Red Reflex Test Research Articles

Approach of Family Physicians to Pediatric Eye Screening in Diyarbakır

Objectives:In Turkey, preventive medicine services are the responsibility of family physicians and vision screening is a key component of this responsibility. In this study, we aimed to investigate the approach of family physicians to vision screening in infants and children.Materials and Methods:Data were collected using a 16-item questionnaire administered to 100 family physicians working in the center and provinces of Diyarbakır.Results:The results indicated that 88 (88%) physicians declared knowing what the red reflex test was, while 12 physicians declared that they had never heard of it. Only 16 (16%) physicians performed the test routinely and 36 (36%) physicians performed it only in suspicious cases. Ten (10%) physicians indicated that they did not refer the patients to an ophthalmologist even though they did not perform the red reflex test. Moreover, 5 (5%) physicians did not have an ophthalmoscope and 12 (12%) physicians reported not knowing how to use an ophthalmoscope. Forty (40%) of the physicians measured preschool visual acuity at least once. Sixty-six (66%) physicians referred younger children who could not express their vision problems to an ophthalmologist. Four (4%) physicians declared that they would delay surgery in children with strabismus until they were old enough for surgery. Ninety-three (93%) physicians suggested that educational seminars about vision screening would be beneficial.Conclusion:Educational seminars about vision screening may have favorable outcomes. The medical devices in family medicine centers should be improved. Vision screening can be added to the negative performance-based compensation system in order to increase physicians’ attention to vision screening. To implement detailed eye screening programs like those in developed countries, an infrastructure should be established for this screening program.

Contemporary management of retinoblastoma in the context of a low-resource country.

Retinoblastoma (RB) is the most common ocular cancer, and it typically presents before the age of 5 years in over 90% of cases. In high resource countries, RB patients tend to survive and retain their sight. This is not the case in low-resource countries because of late presentation and delayed intervention arising mostly from sociocultural and socioeconomic challenges. RB has no gender or racial predilection; the incidence is estimated as 1:16,000-1:18,000 live-births or 11/1 million children under 5 years. Most of the world's RB cases are found in Asia and Africa while most RB treatment centres are in America and Europe. RB is easy to detect by caregivers as a glowing white 'cat eye reflex' at night or when captured on camera. Health workers at primary care level can detect RB in early life if red reflex test and/or squint (Hirschberg) tests are deployed as part of wellness checks done especially during routine immunisation and well-baby clinics in the first 24 months of life. In most cases of RB, biopsies for histological confirmation are not required for diagnosis and treatment decisions to be made. Clinical information, ophthalmic evaluation and imaging modalities are typically used. There have been significant changes in the management of RB using various treatment modalities such as enucleation with orbital implant, use of chemotherapy delivered through intravenous, intravitreal, periocular and intra-arterial routes and targeted treatment with laser, cryotherapy and brachytherapy. Algorithm for management and development of the national RB program within the context of a low-resource country is presented from review of data extracted from Mendeley library, PubMed library, Google Scholar and One Network; full-text articles were mostly retrieved through the American Academy of Ophthalmology.

Pediatric Vision Screening.

1. Allison R. Loh, MD* 2. Michael F. Chiang, MD*,† 1. *Department of Ophthalmology and 2. †Department of Medical Informatics and Clinical Epidemiology, Casey Eye Institute, Oregon Health and Science University, Portland, OR Incorporating vision screening and a basic eye examination in the primary care setting can be challenging. Determining which screening examination to perform and when to refer a patient to a pediatric eye care provider is critical. After completing this article, readers should be able to: 1. Understand the importance of vision screening and know what conditions can be detected by periodic eye examinations. 2. Describe the components of a vision screening examination at different ages and plan an appropriate evaluation of vision. 3. Recognize the indications for referral to pediatric ophthalmology. Vision screening is crucial for early detection and prevention of vision loss in young children. Vision screening can be performed by primary care providers, trained laypersons (eg, school-based screenings), and eye care providers. Vision screening techniques are either provider-based (eg, traditional acuity testing, inspection, red reflex testing) or instrument-based. Instrument-based screening can often be performed at an earlier age than provider-based acuity testing and allows earlier screening for risk factors that are likely to lead to amblyopia and poor vision. The American Academy of Pediatrics (AAP) and the American Association for Pediatric Ophthalmology and Strabismus have developed guidelines to help practitioners screen for vision problems at different ages (Table 1). View this table: Table 1. Age-Appropriate Methods for Pediatric Vision Screening and Criteria for Referral Vision screening allows the early detection of preventable vision-threatening or life-threatening conditions. Amblyopia, …

Pediatric Cataract - Importance of Early Detection and Management.

