first day of birth and several days later by ophthalmologist in standard conditions.Findings:Totally 255 neonates including 141 boys and 114 girls were investigated, 144 of whom were born by cesarean section. There was a significant relationship between method of childbirth (72.9% disorders in CS vs 56.8% in vaginal delivery (P<0.007)), duration of delivery (disorders in prolonged: 100% and 11.8% vs no prolonged: 56.8% and 6.3% in standard and non standard conditions respectively (P<0.0001)), difficult delivery (98.6% disorders vs 6.5% in standard and non standard conditions respectively (P<0.01)) and increase or decrease of red reflex sensitivity test. A significant difference (identification of ophthalmic problems) was seen among neonates’ inspections in primary hours and substandard conditions compared to further inspections in standard conditions particularly from 3rd day of birth.Conclusion:Due to a considerable difference between the results of ophthalmic examination of neonates in different conditions, red reflex examination by pediatricians is suggested for all neonates to early identification of ophthalmic problems at the first step. It is also suggested a red reflex screening for all neonates before being discharged from hospital as well as 6 weeks later and in case of any problem to be referred to ophthalmologist.

Red reflex is a routine part of newborn examination in most high-income countries. It is an inexpensive, noninvasive method of detecting serious ocular abnormalities like cataracts, retinoblastoma, vitreous masses, etc. The American Academy of Pediatrics recommends red reflex examination before discharge from newborn nursery. However, the current rate of red reflex examination in the NICUs in the United States is unknown. We noted a low rate of documentation (19%) in our level III NICU, prompting us to initiate this quality improvement project to improve this rate. We created a key-driver diagram and summarized possible interventions to achieve our aim to increase the documentation rate to >80%. We implemented various interventions over 4 plan-do-study-act cycles. Over 19 months, we educated the nurses and the providers regarding the importance of red reflex assessment, placed visual reminders to check red reflex, implemented discharge checklist for the residents, and improved the accessibility to ophthalmoscope. Infants discharged from our NICU during a 25-month period included 1168 infants who an ophthalmologist did not formally examine. The rate of red reflex documentation improved significantly from a baseline of 19% (6 months before the first plan-do-study-act cycle) to 89.5% (during the 19-month intervention period). One abnormal red reflex was detected during this study. Implementation of this project has led to a culture change at our institution, which will help prevent us from missing the diagnosis of serious visual abnormalities in the future.

Red reflex is a test that can detect potentially life-threatening ocular abnormalities. In 2012, a red reflex screening campaign was started in Umbria, central Italy. In this study, we report the results of the first 3 years (2012-2014) of screening. Red reflex screening was carried out in the 11 regional birth centres. On the first level, the test was performed on all newborns within the third day of life. A pathologic test was an indication for referral to the nearest Ophthalmology Hospital Department (II level). Patients were referred to the Perugia University Ophthalmology Hospital Department if an ulterior evaluation or if treatment was necessary (III level). Between 1 January 2012 and 31 December 2014, 22,884 children were born in Umbria and of these, 22,272 (97.3%) were tested with the red reflex. Four hundred and sixty-one (4.83%) neonates resulted having a positive or equivocal test and were sent to II level. Three of these cases (0.01%) were affected by an important eye disease, in particular two patients (0.009%) presented congenital cataract and one patient (0.005%) presented retinoblastoma. Our results are consistent with the previous findings, although reports on red reflex screening are sporadic in the literature. Despite the high number of false positives, the red reflex test has proven to be a useful, easy to perform and low cost test for the early detection of congenital low vision diseases, and our data confirm that it must become part of normal neonatal assessments.

Introduction: When an eye is illuminated by a light coaxial with the observing eye or camera, the light is reflected by the back of the eye and a red reflex will be observed through the pupil. The intensity of this red reflex varies with the angle of eccentric gaze. The red reflex darkens as the eye fixates at the light source. Brückner described this principle in 1962. Although this effect has been used as a screening test for strabismus ever since, the mechanism that causes this effect is only partly known. None of the current explanations are accepted as conclusively proven. We developed an automated, high-resolution, continuously scanning Brückner device to study the mechanisms underlying the Brückner effect.Method: The right eyes of 6 subjects, students aged 22–31 years, were measured. A subject sat in front of a camera at a distance of about 0.75 m. The luminance of the red fundus reflex and the eye movements were measured continuously while the subject followed a fixation target that moved in two dimensions. Eye movement was also recorded objectively and in the analysis this was used in addition to the position of the fixation target. The eyes were illuminated coaxially using an infrared light source and a beam splitter.Result: By using two methods to record eye rotation and relating this to the continuously measured pupillary luminous intensity and pupillary area, we were able to construct 2-dimensional maps of pupillary luminance. All 6 subjects showed the expected general darkening of the pupil as fixation changed from eccentric fixation to foveal fixation at the center of the camera. However, there were many local fluctuations. The global minimum in pupillary luminance, the “dark spot,” was often roughly circle-shaped with a radius of about 1°. The pupillary luminance kept increasing beyond 2° eccentricity.Discussion: We measured the Brückner effect continuously in two dimensions. Brückner’s original explanation – absorption by the macular pigment – cannot explain our findings as the macular pigment hardly absorbs light beyond 600 nm wavelength. If one assumes that reflection by the inner limiting membrane or diffuse backscatter in the thick retinal nerve fiber layer increase the luminance of the pupil, one would expect the pupil to be brightest at 2° eccentricity, but the pupillary luminance continued to increase beyond that. We used a beam splitter and still found a dark pupil on coaxial fixation, implying that blocking the image that is projected back from the eye by the funduscope only plays a contributory role.

