Neonatal Macular Hemorrhage in a Term Healthy Infant: 18-Year Follow-up

Unobstructed binocular vision is required during the critical period of vision development to obtain optimal visual acuity in each eye and binocular stereopsis. In this article, we report 18-year follow-up of a full-term, otherwise healthy infant noted to have dense premacular hemorrhage occluding the visual axis in the left eye on retinal imaging performed 48 hours after birth. Serial examinations by the retina service were performed weekly for 10 weeks as the hemorrhage resolved spontaneously. Shortly thereafter, visual acuity revealed fixation was present, but the mother noted intermittent left eye esodeviation. At 90 days of life, the infant was seen by pediatric ophthalmology and started on 1 to 2 hours patching of the right eye daily for the esotropia, which was maintained through 24 months. At 18 years of age, the patient had orthophoria alignment, no spectacle correction, vision of 20/20 in the right eye and 20/25 in the left eye, and normal binocularity and stereopsis. Intermittent esodeviation on the left eye was observed when the patient was fatigued. Early identification of a visual axis occlusion led to prompt referral for the esotropia and initiation of patching therapy. This patient ultimately achieved a very favorable visual functional outcome that may not have been possible without early detection and management. This case report describes the longest-term published follow-up of a neonatal macular hemorrhage. [Ophthalmic Surg Lasers Imaging Retina 2024;55:354-357.].

The ocular anterior segment examination of perinatal newborns by wide-field digital imaging system: a cross-sectional study

PURPOSE

The aim of this study was to evaluate and summarize the developmental rules of the ocular anterior segment of neonates by means of wild-field digital imaging system.

METHODS

We used the wide-field digital imaging system to sequentially capture images of the neonates' eyes within 42 days after delivery, including the ocular surface, anterior segment, and fundus. At the same time, basic information at the time of birth and examination was collected.

RESULTS

Among 248 newborns, 51.21% were male. Abnormalities of the anterior segment such as visualization of anterior chamber angle vessels (79.03%) and iris vessels (51.21%), iris process (42.34%), persistent pupillary membranes (19.35%), albinism, congenital cataracts, corneal leucoma, and subconjunctival hemorrhage were observed in this study. There were significant differences in the appearance of iris vessels among different sex, gestational age and birth weight, postmenstrual age and weight at the time of examination and iris color groups. The iris vessels were more visualized in males relative to females (OR = 6.313, 95% CI 2.529-15.759). The greater the postmenstrual age at the time of examination, the lower the visualization of iris vessels (OR = 0.377, 95% CI 0.247-0.575). In addition, although visualization of anterior chamber angle vessels differed within the birth gestation age and weight at examination groups, there was no significant correlation by regression analysis.

CONCLUSIONS

The anterior segment of perinatal neonates can be visualized by the wide-field digital imaging system. The neonatal iris and anterior chamber angle are immature, and the visible vessels at the anterior chamber angle that vanish later than the surface of the iris are characteristic structures.

Time to Treatment of Pediatric Retinal Detachments: A US Claims-based Analysis

PURPOSE

To characterize delays in diagnosis and treatment of retinal detachments (RDs) in a pediatric population.

DESIGN

Retrospective cohort study using insurance claims data.

SUBJECTS

Pediatric patients with RD who underwent repair in the outpatient setting.

METHODS

A retrospective analysis of commercially insured patients from a national cohort (IBM MarketScan Research Databases) aged ≤ 18 years with an incident diagnosis of RD between 2007 and 2016. Patients with preceding eye-related visits, time to diagnosis, and time to repair were calculated and compared between patients with pre-existing ocular diagnosis and those without.

MAIN OUTCOME MEASURES

The time from diagnosis to specialist consultation, time from diagnosis to repair, time from specialist consultation to repair, number of preceding visits, and presence of previous eye-related diagnosis.

RESULTS

Our sample consisted of 826 patients, the majority (77%) of whom were diagnosed with rhegmatogenous RD. Only 40% of patients had at least 1 preceding eye-related visit, and 33% had at least 2 visits before RD diagnosis, with a median time from the last eye-related visit of 32 days (4-197 days) and median time from the second to last visit of 118 days (24-437 days). The median time from RD diagnosis to repair was 2 days (0-9 days). The 323 (37.9%) patients with pre-existing ocular diagnoses more frequently had at least 1 (44% vs. 37%; P = 0.079) or 2 preceding eye-related visits (40% vs. 29%; P = 0.002) compared with those without and also had a shorter time to RD diagnosis (median, 14.5 days vs. 44.5 days; P = 0.011) and repair (1 day vs. 3 days; P = 0.003).

