Red reflex

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The red reflex (also called the fundal reflex) refers to the reddish-orange reflection of light from the back of the eye, or fundus, observed when using an ophthalmoscope or retinoscope. The red reflex may be absent or poorly visible in people with dark eyes, and may even appear yellow in Asians or green/blue in Africans. [1]

Contents

The reflex relies on the transparency of optical media (tear film, cornea, aqueous humor, crystalline lens, vitreous humor) and reflects off the fundus back through media into the aperture of the ophthalmoscope. [2] The red reflex is considered abnormal if there is any asymmetry between the eyes, dark spots, or white reflex (Leukocoria).

Generally, it is a physical exam done on neonates and children by healthcare providers but occasionally occurs in flash photography seen when the pupil does not have enough time to constrict and reflects the fundus known as the red-eye effect.

This is a recommended screening by the American Academy of Pediatrics and American Academy of Family Physicians for neonates and children at every office visit. The objective is to detect ocular pathology that needs early intervention and ophthalmology referral to prevent visual abnormalities and more serious, but rarely, death.

It is difficult to assess the effectiveness of the technique due to the low incidence of some of the pathology the red reflex is used to detect. [3] For example, retinoblastoma, a neuroblastic tumor that can cause a dampened or even white reflex, occurs in 1 in every 20,000 children. [4] Regardless of the effectiveness, it is a fast,inexpensive, and noninvasive exam that could identify ocular pathology which with early identification can alter the course of the disease.

Red reflex technique

There are two techniques used to assess the red reflex listed below. Both are noninvasive, inexpensive, and quick. Dilation of the eyes is unnecessary and not recommended due to the theoretical but rarely seen risks of sympathomimetics and antimuscarinic systemic effects – tachycardia (fast heart rate), hypertension (high blood pressure), and arrhythmia (abnormal heart rhythm). [5] [6]

Red reflex or individual reflex

The traditional red reflex refers to visualizing each eye individually. The American Academy of Pediatrics describes using a direct ophthalmoscope with a lens at 0, approximately 18 inches away in a dimly lit room on each eye. [2]

Bruckner test

The Bruckner test differs in that one will visualize both eyes simultaneously. Unlike the red reflex, this can help determine if the patient has normal ocular alignment. In order to perform this test the patient and physician are normally approximately 2 to 3 feet away from each other. [7]

It is also used to detect opacities in the visual axis, such as a cataract or corneal abnormality. The inequality of red reflection in both the eyes indicates unequal refraction, indicating a refractive error. [8]

Limitations

Differential diagnosis

The differential diagnosis for what could be causing an abnormal reflex ranges in severity from causes that will resolve on their own to pathology that can be life-threatening, which is why expert evaluation is essential. Below are a few of the most referenced pathologies.

Needs intervention

Benign

Recommendations

Both the pediatric and family physician associations encourage newborn screening and continued assessment at all visits because some diseases only develop later in life. Two examples include: Familial exudative vitreoretinopathy and polar cataracts. This is considered an urgent referral that needs a "hot hand-off" or direct communication between the physician that found an abnormality and the ophthalmologist receiving the referral to discuss the patients history and current exam.

When to refer to children's ophthalmology?

For any of the reasons below a newborn or child should be seen by a physician that specializes in eye disease (see ophthalmologist).

See also

Related Research Articles

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<span class="mw-page-title-main">Retinoblastoma</span> Cancerous tumor of the developing eye

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<span class="mw-page-title-main">Amblyopia</span> Failure of the brain to process input from one eye

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<span class="mw-page-title-main">Eye examination</span> Series of tests assessing vision and pertaining to the eyes

An eye examination, commonly known as an eye test, is a series of tests performed to assess vision and ability to focus on and discern objects. It also includes other tests and examinations pertaining to the eyes. Eye examinations are primarily performed by an optometrist, ophthalmologist, or an orthoptist. Health care professionals often recommend that all people should have periodic and thorough eye examinations as part of routine primary care, especially since many eye diseases are asymptomatic.

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<span class="mw-page-title-main">Leukocoria</span> Abnormal white reflection from the eyes retina

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<span class="mw-page-title-main">Fundus (eye)</span> Concave interior of the eye

The fundus of the eye is the interior surface of the eye opposite the lens and includes the retina, optic disc, macula, fovea, and posterior pole. The fundus can be examined by ophthalmoscopy and/or fundus photography.

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Elias I. Traboulsi is a physician in the fields of ophthalmic genetics and pediatric ophthalmology.

