Red reflex examination in reproductive and child health clinics for early detection of paediatric cataract and ocular media disorders: cross-sectional diagnostic accuracy and feasibility studies from Kilimanjaro, Tanzania.Eye (Lond). 2021;35:1347-1353. [PMID: 32546747 DOI: 10.1038/s41433-020-1019-5]

Universal newborn eye screening: a systematic review of the literature and review of international guidelines

Background

This systematic review assessed the effectiveness of universal screening for newborn eye abnormalities compared with no screening in improving infant vision and health outcomes.

Methods

We searched CENTRAL (Cochrane Library), MEDLINE, Embase, Global Health, Global Index Medicus, clinical trials databases, and bibliographies of relevant articles. We included randomized and observational studies of all newborns, regardless of illness or risk factors, that compared universal screening for any eye abnormality by eight weeks of age with no universal screening. Two authors independently selected studies, extracted data, and evaluated the risk of bias. We used GRADE to assess the certainty of evidence. We also reviewed available recommendations on newborn eye screening.

Results

Fourteen studies were identified but only three compared universal red reflex screening with no screening. Findings suggest that universal red reflex testing in maternity wards (MWs) may increase the number of newborns with congenital cataracts referred for eye care from MWs or well-baby clinics (WBCs) in the first year of life (risk ratio (RR) = 9.83, 95% confidence interval (CI) = 1.36-71.20; low certainty evidence). However, the effect of screening in WBC is uncertain (RR = 6.62, 95% CI = 0.87-50.09). The effect of MW or WBC screening on referral from any health care facility (MWs, WBCs, paediatrician clinic, other) in the first year is uncertain (MW screening: RR = 1.22, 95% CI = 0.63-2.39; WBC screening: RR = 0.97, 95% CI = 0.46-2.05). However, referral or surgery by 6 weeks of age may be higher with universal MW screening (early referral: RR = 4.61, 95% CI = 1.12-19.01; early surgery: RR = 8.23, 95% CI = 1.13-59.80; low certainty evidence). The effect of WBC screening on early referral and surgery is uncertain (early referral: RR = 1.98, 95% CI = 0.43-9.19; early surgery: RR = 3.97, 95% CI = 0.50-31.33; very low certainty evidence). Universal red reflex testing may increase clinical conjunctivitis (OR = 1.22, 95% CI = 1.01-1.47; low certainty evidence) but the effect on confirmed bacterial conjunctivitis is uncertain (OR = 1.20, 95% CI = 0.76-1.90; very low-certainty evidence). Nine guidelines recommended universal newborn eye screening using red reflex testing.

Conclusions

Evidence supports the role of red reflex testing shortly after birth to increase early identification, referral, and surgery for congenital cataracts.

Use of a Smartphone-Based Device for Fundus Examination in Birds: A Pilot Study

Simple Summary

Eye examination is crucial for therapeutic plans and rehabilitation of birds in wildlife rehabilitation centers. However, fundus examination using classical direct or indirect ophthalmoscopy techniques can be challenging in those species. The aim of the study was to assess the use of a smartphone-based retinal imaging system in birds. Fundus examination was feasible in most bird species examined in this study. The difficulties of carrying out the examination seem to be related to the form of the globe, the color of the iris, and the quality of pupil dilation. Further investigations are necessary to confirm these findings.

Abstract

Ophthalmic examination is essential in the avian triage process in order to apply prompt therapeutic plans and evaluate rehabilitation potential. Fundoscopy is traditionally performed by direct or indirect ophthalmoscopy. Recent technological developments have enabled the design of a small-sized and affordable retinal imaging system to examine the fundus. We investigate the use of a smartphone-based device to realize fundus examination through a prospective cross-sectional observational study. Seventy-seven eyes of 39 birds of 15 different species were evaluated using the smartphone-based device in a rescue wildlife center. Pupil dilation was achieved prior to examination via rocuronium topical application. Assessment of fundus by the smartphone was classified as satisfactory, moderately satisfactory, and unsatisfactory. Fundus examination was also performed with a 20D, 30D, or 78D lens for comparison. Pupillary dilation was satisfactory, moderately satisfactory, or absent in 17, 32, and 28 eyes, respectively. Fundus examination with the smartphone-based device was satisfactory, moderately satisfactory, or unsatisfactory in 44, 15, and 18 eyes, respectively. The feasibility of the fundus examination was affected by the form of the globe; by the quality of pupil dilation; by the color of the iris (images could not be obtained from species with an orange, bright iris); and by the species, with owls (Strigiformes) being the easiest to observe. Based on these findings, fundus examination was feasible in most bird species examined in this study.