CONCLUSIONS

Retinal detachment is an important cause of morbidity in children. This work highlighted how pediatric patients without previous ocular diagnoses and visits with eye care professional may have a delayed diagnosis and repair of their RD.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Development of Sensory Processing in Premature Infants and Implications for Evidence-Based Music Therapy in the NICU

The purpose of this article is to provide an overview of the development of sensory processing in premature infants with implications for music therapists providing evidence-based care in a NICU. An overview of sensory processing and sensory processing disorders in premature infants is included, with specific emphasis on development of sensory systems of premature infants. Implications for developmentally appropriate music as therapy for premature infants are identified. Evidence-based NICU-MT can be combined with nursing care to reduce the risks of sensory processing disorder for the developing premature infant.

Trends in Neonatal Ophthalmic Screening Methods

Neonatal ophthalmic screening should lead to early diagnosis of ocular abnormalities to reduce long-term visual impairment in selected diseases. If a treatable pathology is diagnosed within a few days after the birth, adequate therapy may be indicated to facilitate the best possible conditions for further development of visual functions. Traditional neonatal ophthalmic screening uses the red reflex test (RRT). It tests the transmittance of the light through optical media towards the retina and the general disposition of the central part of the retina. However, RRT has weaknesses, especially in posterior segment affections. Wide-field digital imaging techniques have shown promising results in detecting anterior and posterior segment pathologies. Particular attention should be paid to telemedicine and artificial intelligence. These methods can improve the specificity and sensitivity of neonatal eye screening. Both are already highly advanced in diagnosing and monitoring of retinopathy of prematurity.

Evaluation of the prematurity retinopathy and other eye changes in the newborn

Objective

To assess the prevalence of ophthalmologic manifestations in newborns in a maternity hospital in the city of São Paulo, SP, and the main risk factors related with the development of retinopathy of prematurity.

Methods

A retrospective, longitudinal study with patients born from 2015 to 2017 who required ophthalmological evaluation. The research variables were obtained by analysis of the newborn medical charts.

Results

A total of 773 patients were studied. The sample consisted of 288 examinations performed by indication of gestational age ≤32 weeks: 118 (42.4%) in 2015, 105 (42.2%) in 2016, 65 (26.4%) cases in 2017. There were 329 evaluations indicated due to birth weight: 113 (40.6%) in 2015, 108 (43.4%) in 2016, and 108 (43.9%) in 2017. The prevalence of associated risk factors was 97 (34.9%) cases in 2015, 96 (38.6%) in 2016, and 54 (22%) in 2017, followed by mechanical ventilation with 82 (29.5%) cases in 2015, 64 (25.7%) in 2016 and 41 (16.7%) in 2017, and continuous positive airway pressure with 59 (21.2%) cases in 2015, 72 (28.9%) in 2016, and 46 (18.7%) in 2017. For the other indications, the evaluations performed due to congenital syphilis were the majority in the 3-year period of the study, with 55 (19.8%) newborns in 2015, 54 (21.7%) in 2016, and 59 (24.0%) in 2017. The most prevalent ophthalmologic diagnosis was retinopathy of prematurity, with 79 (35.3%) cases in 2015, 64 (32.2%) in 2016, and 41 (24.1%) in 2017.

Conclusion

Most neonates born in the organization do not present risk factors for ophthalmological manifestations. Retinopathy of prematurity was the disease with greater strength of association found in our study. For the other indications, the evaluations performed due to congenital syphilis prevail in the 3- year period of the study.

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.].

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.

Early detection of ocular abnormalities in a Chinese multicentre neonatal eye screening programme-1-year result

PURPOSE

Early detection of ocular abnormalities in newborns is essential for timely diagnosis and treatment. This study aimed to assess the 1-year result of a multicentre prospective neonatal eye examination programme with wide-field digital imaging system in China.

METHODS

A multicentre collaborative prospective study group for neonatal eye screening was established in nine hospitals, including eight Maternal and Children's Hospitals, and one general hospital across China from July 2016 to June 2017. Ocular examinations were performed on newborns within 28 days after birth using a wide-field digital imaging system. Data were reviewed and analysed. The primary outcome was the prevalence of ocular abnormalities in neonates.