Pediatric cataract is often diagnosed and managed late. This delay may be due to the ignorance on the part of the community, financial constraints, delay in the diagnosis and lack of tertiary care facilities. There is an urgent need to include rubella vaccination in the universal immunization program. A Simple Red Reflex test to detect a cataract and guiding the parent for early intervention will go a long way in achieving the target of eliminating cataract as a cause of childhood blindness. The importance of early detection and quick referral to a multispecialty center can save the child of lot many blind-years. These children have the potential to achieve the best possible visual acuity if managed early.

Outcome of universal newborn eye screening with wide-field digital retinal image acquisition system: a pilot study.

PurposeTo evaluate the outcome of universal newborn eye screening with wide-field digital retinal imaging (WFDRI) system.MethodsIn this pilot study, we examined 1152 apparently healthy newborn infants in the obstetrics and gynecology ward of a civil hospital in Eastern India over 1.5 years. The examination included external eye examination, red reflex test and fundus imaging by WFDRI (RetCam II, Clarity medical system, Pleasanton, CA, USA) by a trained optometrist. The pathologies detected, net monetary gain and skilled manpower saved were documented. The results were compared with three similar studies thus far published in the literature.ResultsOcular abnormality of any kind was seen in 172 (14.93%) babies. Retinal hemorrhage in 153 babies (88.9% of all abnormal findings) was the most common abnormality; it was bilateral in 118 (77.12%) babies and 4 babies had foveal hemorrhage. Other abnormalities included vitreous hemorrhage (n=1), congenital glaucoma (n=2), uveal coloboma (n=2), retinopathy mimicking retinopathy of prematurity (n=2), and cystic fovea (n=3). The retinal hemorrhages resolved spontaneously in all eyes. One baby with congenital glaucoma received surgery and the other was treated medically. The benefits included savings in skilled manpower, a net monetary gain of INR 4.195 million (US$ 62,612) and skilled manpower saving by 319.4 h.ConclusionsThe universal neonatal eye screening using WFDRI detected pathologies that needed immediate care or regular follow up; saved skilled manpower with a net monetary gain. But compared to a red reflex test the benefits were marginal in terms of detecting treatment warranting ocular pathologies.

Red reflex examination in neonates: evaluation of 3 years of screening.

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.

Sensitivity and Specificity of Red Reflex Test in Newborn Eye Screening

To validate the sensitivity of an isolated red reflex test in detection of ocular abnormalities of the anterior and posterior segments in newborns. Red reflex test and comprehensive eye examinations including external inspection, pupil examination, hand-held slit lamp examination, and RetCam fundus imaging (Clarity Medical Systems, Pleasanton, California) were performed in 7641 newborns. All results were documented as negative or positive. Sensitivity and specificity of red reflex test were calculated by the use of comprehensive eye examinations as the reference standard. Anterior abnormalities were separated from posterior abnormalities, and the sensitivity of red reflex test for each group was calculated. The proportion of abnormalities that were correctly classified by red reflex test was greater in anterior segment group (sensitivity = 99.6%, 95% CI 97.1%-100%) than in the posterior group (sensitivity = 4.1%, 95% CI 3.3%-5.1%, χ2 = 1521.382, φ = 0.836, P < .001). The red reflex test was a useful universal screening tool in detection of anterior abnormalities; however, the test has limitations in detection of posterior abnormalities. The generalization of these results to infants and children and observers with varying levels of expertise may need to be established further.

Visual System Assessment in Infants, Children, and Young Adults by Pediatricians

Appropriate visual assessments help identify children who may benefit from early interventions to correct or improve vision. Examination of the eyes and visual system should begin in the nursery and continue throughout both childhood and adolescence during routine well-child visits in the medical home. Newborn infants should be examined using inspection and red reflex testing to detect structural ocular abnormalities, such as cataract, corneal opacity, and ptosis. Instrument-based screening, if available, should be first attempted between 12 months and 3 years of age and at annual well-child visits until acuity can be tested directly. Direct testing of visual acuity can often begin by 4 years of age, using age-appropriate symbols (optotypes). Children found to have an ocular abnormality or who fail a vision assessment should be referred to a pediatric ophthalmologist or an eye care specialist appropriately trained to treat pediatric patients.

Les items d’ophtalmologie du carnet de santé sont-ils réalistes ?