EyeScreen

Purpose

Early diagnosis and treatment of retinoblastoma are of paramount importance for a positive clinical outcome. The most common sign of retinoblastoma is leukocoria, or white pupil. Effective, easy-to-perform, community-based screening is needed to improve outcomes in lower-income regions. The EyeScreen (developed by Joshua Meyer from the University of Michigan) Android (Google LLC) smartphone application is an important step toward addressing this need. The purpose of this study was to examine the potential of the novel use of low-cost technologies—a cell phone application and machine learning—to identify leukocoria.

Design

A cell phone application was developed and refined with the feedback from on-site, single-population use in Ethiopia. Application performance was evaluated in this technology validation study.

Participants

One thousand four hundred fifty-seven participants were recruited from ophthalmology and pediatric clinics in Addis Ababa, Ethiopia.

Methods

Photographs obtained with inexpensive Android smartphones running the EyeScreen Application were used to train an ImageNet (ResNet) machine learning model and to measure the performance of the app. Eighty percent of the images were used in training the model, and 20% were reserved for testing.

Main Outcome Measures

Performance of the model was measured in terms of sensitivity, specificity, receiver operating characteristic (ROC) curve, and precision-recall curve.

Results

Analyses of the participant images resulted in the following at the participant level: sensitivity, 87%; specificity, 73%; area under the ROC curve, 0.93; and area under the precision-recall curve, 0.77.

Conclusions

EyeScreen has the potential to serve as an effective screening tool in the areas of the world most affected by delayed retinoblastoma diagnosis. The relatively high initial performance of the machine learning model with small training datasets in this early-phase study can serve as a proof of concept for future use of machine learning and artificial intelligence in ophthalmic applications.

A Retrospective Study on the Eye-Related Quality of Life, Functional Vision, and Their Determinants Among Children Following Congenital and Developmental Cataracts Surgery and Its Impact on Their Families Using the PedEyeQ

Objectives

To evaluate the eye-related quality of life (ER-QOL), functional vision, and their determinants in children following congenital and developmental cataract surgery, as the impact on their families, using the Pediatric Eye Questionnaire (PedEyeQ).

Materials and Methods

This was a retrospective cross-sectional study involving 107 children (aged 0–11 years) with congenital and developmental cataracts who had undergone surgery, as well as 59 visually healthy controls (aged 0–11 years). One parent for each child completed either the Proxy 0–4 PedEyeQ, the Proxy 5–11 PedEyeQ, or the Parent PedEyeQ, depending on their child's age. Mann-Whitney U and Kruskal-Wallis tests were then conducted to compare the differences between groups and to analyze their determinants.

Results

PedEyeQ scores were found to be lower in postoperative children with congenital and developmental cataracts compared with the control group across all study domains. The PedEyeQ Proxy 0 to 4 years' greatest mean difference was 27 points worse in the Functional Vision domain (95% CI −34 to −19; p < 0.001). We also found that the occurrence of nystagmus (p < 0.005) and strabismus (p < 0.005) were the major factors affecting participants' functional vision. The PedEyeQ Proxy 5 to 11 years' greatest mean difference was 23 points worse in this same domain (95% CI −30 to −15; p < 0.001), with nystagmus (p < 0.05) being the main determinant herein. Parent PedEyeQ 0 to 4 years' greatest difference was 46 points worse on the Worry about their Child's Eye Condition domain (95% CI −57 to −36; p < 0.001). Similarly, parents of children with ophthalmologic abnormalities, including nystagmus (p < 0.001) and strabismus (p < 0.05), were significantly more worried about their children's eye condition. Parent PedEyeQ 5 to 11 years' greatest difference was also found to be 30 points worse on the Worry about their Child's Eye Condition domain (95% CI −43 to −17; p < 0.005).

Conclusions

Children who have undergone congenital and developmental cataract surgery experience a lower quality of life and reduced functional vision. Their families are also significantly and adversely affected herein. Thus, more attention is needed on these groups, with more focused measures being administered to both children and their families.

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.

Evaluation of the red reflex: An overview for the pediatrician

BACKGROUND

Red reflex test (RRT) is a simple, non-invasive method that can be performed easily by pediatricians during the clinical examination in neonatal period, infancy and childhood. Abnormal reflexes can lead to prompt diagnosis of several ocular disorders, with potentially severe consequences on patient's vision, cognitive function and even life.

AIM

To underline the contribution of pediatricians to early detection of vision and life threatening diseases by using RRT effectively.

METHODS

For the present systematic review, PubMed searches were performed using the key words "red reflex and newborn"; "red reflex and neonate"; "red reflex and complications"; "red reflex and necessity"; "red reflex and retinoblastoma"; "red reflex and congenital cataract"; "red reflex and glaucoma"; "red reflex and prematurity"; "red reflex and leukocoria"; "red reflex and blindness"; "red reflex sensitivity and specificity"; "red reflex and differential diagnosis"; "red reflex and guidelines". The relevant articles were selected without language restrictions. When a full-text publication was not available, their English abstracts were used. In some cases, studies from the reference lists of the selected articles provided useful information. The research took place in September 2020, in the Ophthalmology Department of University Hospital of Alexandroupolis.

