Red Reflex Test Research Articles

Red Reflex Examination in Neonates, Infants, and Children

Red reflex testing is an essential component of the neonatal, infant, and child physical examination. This statement, which is a revision of the previous policy statement published in 2002, describes the rationale for testing, the technique used to perform this examination, and the indications for referral to an ophthalmologist experienced in the examination of children.

Lack of Efficacy of Dilated Screening for Retinoblastoma

To assess red reflex testing of the pharmacologically dilated pupil in screening for retinoblastoma. Children with a family history of retinoblastoma or a history of treated retinoblastoma who were admitted to our institution for examination using anesthesia during a 3-month period underwent red reflex testing of the pharmacologically dilated pupil in a masked fashion. Red reflexes were classified as normal (unremarkable), abnormal (in brightness or color), or absent (no reflex, black pupil). The results of the screenings were later compared with actual retinal findings. Red reflex testing of the dilated pupil failed to identify all 13 eyes that harbored retinoblastoma lesions (all 13 were classified as normal). The 3 eyes that were identified as having abnormal red reflexes had neither disease nor significant refractive error. Red reflex testing of the dilated pupil is a poor screening technique for retinoblastoma.

Screening for retinoblastoma: presenting signs as prognosticators of patient and ocular survival.

To correlate 3 common presenting signs of retinoblastoma with patient and ocular survival and to assess the efficacy of current pediatric screening practices for retinoblastoma. A retrospective study was conducted of 1831 retinoblastoma patients from our center (1914-June 2000). Patient survival (excluding deaths from other primary neoplasms) and ocular survival (presenting eyes) rates were calculated and analyzed using the Kaplan-Meier method. Leukocoria correlated with excellent patient survival (>86%, 5 years) but poor ocular survival in unilateral (4%, 5 years) and bilateral patients (29%, 5 years). A total of 308 (19%) of 1654 patients presented with strabismus: patient survival was excellent (90%, 5 years), and ocular survival was poor (17%, 5 years) yet better than leukocoria. Patients who had a family history of retinoblastoma and were clinically screened for retinal tumors from birth were diagnosed younger (8 months of age) and earlier (Reese Ellsworth group 1 = 26 [58%] of 45) and had better ocular survival than nonscreened patients with a family history. More patients were initially detected by family/friends (1315 [80%] of 1632) than pediatricians (123 [8%] of 1632) or ophthalmologists (156 [10%] of 1632). Most US children whose retinoblastoma is diagnosed initially present with leukocoria detected by a parent, despite routine pediatric screening for leukocoria via the red reflex test. Initial disease detection at the point of leukocoria or strabismus correlated with high patient survival rates and poor ocular survival rates for the presenting eye. Saving eyes and vision requires disease recognition before leukocoria, as demonstrated by the better ocular salvage rate among patients who had a positive family history and received clinical surveillance via early, routine dilated funduscopic examinations by an ophthalmologist.

Compliance With Vision-Screening Guidelines Among a National Sample of Pediatricians

The American Academy of Pediatrics (AAP) recommends vision screening from birth through adolescence, with visual acuity testing and binocular screening to begin at age 3 years. The 1996 AAP guidelines advised referral for visual acuity worse than 20/40 for children aged 3 to 5 years and worse than 20/30 for children aged 6 years and older. Our objective was to describe vision-screening and referral practices in a national sample of primary care pediatricians. We mailed a survey to a random sample of US pediatricians. Initial nonresponders were mailed up to 3 additional surveys. All mailings occurred between May and October 1998. Analyses focused on primary care pediatricians and consisted of descriptive statistics and regression analyses. The main outcome measure was compliance with 1996 AAP recommendations for vision screening. Of the 1491 surveys mailed, 888 (60%) were returned, including 576 (65%) from primary care pediatricians. Vision-screening methods included visual acuity testing (92%), cover test (64%), red reflex test (95%), fundoscopic examinations (65%), and stereopsis testing (32%). Respondents routinely performed visual acuity testing at 3 years (37%), 4 years (79%), 5 years (91%), 6 years (80%), 7-12 years (82%), and 13-18 years (80%). Visual acuity thresholds for referring 3- and 4-year-olds were 20/40 (47%, 51%), 20/50 (36%, 32%), or worse than 20/50 (14%, 12%). The majority of pediatricians referred children aged 5 years and older at 20/40, although thresholds worse than 20/40 were reported commonly (18%-33%). Logistic regressions were done to identify factors associated with higher likelihood of performing specific screening tests. Although no factor was consistently associated with use of all screening tests, size of the practice was significant in several regression models. Many pediatricians do not follow AAP guidelines for vision screening and referral, especially in younger children. Two thirds of pediatricians do not begin visual acuity testing at age 3 years as recommended, and about one fifth do not test until age 5 years. In addition, one fourth do not perform cover tests or stereopsis testing at any age.

Refractive Errors in Children

Optical correction of refractive errors in infants and young children is indicated when the refractive errors are sufficiently large to cause unilateral or bilateral amblyopia, if they are impairing the child's ability to function normally, or if the child has accommodative strabismus. Screening for refractive errors is important and should be performed as part of the annual physical examination in all verbal children. Screening for significant refractive errors in preverbal children is more difficult; however, the red reflex test of Bruckner is useful for the detection of anisometropic refractive errors. The photorefraction test, which is an adaptation of Bruckner's red reflex test, may prove to be a useful screening device for detecting bilateral as well as unilateral refractive errors. Objective testing as well as subjective testing enables ophthalmologists to prescribe proper optical correction for refractive errors for infants and children of any age.

Validation of performance of certified medical assistants in preschool vision screening examination

Preschool vision screening examination is still a new concept in Nepal. There is a need for developing cost-effective tools for detecting amblyogenic factors in Nepalese children. Certified medical assistants (CMA) are health personnel who work in village health posts. To find out the effectiveness of vision screening by certified medical assistants using simple tools like an HOTV chart and the Red Reflex test. A cross sectional and validation study was carried out in two phases. In the first phase, 20 CMAs from each Village Development Centre (VDC) of the Bhaktapur District were given training on visual acuity test by using an HOTV chart, Bruckner test by using a retinoscope and the test for ocular alignment by a torch light. In the second phase, children aged 3 - 7 years were examined by trained certified medical assistants in five remote VDCs of Bhaktapur District. These children underwent the gold standard examination by two pediatric ophthalmologists blind to the CMAs± findings. The mean age of children was 5.26 ± 376 years. The overall sensitivity of certified medical assistants examination was 58 % and the specificity was 98 %. While comparing the test characteristics of different examination tools, the HOTV test was found to be the most effective one with the sensitivity of 80 % and the specificity of 98 %. Vision screening by certified medical assistants can help in detection and early referral of children having amblyogenic risk factors with high sensitivity. The HOTV test is the most effective one with high sensitivity and specificity. In developing countries like Nepal,where access to regular eye examination is a rare possibility, preschool vision screening using the HOTV test can be effective.