The analysis of posterior segment findings in term and premature infants using RetCam images

Accidentally diagnosed ocular abnormalities identified during close screening for retinopathy of prematurity

PURPOSE

To report the variety of ocular findings which have been identified serendipitously during the screening for retinopathy of prematurity (ROP) in a tertiary referral center during seven-year period.

METHODS

The charts of 1568 preterm infants who screened for ROP were reviewed retrospectively. Any ocular lesion except for ROP were noted. All infants had undergone routine ocular examination of the external eye, pupillary light reflex, anterior and posterior segment. Wide-angle digital retinal image acquisition system for any vitreoretinal pathology requiring a close follow-up had been utilized.

RESULTS

Abnormal ocular findings other than ROP were diagnosed in 296 infants (19.2%). Tunica vasculosa lentis was the most common finding (25%) followed by vitreous or retinal hemorrhages (17.2%) and retinal white lesions (16.6%). Retina was the most frequently involved anatomic site. Other frequent ocular findings included optic disc cupping, congenital cataract, optic nerve hypoplasia, choroidal nevus, persistent fetal vasculature, lid hemangioma, and tilted disc. However, life-threatening pathologies such as lipemia retinalis and even retinoblastoma were also diagnosed.

CONCLUSION

A duly ophthalmologic examination is mandatory in premature infants for ROP screening. During such examinations, ophthalmologists must be aware of coexisting ocular findings; which could be sight-threatening or even life-threatening.

Referable Macular Hemorrhage-A Clinically Meaningful Screening Target in Newborn Infants. Position Statement of the Association of Pediatric Retina Surgeons

Universal newborn eye screening facilitates early diagnosis of ocular abnormalities and mitigates vision loss. "Referral warranted" eye disease is present at birth in about 5.5% of term infants, with "macular hemorrhage impinging on the fovea" representing about 50% of referral warranted disease. The Association of Pediatric Retina Surgeons held a symposium on February 9, 2021 that culminated in a position statement on "referable macular hemorrhage" (RMH) in newborn infants. RMH is meaningful in that in can cause amblyopia through deprivation, can be readily captured with wide-angle photography in a safe and efficient manner, and may lead to early intervention with mitigation of vision loss. [Ophthalmic Surg Lasers Imaging Retina. 2022;53:3-6.].

Newborn Eye Screening as an Application of AI

Artificial intelligence (AI) applications are diverse and serve varied functions in clinical practice. The most successful products today are clinical decision tools used by physicians, but autonomous AI is gaining traction. Widespread use of AI is limited in part because of concerns about bias, fault-tolerance, and specificity. Adoption of AI often depends on removing cost and complexity in clinical workflow integration, providing clear incentives for use, and providing clear demonstration of clinical outcome. Existing wide-angle photographic screening could be integrated into the clinical workflow based on prior implementations for premature babies and linked with AI interpretation with existing technology. Incidence of retinal abnormality, clinical considerations, AI performance, grading variation for AI-augmented human grading, and cost and policy aspects play a significant role. Improved outcomes for newborns and a relatively high estimated incidence of abnormality have been named as benefits to counterweigh costs in the long term. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:S17-S22.].

The Utility of Universal Newborn Eye Screening: A Review

Universal newborn eye screening can identify ocular abnormalities early and help mitigate long-term visual impairment. Traditional neonatal and infant eye screening is administered by neonatologists and pediatricians using the red reflex test. If this test identifies an ocular abnormality, then the patient is examined by an ophthalmologist. Notably, the red reflex test may be unable to detect amblyogenic posterior segment pathology. Recent studies using fundus imaging and telemedicine show reduced cost of human resources and increased sensitivity compared with traditional approaches. In this review, the authors discuss universal newborn eye screening pilot programs with regard to disease prevalence, referral-warranted disease, and cost-effectiveness. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:S6-S16.].

Neonatal eye screening for 203 healthy term new-borns using a wide-field digital retinal imaging system

Background

The current practice for new-born eye examination by an Ophthalmologist in Malaysian hospitals is limited to only preterm new-borns, syndromic or ill infants. Healthy term new-borns are usually discharged without a thorough eye examination. This study is aimed at determining the proportion and types of ocular abnormalities detected in purportedly healthy term new-borns.

Method

This cross-sectional study is comprised of 203 participants, all purportedly healthy term new-born infants from the Obstetrics and Gynaecology ward at Hospital Kuala Lumpur over a 6 months period. The examination list includes external eye examination, red reflex test, and fundus imaging using a wide-field digital retinal imaging system (Phoenix Clinical ICON Paediatric Retinal Camera) by a trained Investigator. The pathologies detected were documented. The results were compared and correlated with similar studies published in the literature previously.

Results

Total ocular abnormalities were detected in 34% of the infants. The most common finding was retinal haemorrhage in 29.6% of the infants, of which 53.3% occurred bilaterally. Spontaneous vaginal delivery (SVD) remained the greatest risk factor which has nearly 3.5 times higher risk of new-borns developing retinal haemorrhage compared to Lower Segment Caesarean Section (LSCS). There was a 6% increased likelihood of developing retinal haemorrhage for every 1-min increment in the duration of 2nd stage of labour.

Conclusion

Universal eye screening for all new-borns using a wide-field digital imaging system is realistically possible, safe, and useful in detecting posterior segment disorders. The most common abnormality detected is retinal haemorrhage.

Effect of macular edema in the premature period on refraction in infants screened and treated for retinopathy of prematurity

BACKGROUND

To determine the effect of macular edema on refraction in infants with retinopathy of prematurity (ROP) at the ages of one, two and three years using Optical Coherence Tomography (OCT).

METHODS

Optical coherence tomography (OCT) was performed to detect and categorize edema in 280 eyes of 280 premature infants. The cross-sectional spectral domain OCT imaging of the macular region was performed between weeks 36 and 42 to assess macular development. Refraction measurement was performed during follow-up at the ages of one, two and three years. Macular thickness, choroidal thickness, macular edema severity, and the spherical, cylindrical and spherical equivalent (SE) values were measured.

RESULTS

A positive correlation was found between macular thickness in the premature period and the SE value at age one and a negative correlation at age three. No correlation was found between gestational age and the SE value, but there was a positive correlation between birth weight and the SE value at ages one and two. Although no correlation was determined between edema and gestational age or between edema and birth weight, the prevalence of macular edema in infants with ROP was significantly higher than that of infants without this disease.

CONCLUSIONS

Macular edema during the premature period can have an impact on refraction at the ages one, two and three years by effecting the emmetropization process.