Evaluation of the red reflex: An overview for the pediatrician

Abstract

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.

Newborn Screening: A Practical Guide to Pediatricians and Neonatologists

“…Red reflex examination of neonates helps in the early detection of severe eye conditions, such as cataracts, retinoblastoma, lens dislocation, strabismus, and glaucoma. 15 Studies have shown that universal newborn screening in the first 6 weeks of life can detect about 50%–75% of congenital cataracts requiring surgery. 16 This enables early surgery before 3 months of age, with improved long-term visual outcomes.…”

Automatic Refractive Error Estimation Using Deep Learning-Based Analysis of Red Reflex Images

“…The examiner then looks through the ophthalmoscope and focuses on both corneas simultaneously, noting a red reflex in each pupil [18]. A normal test consists of symmetrically bright and round red reflexes in both eyes [19]. Asymmetry of the reflexes may be associated with strabismus, anisometropia, media opacities or cataracts, retinoblastoma, colobomas, and pigment abnormalities of the posterior pole [18,20].…”

Trends in Neonatal Ophthalmic Screening Methods

“…The test is negative if the appearance is symmetric in both eyes and the reflex is round and bright. Any asymmetry, lack of a red reflex or white or dark defects means positivity of the test, and the infant must be referred to the ophthalmologist for further examination [1,2].…”

“…All peripheral retinal lesions remain, therefore, unrecognized. On the other hand, various anatomical, racial, technical, and other conditions make RRT difficult for non-ophthalmologists, and false-positive screening tests are common [2]. Corneal opacity usually forms part of a complex developmental disorder of the whole anterior part of the eye (dysgenesis of the anterior segment) (Figure 1).…”

“…All peripheral retinal lesions remain, therefore, unrecognized. On the other hand, various anatomical, racial, technical, and other conditions make RRT difficult for nonophthalmologists, and false-positive screening tests are common [2].…”