Since 2006, French general practitioners have had to carry out an ophthalmological screening for children, using a methodology contained within the child's health record (carnet de santé). The purpose of this screening is to allow an early diagnosis of sight-threatening as well as potentially life-threatening conditions (e.g., retinoblastoma). The aim of the present study was to evaluate the theoretical knowledge and the clinical skills of practitioners implementing the screening, with regards to two specific items of the health record screening schedule, by means of a questionnaire. From December 2013 to September 2014, 42 practitioners (16 general practitioners, 14 pediatricians, 12 resident physicians) from four distinct locations in Normandy, France, were questioned using a questionnaire on two ophthalmological items of the French health record: one on red reflex and one on eyeball size. Only four of 42 practitioners provided correct answers on the red reflex color. Thirty of 42 practitioners reported difficulties performing the red reflex test, mostly because they did not know the normality criteria and the purpose served by this test. Thirty-three of 42 practitioners declared that they found it difficult to know whether or not eyeball sizes were normal, mostly because they were unaware of the normality criteria. None of the practitioners provided the correct (to within ± 1 mm) mean horizontal cornea diameter in full-term newborns and adults. This study demonstrates that there is poor theoretical knowledge and a low level of clinical skill for practitioners performing the ophthalmological screening based on the French health record schedule. This schedule therefore does not seem to meet its purpose.

Importance of the red reflex test in the diagnosis of eye cancer

Retinoblastoma is the most common malignant tumour of the eye in children and accounts for 3% of all childhood cancers. It can occur either unilaterally or bilaterally and generally develops before the first five years of life. A red reflex test must be performed if a child presents with any of the following: a white reflex (leukocoria) or an abnormal reflex in flash photographs; a recently onset squint (strabismus); a change in colour to the iris; deterioration in vision; a red, sore or swollen eye without infection. The presentation of any of these signs or symptoms in isolation can indicate retinoblastoma. However, it is vital to note that a child with retinoblastoma may appear well, apart from one or more of these signs. This article gives detailed instruction on how to carry out a red reflex test and appropriate referral information for suspected cases. A swift referral pathway is vital to reduce loss of vision and the risk of mortality.

Towards early detection of retinoblastoma.

Survival rates for retinoblastoma (RB) in a region of South Africa (SA) of only 50% reflect the high frequency of late presentation, the simple reason for which is lack of effective screening. Early detection of suspected RB would significantly reduce this unacceptably high mortality rate. The SA health system has the expertise to manage a child with RB well. The issue at stake is timely referral of the affected child to one of the specialist treatment centres. Until universal screening with digital imaging becomes a reality, the red reflex test should be mandatory at discharge from all neonatal services and at all subsequent routine health supervision visits. Most RBs would then be detected early.

Pediatric Vision Screening

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. …

Bruckner Red Light Reflex Test in a Hospital Setting

Childhood blindness is a major problem in developing world including Nepal that needs to be addressed. The objective of study was to measure the effectiveness of the Bruckner red reflex test for screening of posterior segment opacities in children. Patients aged less than five years who came to the Tilganga Institute of Ophthalmology, Kathmandu from March to August, 2009 were recruited in this cross-sectional descriptive study. Children were screened with the Bruckner red light reflex test in a dark room. Patients with abnormal Bruckner tests had their eyes dilated for further investigations. Abnormalities were recorded. The number of patients with an abnormal Bruckner test was recorded and correlated with their potential pathology. A total of 172 patients with 97 boys and 75 girls were included. Twenty-three had abnormal Bruckner test results in either one or both eyes. Four of these twentythree patients had no pathology diagnosed; hence the sensitivity of the Bruckner screen to diagnose significant pathology was calculated at 82.6%. Of the 153 patients with normal results, two patients were found to have pathology detected, which included cataract and strabismus. Hence, the specificity of this test was 98.7%. The screening test had a positive predictive value of 90.5% and a negative predictive value of 97.4%. Bruckner test screening is a sensitive and specific marker for detecting the posterior segment opacities in children. We recommend utilizing the test to evaluate these problems where other technologies are rare.