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References

  1. ↑ "PhotoRED Technique". WE C Hope. Retrieved 2024-05-21.
  2. 1 2 3 4 5 6 7 American Association for Pediatric Ophthalmology and Strabismus; American Academy of Ophthalmology; American Association of Certified Orthoptists (2008). "Red Reflex Examination in Neonates, Infants, and Children". Pediatrics. 122 (6): 1401–1404. doi: 10.1542/peds.2008-2624 . PMID   19047263.
  3. ↑ Li, J.; Coats, D. K.; Fung, D.; Smith, E. O.; Paysse, E. (2010). "The Detection of Simulated Retinoblastoma by Using Red-Reflex Testing". Pediatrics. 126 (1): e202–e207. doi:10.1542/peds.2009-0882. PMID   20587677. S2CID   7071311.
  4. ↑ Shrestha, UD; Shrestha, MK; Yoon, PD; Yun, S.; Saiju, R. (2013). "Bruckner Red Light Reflex Test in a Hospital Setting". Kathmandu University Medical Journal. 10 (2): 23–26. doi: 10.3126/kumj.v10i2.7338 . PMID   23132470.
  5. ↑ Oğüt, M. S.; Bozkurt, N.; Ozek, E.; Birgen, H.; Kazokoğlú, H.; Oğüt, M. (1996). "Effects and side effects of mydriatic eyedrops in neonates". European Journal of Ophthalmology. 6 (2): 192–6. doi:10.1177/112067219600600218. PMID   8823596. S2CID   42351069.
  6. ↑ Gaynes BI (1998). "Monitoring drug safety: cardiac events in routine mydriasis". Optom Vis Sci. 75 (4): 245–246. doi:10.1097/00006324-199804000-00019. PMID   9586747.
  7. ↑ Pediatric eye exam and disease states, Mara Hover, DO. A T still University school of osteopathic medicine. November 2012.
  8. ↑ Procedures for the Evaluation of the Visual System by Pediatricians. Sean P. Donahue, MD, PhD, FAAP, Cynthia N Baker, MD, FAAP, COMMITTEE ON PRACTICE AND AMBULATORY MEDICINE, SECTION ON OPHTHALMOLOGY, AMERICAN ASSOCIATION OF CERTIFIED ORTHOPTISTS, AMERICAN ASSOCIATION FOR PEDIATRIC OPHTHALMOLOGY AND STRABISMUS, AMERICAN ACADEMY OF OPHTHALMOLOGY. https://pediatrics.aappublications.org/content/pediatrics/early/2015/12/07/peds.2015-3597.full-text.pdf
  9. ↑ Khan, A. O.; Al-Mesfer, S. (2005). "Lack of efficacy of dilated screening for retinoblastoma". Journal of Pediatric Ophthalmology and Strabismus. 42 (4): 205–10, quiz 233–4. doi:10.3928/01913913-20050701-01. PMID   16121549.
  10. ↑ American Academy of Ophthalmology Pediatric Ophthalmology/Strabismus Panel. Preferred practice pattern guidelines. Pediatric eye evaluations. San Francisco, Calif.: American Academy of Ophthalmology; 2007.
  11. ↑ Tongue, Andrea Cibis; Cibis, Gerhard W. (1981). "Brückner Test". Ophthalmology. 88 (10): 1041–1044. doi:10.1016/S0161-6420(81)80034-6. PMID   7335307.
  12. ↑ Paysse, E. A.; Williams, G. C.; Coats, D. K.; Williams, E. A. (2001). "Detection of Red Reflex Asymmetry by Pediatric Residents Using the Bruckner Reflex Versus the MTI Photoscreener". Pediatrics. 108 (4): e74. doi: 10.1542/peds.108.4.e74 . PMID   11581482.
  13. ↑ Wan, Michael J.; Vanderveen, Deborah K. (2015). "Eye disorders in newborn infants (Excluding retinopathy of prematurity)". Archives of Disease in Childhood - Fetal and Neonatal Edition. 100 (3): F264–F269. doi:10.1136/archdischild-2014-306215. PMID   25395469. S2CID   36687619.
  14. ↑ Hered RW (2011). "Effective vision screening of young children in the pediatric office". Pediatr Ann. 40 (2): 76–82. doi:10.3928/00904481-20110117-06. PMID   21323203.
  15. ↑ Melamud A, Palekar R, Singh A (2006). "Retinoblastoma [published correction appears in Am Fam Physician. 2007;75(7) 980]". Am Fam Physician. 73 (6): 1039–1044.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  16. 1 2 American Academy of Ophthalmology Pediatric Ophthalmology/Strabismus Panel. Preferred practice pattern guidelines. Pediatric eye evaluations. San Francisco, Calif.: American Academy of Ophthalmology; 2012.
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