RESULTS

We detected 13 514 (20.91%) abnormal cases in 64 632 newborns. The most frequent abnormality was retinal haemorrhage (RH; 11.83%). Most of mild RH resolved spontaneously. Among those who were beyond retinopathy of prematurity (ROP) screening criteria of China (gestational age ≥32 w and birthweight ≥2000 g), the total number of neonates with ocular abnormality was 12 218/62 799(19.45%). 59.44% of neonatal ocular abnormalities detected (accounting for 11.56% of all the screened population) needed further interference or observation. Among them, 258 patients (0.41% of all the screened population) needed immediate or timely intervention, including congenital cataract, retinal detachment, retinoblastoma and other ocular abnormalities. One thousand and ninety-eight patients (1.75% of all the screened neonates) should be followed up closely and needed further diagnosis or intervention if necessary, such as ROP or ROP-like retinopathy, familial exudative vitreoretinopathy and persistent hyperplasia of primary vitreous. Five thousand nine hundred and six patients (9.4%) with minor clinical significance needed short-term follow-up.

CONCLUSIONS

This prospective multicentre study of newborn ocular examination showed a relatively high prevalence of ocular abnormalities. There are a relatively high percentage of congenital eye pathology that required further referral and treatment in those neonates who were not screened routinely. According to the benefits and risks associated with neonatal eye examinations, neonatal ocular screening programme can detect ocular abnormalities at the very early stage and may play a positive role in promoting paediatric eye health.

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.

Comprehensive Ocular Examination of Healthy Newborns in the Middle East

Purpose: To report the prevalence of the perinatal ocular disease in healthy infants referred to a referral eye centre in the Middle East region for comprehensive ocular examinations.Methods: All healthy full-term babies born at a tertiary care women's and children hospital were referred to Moorfields Eye Hospital Centre in Abu Dhabi (MEHCAD), the United Arab Emirates for comprehensive ocular examination between January 2018 and April 2019. The examination included red-reflex testing, external, anterior and dilated posterior segment examination, and refraction.Results: Out of 6836 newborns, 4719 (69%) were not referred due to lack of national insurance (n = 3089), out of network referral (n = 1405), required ROP screening (n = 220) and identification of systemic diagnosis (n = 5). Of 2117 eligible referrals 897 (42%) babies were not examined because they either did not attend (890) or had a double booking for ROP screening (7); hence, 1220 babies (56%) were examined. Their mean age was 39 ± 16 days, and 48.8% were male, 51.2% were female. One hundred and sixty-four (13.4%) babies had an ocular abnormality in 249 (10.2%) eyes. The commonest abnormalities were nasolacrimal duct obstruction (36%) and refractive errors in 53 patients (32.3%). Congenital cataract and ptosis were present in four (0.3%) and three (0.2%) babies, respectively. The commonest retinal findings were intra-retinal haemorrhages (1.4%). Other posterior pole abnormalities included optic disc pit (0.08%) and myelinated nerve fibers (0.08%). One eye (0.08%) had a congenital macular hole.Conclusion: Comprehensive ocular examinations of healthy infants identifies a number of ocular abnormalities that would not be detected using red-reflex testing by a paediatrician or nurse.

Sensitivity and specificity of the red reflex in Costa Rican newborns

OBJECTIVE

To compare the results of indirect ophthalmoscopy versus determination of the red reflex in newborns admitted to the intermediate neonatal intensive care unit.

METHODS

All the patients (71) admitted to the intermediate neonatal intensive care unit from July to September of 2017 were screened with the red reflex. Immediately afterwards, they were pharmacologically dilated and indirect ophthalmoscopy was performed. All of the red-reflex screening and the funduscopic examination were performed by the same evaluator.

RESULTS

A total of 14.1% (20/142) of the eyes had an altered red reflex. Indirect ophthalmoscopy revealed that 21.8% (31/142) of the eyes had intraocular abnormalities. Two of these eyes had optic nerve colobomas, two eyes had cataracts, and the rest had intra-retinal haemorrhages. Indirect ophthalmoscopy revealed that only 35% (7/20) of the eyes with an altered red reflex had intraocular disease. Indirect ophthalmoscopy also revealed that intraocular disease was present in 77.4% (24/31) of the eyes despite a normal red reflex. The false positive rate of the red reflex was calculated to be 9.2%, and the false negative rate was 16.9%. The sensitivity of the red reflex was only 56.4%, and the specificity was 89.5%. The positive predictive value was 70.4%, and the negative predictive value was 82.2%.

CONCLUSIONS

Neonatal screening with the red reflex is not sufficient to detect intraocular disease. A normal neonatal red reflex does no exclude intraocular disease. It has a specificity of nearly 90%, but its sensitivity is only 56%. Most retinal haemorrhages are undiagnosed as they cannot be detected with a red reflex.