Sensitivity and specificity of the red reflex in Costa Rican newborns

Comparison between wide-field digital imaging system and the red reflex test for universal newborn eye screening in Brazil

PURPOSE

To compare neonatal eye screening using the red reflex test (RRT) versus the wide-field digital imaging (WFDI) system.

METHODS

Prospective cohort study. Newborns (n = 380, 760 eyes) in the Maternity Ward of Irmandade Santa Casa de Misericórdia de São Paulo hospital from May to July 2014 underwent RRT by a paediatrician and WFDI performed by the authors. Wide-field digital imaging (WFDI) images were analysed by the authors. Validity of the paediatrician's RRT was assessed by unweighted kappa [κ] statistic, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV).

RESULTS

While WFDI showed abnormalities in 130 eyes (17.1%), RRT was only abnormal in 13 eyes (1.7%). Wide-field digital imaging (WFDI) detected treatable retina pathology that RRT missed including hyphema, CMV retinitis, FEVR and a vitreous haemorrhage. The sensitivity of the paediatrician's RRT to detect abnormalities was poor at 0.77% (95% confidence interval, CI, 0.02%-4.21%) with a PPV of only 7.69% (95% CI, 1.08%-38.85%). Overall, there was no agreement between screening modalities (κ = -0.02, 95% CI, -0.05 to 0.01). The number needed to screen to detect ocular abnormalities using WFDI was 5.9 newborns and to detect treatable abnormalities was 76 newborns.

CONCLUSION

While RRT detects gross abnormalities that preclude visualization of the retina (i.e. media opacities and very large tumours), only WFDI consistently detects subtle treatable retina and optic nerve pathology. With a higher sensitivity than the current gold standard, universal WFDI allows for early detection and management of potentially blinding ophthalmic disease missed by RRT.

Red reflex test screening for neonates: A systematic review and meta analysis

Red reflex test (RRT) screening is yet to be a part of the neonate's normal examination before discharge from hospital in a majority of low- and middle-income countries. The purpose was this review was to systematically evaluate the diagnostic accuracy of RRT for the detection of ocular abnormalities in newborns. PubMed, EMBASE, Scopus, Web of Science, and Cochrane database of systematic reviews were the data sources. Quality of Diagnostic Accuracy Studies-2 (QUADAS-2) was utilized for quality assessment of bias and applicability. Random effects models were used to summarize sensitivities, specificities, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR), and respective confidence intervals (CI). The pooled sensitivity, calculated from the meta analysis of 11 studies, was 23% (95% CI: 21-24%) and pooled specificity was 98% (95% CI: 98-98%). The PLR was 32.52 (95% CI: 7.89-134.15), NLR was less than 1 (0.69 [95% CI: 0.55-0.88]), and DOR calculated was 138.48 (95% CI: 23.85-803.97). The area under the curve (AUC) and Q* index for RRT were 0.98 ± 0.02 and 0.95 ± 0.045, respectively. The results of our study justify the conclusion that RRT is a highly sensitive and specific test for the detection of anterior segment abnormalities.

Diagnostic Test Accuracy of the Red Reflex Test for Ocular Pathology in Infants: A Meta-analysis

Importance

Red reflex testing is a simple and inexpensive method implemented in many countries as an important part of infant screening for ocular pathologies.

Objectives

To review the literature on the diagnostic accuracy of the red reflex test in infant screening for ocular pathologies and to perform meta-analyses to provide summary estimates.

Data Sources

The following literature databases were searched for English-language, peer-reviewed literature, published until April 19, 2020: Cochrane Central, PubMed/MEDLINE, Embase, Web of Science Core Collection, BIOSIS Previews, Current Contents Connect, Data Citation Index, Derwent Innovations Index, KCI-Korean Journal Database, Russian Science Citation Index, SciELO Citation Index, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and ClinicalTrials.gov.

Study Selection

Eligibility criteria were defined according to population (studies of consecutively screened infants), exposure (red reflex or Brückner test as the index test), comparator (any ophthalmological examination), and study type (any study with diagnostic test accuracy data).

Data Extraction and Synthesis

The Preferred Reporting Items for Systematic Reviews and Meta-Analysis of Diagnostic Test Accuracy Studies (PRISMA-DTA) guidelines were followed. Data were extracted independently by 2 authors. For summary estimates of diagnostic test accuracy, the hierarchical summary receiver operating characteristics curve was used. Prevalence of ocular pathologies was introduced for a prevalence meta-analysis, which was then used in calculations of diagnostic accuracy of the red reflex test when applied in infant screening.

Main Outcomes and Measures

True-positive, false-positive, true-negative, and false-negative findings; sensitivity; specificity; and positive and negative predictive values.

Results

In this meta-analysis, 8713 unique infants from 5 unique studies were eligible for qualitative and quantitative review. All studies used the red reflex test without pupillary dilation and were compared with a reference test performed with pupillary dilation. For any ocular pathology, an estimated sensitivity of 7.5% (95% CI, 7.4%-7.5%) and specificity of 97.5% (95% CI, 97.5%-97.5%) was found. Focusing on ocular pathologies that required a medical or surgical intervention, sensitivity improved to 17.5% (95% CI, 0.8%-84.8%) and specificity remained high at 97.6% (95% CI, 87.7%-99.6%).

Conclusions and Relevance

These findings suggest that an abnormal red reflex finding most likely reflects an underlying ocular pathology. However, a normal red reflex finding during screening does not exclude ocular disease.