Exploring Pre-school Vision Screening in Primary Care Offices in Alabama

To investigate practices, barriers, and facilitators of universal pre-school vision screening (PVS) at pediatric primary care offices. Focus group sessions (FGS) were moderated on-site at nine pediatric practices. A semi-structured topic guide was used to standardize and facilitate FGS. Discussions were audiotaped, and transcriptions were used to develop themes. All authors reviewed and agreed on the resultant themes. FGS included 13 physicians and 32 nurses/certified medical assistants (CMAs), of whom 82% personally conducted some facet of PVS. In all practices, nurses/CMAs tested visual acuity (most using a non-recommended test), and physicians completed vision screening with external observation, fix/follow, red reflex, and cover test. Facilitators included (1) accepting that PVS is a routine part of the well-child visit, and (2) using an electronic medical record with prompts to record acuity (eight of nine practices). Barriers were related to difficulty testing pre-schoolers, distractions in the office setting, time constraints, and limited reimbursement. Responsibility for PVS is shared by physicians and nurses/CMAs; thus, interventions to improve PVS should target both. Few practices are aware of new evidence-based PVS tests; thus, active translational efforts are needed to change current primary care practices.

Implantação do exame do reflexo vermelho em crianças da região do Hospital das Clínicas da Faculdade de Medicina de Botucatu - SP - Brasil

To describe the implantation of the red reflex test in 30 cities in the area of Botucatu Medical School Clinical Hospital, (480,337 inhabitants) and the creation of a reference Center for children with red reflex changes, the Red reflex screening and another Center for treatment of childhood cataract. The red reflex exam was released in 30 cities of the surrounding Botucatu area, lectures were done in the cities invited to participate by the Regional Department of Health.109 pen torch ophthalmoscopes were distributed to the hospital maternities and primary care units. The Red reflex screening attended cases of altered or doubtful red reflex and established the diagnosis. The Center for treatment of childhood cataract performed the preoperative examination, surgical treatment and follow-up of children with cataracts. After one year the Red reflex screening attended 29 children, 17 males and 12 females, mean age and pattern deviation (PD) of 10.09 ± 20.35 months (7 days - 98 months old). 16 patients were referred with altered red reflex, with a mean age and pattern deviation of 13.17 ± 24.14 months (7 days - 98 months old). The alteration was confirmed in all of these cases. 13 children had cataract. In 13 children with doubtful exam, with a mean age and PD of 6.29 ± 14.46 months (7 days - 54 months old), the alteration was not confirmed in any of these patients. The incidence of negative red reflex found among newborns was 9.2/10,000 and the incidence cataracts in this same group was 7.9/10,000. We described the implantation of the red reflex exam in the Botucatu area, and the creation of a reference Center for eye examination of children with changes in the red reflex, and the creation of a reference Center for treatment of childhood cataract and difficulties.

Retinoblastoma in a Child After Normal Autorefraction and Traditional Vision Screening

Retinoblastoma is an ocular malignancy that can put a patient's sight and, in some instances, life at risk. Here we report the case of a 2-year-old child who presented to her pediatrician with a 2-week history of left-sided leukocoria caused by retinoblastoma. Results of traditional office-based vision screening and automated vision screening, which often identify but are not specifically designed to detect rare diseases such as retinoblastoma, had been normal in the antecedent 7 months. She underwent enucleation of the left eye and has done well postoperatively. This case highlights the importance of assessing ocular media clarity by using red-reflex testing at multiple intervals during the preschool years, particularly in light of the recently published US Preventive Services Task Force guidelines for preschool vision screening, which gave an "insufficient evidence" level for vision screening in children younger than 3 years and failed to address red-reflex examination.

The Brückner Transillumination Test: Limited Detection of Small-Angle Esotropia

To evaluate the sensitivity of the Brückner test in detecting esotropia of 2° to 10° by interocular asymmetry of the red fundus reflex.Single-blinded evaluation of the diagnostic test.Five blinded observers and 20 isometropic orthotropes.Set-up 1 included monocular evaluation of the Brückner reflex test for each eye of 10 subjects. The subjects alternated fixation between an ophthalmoscope light and an eccentric target (2.5°, 5°, 7.5°, and 10°). Set-up 2 comprised simulation of esotropia of 2° to 5°, 7.5°, and 10° by base-in prisms placed in front of both eyes of 20 subjects. The subjects fixated with either their right or left eye. As a control experiment, 0.5° base-in prisms were used.Set-up 1 tested the sensitivity in detecting a change in reflex between central and eccentric retinal illumination. Set-up 2 tested the sensitivity and specificity in detecting asymmetry of the Brückner reflex between the 2 eyes as a dimming of the reflex of the fixating eye in a 2° to 10° simulated esotropia.In set-up 1, fixation of the ophthalmoscope light owing to foveal dimming was discriminated from fixation of the eccentric target in 98.2% of the trials, regardless of target eccentricity. In set-up 2, esotropia of 2° to 5° was detected in 62% of 100 trials by red reflex asymmetry. Dimming of the reflex in the fixating eye was found in 48% of 100 trials. Esotropia of 7.5° and 10° was detected in 85% and 97% of the trials, respectively. Dimming in the fixating eye was present in 75% and 86% of the trials, respectively. Thirty-six percent of the 300 control tests were false-positives.When the eccentric fundus reflex was compared with the central reflex in the same eye, dimming owing to central fixation of the ophthalmoscope was reliably detected. However, comparison of the eccentric red reflex in the strabismic eye with the central reflex in the fixating eye showed that the Brückner red reflex test was not suitable for detecting small angles of squint.The authors have no proprietary or commercial interest in any of the materials discussed in this article.