The red reflex is produced when coaxial light from the retina is reflected from patient to observer, and acts as an important tool in ophthalmic surgery owing to its application in screening various ocular abnormalities associated with the cornea and iris. Visualization of these intraocular structures could improve surgeons’ ability to perform ophthalmic procedures safely. The aim of this podcast, featuring Dr. Laurence Woodard (Medical Director of Omni Eye Services, Atlanta), is to highlight the clinical utility of red reflex stability and intensity provided by nearly collimated and focused beam microscope illumination systems used in ophthalmic surgery. Quantifying red reflex intensity can be challenging due to its subjective nature. Other factors such as phacoemulsification and individual characteristics of the eye, such as pupil size or iris pigment, may affect red reflex intensity. Red reflex stability and intensity may also be altered during the procedure because of excessive eye movement, lack of centering, or if the eye is not perpendicular to the light beam. In addition, differences in nearly collimated and focused illumination systems may affect surgeon fatigue and surgery success. The intensity of the red reflex dictates surgeons’ ability to maintain adequate visualization during surgery as well as identify ocular abnormalities. In conclusion, the more intense the red reflex, the more likely a surgeon will be able to maintain adequate visualization during surgery as well as identify corneal and anterior segment abnormalities. The podcast and transcript can be viewed below the abstract of the online version of the manuscript. Alternatively, the podcast can be downloaded here: https://doi.org/10.6084/m9.figshare.14779212.The Stability of the Red Reflex Produced by Different Surgical Ophthalmic Microscopes (MP4 24363 kb)Supplementary InformationThe online version contains supplementary material available at 10.1007/s40123-021-00367-w.

A capsulorhexis technique with a 23-gauge vitreous cutter in intumescent cataract surgery is presented. These patients have a high risk of uncontrollable extension of the opening of the anterior lens capsule. We used vitreous cutter for capsulorhexis along with the other steps performed as in standard phacoemulsification surgery. This technique allows controlled capsulorhexis and may be an alternative method in patients with intumescent cataracts with high intralenticular pressure and absence of red reflex.

IgG4-associated ocular inflammatory pseudotumor is a rare, non-neoplastic inflammatory process with an incidence of 0.28-1.08 per 100,000 people. The diagnosis of this pathology is one of exclusion, having to meet histopathological criteria, enlargement of a specific organ, and serious concentrations of IgG4. Treatment aims to avoid secondary complications. Clinical case: A 54-year-old woman with no previous re-ported pathologies, reports that for the past 6 months she has itching at the level of the eyeball and the left eyelid, suddenly and without apparent cause, in addition to decreased visual acuity and retro-ocular pain; this is why she asked for the evaluation. The physical examination revealed normal eye movements, left proptosis, pain on palpation, subconjunctival hyperemia, corneal opacity, absence of red reflex, and the left eye being more resistant to pressure in relation to the contralateral eye. The cranio-thoraco-abdominal tomography reported images at the left ocular level that were suggestive of choroidal melanoma without findings of metastatic activity. Enucleation of the left eye was performed. The specimen was sent to pathology which reported diffuse lymphoplasmacytic infiltrate positive for IgG4. Conclusion: Ocular IgG4 disease is a very rare pathology with non-specific symptoms and complex diagnosis. However, a quick and correct approach is essential to avoid complications.

Case PresentationAn 88-year-old female presented to the emergency department (ED) with complaints of painful vision loss four days after an intravitreal injection for her neovascular macular degeneration. Her right eye visual acuity was markedly diminished with an absence of red reflex. A point-of-care ocular ultrasound was performed and demonstrated hyperechoic vitreous debris concerning for endophthalmitis.DiscussionEndophthalmitis is an infection of the vitreous or aqueous humors commonly caused by exogenous sources, such as inoculation of bacteria into the eye from surgery, injections, or trauma. It is an ophthalmologic emergency as it is a vision-threatening infection. Although a rare complication, post-surgery or post-injection are the leading causes of endophthalmitis. Point-of-care ocular ultrasound findings suggestive of endophthalmitis, such as hyperechoic vitreous debris, aid in the timely diagnosis and treatment of patients in the ED.

Capsulorhexis in intumescent cataract