RESULTS

A total of 45 articles were selected according to the used key words. After reviewing data from these articles, it is supported that red reflex remains an effective tool of undeniable importance for early detection of severe eye conditions, such as cataract, retinoblastoma, retinopathy of prematurity and glaucoma. Although literature reports some limitations of RRT, including a notable percentage of false positive tests, the inability to detect small, peripheral retinoblastomas and the lower sensitivity for posterior segment pathology, it is widely accepted that the benefits from the regular evaluation of the test on public health are significant. Therefore, RRT has been established by international guidelines and should be an essential component of pediatricians clinical practice. Red reflex implementation should be incorporated in pediatricians educational programs, so that they would be able to provide quality services and safe diagnoses.

CONCLUSION

The implementation of RRT should be encouraged in all neonatal/pediatric departments. Prompt education of pediatricians should be empowered in order to achieve careful vision screening, according to current guidelines.

Identification of amblyogenic risk factors with the Brückner reflex test using the low-cost Arclight direct ophthalmoscope

BACKGROUND/OBJECTIVES

The Arclight is a novel, low-cost, solar-powered direct ophthalmoscope developed for low resource settings as an alternative to more expensive, conventional devices. The Brückner reflex test (BRT) is a quick and effective means to screen for eye disease and amblyogenic risk factors. This test is however rarely performed in low resource settings due to the lack of access to ophthalmoscopes and trained health care workers. Our aim was to establish the sensitivity and specificity of the BRT when performed by a non-expert using an Arclight and compare to an expert as well as the results of a full clinic workup.

SUBJECTS/METHODS

In this prospective, blinded study, 64 patients referred to a paediatric ophthalmology clinic had the BRT performed by a 'non-expert' observer (medical student) then an 'expert' observer (consultant ophthalmologist). These results were then compared against the 'gold standard' outcomes of a full clinical workup.

RESULTS

BRT screening by the expert observer led to a sensitivity of 75.0% [95% CI: 57.9-86.8%] and a specificity of 90.6% [95% CI: 75.8-96.8%] in picking up media opacity, strabismus, refractive error or a combination of the above. For the non-expert, the sensitivity and specificity were 71.9% [95% CI: 54.6-84.4%] and 84.4% [95% CI: 68.3-93.1%], respectively.

CONCLUSIONS

The Arclight can be effectively used to perform the BRT and identify eye disease and common amblyogenic risk factors. Even when performed by a non-expert the results are highly specific and moderately sensitive. This study consequently offers support for the use of this low-cost ophthalmoscope in the expansion of eye screening by health care workers in low resource settings.

Integrating eye health training into the primary child healthcare programme in Tanzania: a pre-training and post-training study

OBJECTIVES

To evaluate a primary child eye care training module for use in the WHO/UNICEF Integrated Management of Newborn and Childhood Illness (IMNCI) programme by primary healthcare workers.

DESIGN

Pre-training and post-training study.

SETTING

Primary healthcare facilities in a semirural district, central Tanzania.

PARTICIPANTS

54 primary healthcare workers selected by the Ministry of Health were trained during routine IMNCI training. All these healthcare workers were assessed pre-intervention and post-intervention. A subgroup of 40 were also assessed 6 months after the completion of training.

INTERVENTION

Training in an IMNCI eye module, developed for child primary healthcare workers with the Tanzania Ministry of Health and eye care experts.

MAIN OUTCOME MEASURES

Knowledge, skills and attitudes were assessed using multiple choice questions, case studies and a self-assessment of skills using a Likert scale before and immediately after training, and 6 months later. A total score was derived. At 6 months, attitudes were assessed in semistructured interviews.

RESULTS

69% PHWs trained were nurses. The baseline (before training) score was 29.9 (95% CI 27.5 to 32.4) and increased by 11.2 points (95% CI 8.3 to 14) immediately after training, and by 12.4 points (95% CI 9.2 to 15.6) at 6 months post the training. Therefore, the post-training scores increased and there was no evident difference in scores from immediately after training to 6 months later. Self-assessed confidence in skills decreased from 9/18 (95% CI 9 to 10) to 6/18 (95% CI 6 to 7). At 6 months, the module was reported as easy to understand and use, with challenges including difficulties in examining children's eyes and poor referral systems.

CONCLUSIONS

The module increased knowledge of child eye health in primary healthcare workers, which was maintained, and was acceptable. The module has since been included into the national IMNCI health policy in Tanzania.