Association of the red reflex in newborns with neonatal variables

The aim of this study was to investigate the results of the red reflex test and to associate these results with neonatal variables. This descriptive study was conducted with 190 newborns in a public maternity hospital. A total of 187 infants presented no alteration and three presented suspect results. Different shades of reflex color were observed: 50 (26.3%) presented red; 34 (17.9%) orange-red, 92 (48.4%) orange, 11 (5.8%) light yellow and three (1.6%) milky white spots. Statistically significant associations between the color gradient instrument and neonatal variables were found: weight (p=0.03), gestational age (p=0.019) and oxygen therapy (p=0.024). Nurses trained to practice and evaluate this test may become professionals in the potential for the prevention of childhood blindness.

Assessment of the Current Ocular Health Practices Within Neonatal Units in the City of São Paulo, Brazil

Purpose: To assess the ocular health practices within the neonatal units of the City of São Paulo, Brazil.Methods: A questionnaire was sent to 36 neonatal units that performed 3000 or more deliveries during 2004. Data were collected on Credè’s method of ophthalmia neonatorum prophylaxis, red reflex testing, retinopathy of prematurity (ROP) screening and treatment, and ophthalmic referral systems.Results: All of the identified neonatal units completed the survey. Credè’s method was used correctly in 31 (86%) units and the red reflex test was performed in 29 (81%) units. All units were aware of the risk factors for ROP, but the examination for its detection was executed on a routine basis in only 31 (86%) units and only 22 (61%) of the units were aware of the correct timing for the first examination for ROP. Treatment for ROP was done by the identifying hospital in 17 (55%) units and 14 (45%) hospitals transferred the neonate to an external service. After the patient’s discharge, 30 (83%) neonatal units reported that they appropriately referred neonates for ophthalmic follow up.Conclusions: Prophylaxis against gonococcal conjunctivitis and the red reflex test need to be implemented more widely, tertiary referral systems need to be established in some services and the management of ROP should be improved. These recommendations may be achieved by designing and implementing guidelines around prevention and control activities to ensure that all avoidable ocular diseases are identified and managed appropriately within this vulnerable age group.

The Detection of Simulated Retinoblastoma by Using Red-Reflex Testing

To determine the ability to detect simulated retinoblastoma by using the red-reflex test. Discs that simulated retinoblastoma lesions were affixed to the retina of model eyes with an 8- or 3-mm pupil. The diameter, height, and location of the discs varied. Five examiners evaluated the red reflex with direct ophthalmoscopy by using straight-on and oblique viewing. The generalized estimating equation was used to assess the effects of pupil dilation and observer viewing orientation on tumor detection. Significant 3-way interactions between pupil dilation, observer orientation, and tumor diameter (P < .004) or height (P < .02) were detected; these relationships depended on tumor diameter and height. A similar 3-way interaction was found between pupil dilation, observer orientation, and tumor location in degrees from the fovea (P < .001). Oblique viewing and pupillary dilation improved the tumor-detection rate. With straight-on viewing, the degree of detection was <48% (95% confidence interval [CI]: 39%-57%) for even the largest lesions, compared with 96% (95% CI: 93%-98%) for oblique viewing. For peripheral lesions, the percentage detection for straight-on viewing was 35% (95% CI: 21%-50%) for 30 degrees from the fovea and 16% (95% CI: 2%-31%) for 60 degrees from the fovea; these detection rates significantly improved with oblique viewing to 70% or higher (P < .001). Detection of simulated retinoblastoma was better when lesions were large and when oblique viewing and dilation were used. Peripheral location was negatively associated with detection. Red-reflex testing to detect leukocoria may be improved with oblique viewing and pharmacologic dilation.