Red reflex

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The red 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 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. [1] The red reflex is considered abnormal if there is any asymmetry between the eyes, dark spots, or white reflex (Leukocoria).

Contents

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. [2] For example, retinoblastoma, a neuroblastic tumor that can cause a dampened or even white reflex, occurs in 1 in every 20,000 children. [3] 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). [4] [5]

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. [1]

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. [6]

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. [7]

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

Red-eye effect

The red-eye effect in photography is the common appearance of red pupils in color photographs of the eyes of humans and several other animals. It occurs when using a photographic flash that is very close to the camera lens in ambient low light.

Ophthalmology Field of medicine treating eye disorders

Ophthalmology is a branch of medicine and surgery that deals with the diagnosis and treatment of disorders of the eye. An ophthalmologist is a physician who specializes in ophthalmology. The credentials include a degree in medicine, followed by additional four to five years of residency training in ophthalmology. Residency training programs for ophthalmology may require a one-year internship with training in internal medicine, pediatrics, or general surgery. Additional specialty training may be sought in a particular aspect of eye pathology. Ophthalmologists are allowed to prescribe medications to treat eye diseases, implement laser therapy, and perform surgery when needed. Ophthalmologists may participate in academic research on the diagnosis and treatment for eye disorders.

Diabetic retinopathy Medical condition

Diabetic retinopathy, also known as diabetic eye disease (DED), is a medical condition in which damage occurs to the retina due to diabetes mellitus. It is a leading cause of blindness in developed countries.

Retinoblastoma Medical condition

Retinoblastoma (Rb) is a rare form of cancer that rapidly develops from the immature cells of a retina, the light-detecting tissue of the eye. It is the most common primary malignant intraocular cancer in children, and it is almost exclusively found in young children.

Retinopathy of prematurity (ROP), also called retrolental fibroplasia (RLF) and Terry syndrome, is a disease of the eye affecting prematurely born babies generally having received neonatal intensive care, in which oxygen therapy is used due to the premature development of their lungs. It is thought to be caused by disorganized growth of retinal blood vessels which may result in scarring and retinal detachment. ROP can be mild and may resolve spontaneously, but it may lead to blindness in serious cases. Thus, all preterm babies are at risk for ROP, and very low birth-weight is an additional risk factor. Both oxygen toxicity and relative hypoxia can contribute to the development of ROP.

Amblyopia Failure of the brain to process input from one eye

Amblyopia, also called lazy eye, is a disorder of sight in which the brain fails to process inputs from one eye and over time favors the other eye. It results in decreased vision in an eye that otherwise typically appears normal. Amblyopia is the most common cause of decreased vision in a single eye among children and younger adults.

Eye examination A series of tests assessing vision and pertaining to the eyes

An eye examination 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, orthoptist, or an optician. 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.

Pediatric ophthalmology is a sub-speciality of ophthalmology concerned with eye diseases, visual development, and vision care in children.

Leukocoria Medical condition

Leukocoria is an abnormal white reflection from the retina of the eye. Leukocoria resembles eyeshine, but leukocoria can also occur in animals that lack eyeshine because their retina lacks a tapetum lucidum.

Coats disease Human eye disease causing full or partial blindness

Coats' disease, is a rare congenital, nonhereditary eye disorder, causing full or partial blindness, characterized by abnormal development of blood vessels behind the retina. Coats' disease can also fall under glaucoma.

In the fields of optometry and ophthalmology, the Hirschberg test, also Hirschberg corneal reflex test, is a screening test that can be used to assess whether a person has strabismus.

Fundus (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.

Polycoria is a pathological condition of the eye characterized by more than one pupillary opening in the iris. It may be congenital or result from a disease affecting the iris. It results in decreased function of iris and pupil, affecting the physical eye and visualization.

Fundus photography

Fundus photography involves photographing the rear of an eye, also known as the fundus. Specialized fundus cameras consisting of an intricate microscope attached to a flash enabled camera are used in fundus photography. The main structures that can be visualized on a fundus photo are the central and peripheral retina, optic disc and macula. Fundus photography can be performed with colored filters, or with specialized dyes including fluorescein and indocyanine green.

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

Congenital cataract Medical condition

Congenital cataracts refers to a lens opacity which is present at birth. Congenital cataracts cover a broad spectrum of severity: whereas some lens opacities do not progress and are visually insignificant, others can produce profound visual impairment.

Teleophthalmology

Teleophthalmology is a branch of telemedicine that delivers eye care through digital medical equipment and telecommunications technology. Today, applications of teleophthalmology encompass access to eye specialists for patients in remote areas, ophthalmic disease screening, diagnosis and monitoring; as well as distant learning.

Chloroquine retinopathy Medical condition

Chloroquine retinopathy, is a form of toxic retinopathy caused by the drugs chloroquine or hydroxychloroquine, which are sometimes used in the treatment of autoimmune disorders such as rheumatoid arthritis and systemic lupus erythematosus. This eye toxicity limits long-term use of the drugs.

Indocyanine green angiography

Indocyanine green angiography (ICGA) is a diagnostic procedure used to examine choroidal blood flow and associated pathology. Indocyanine green (ICG) is a water soluble cyanine dye which shows fluorescence in near-infrared range, with peak spectral absorption of 800-810 nm in blood. The near infrared light used in ICGA penetrates ocular pigments such as melanin and xanthophyll, as well as exudates and thin layers of sub-retinal vessels. Age-related macular degeneration is the third main cause of blindness worldwide, and it is the leading cause of blindness in industrialized countries. Indocyanine green angiography is widely used to study choroidal neovascularization in patients with exudative age-related macular degeneration. In nonexudative AMD, ICGA is used in classification of drusen and associated subretinal deposits.

Sickle cell retinopathy can be defined as retinal changes due to blood vessel damage in the eye of a person with a background of sickle cell disease. It can likely progress to loss of vision in late stages due to vitreous hemorrhage or retinal detachment. Sickle cell disease is a structural red blood cell disorder leading to consequences in multiple systems. It is characterized by chronic red blood cell destruction, vascular injury, and tissue ischemia causing damage to the brain, eyes, heart, lungs, kidneys, spleen, and musculoskeletal system.

References

  1. 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.
  2. ↑ 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.
  3. ↑ 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.
  4. ↑ 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.
  5. ↑ 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.
  6. ↑ Pediatric eye exam and disease states, Mara Hover, DO. A T still University school of osteopathic medicine. November 2012.
  7. ↑ 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
  8. ↑ 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.
  9. ↑ American Academy of Ophthalmology Pediatric Ophthalmology/Strabismus Panel. Preferred practice pattern guidelines. Pediatric eye evaluations. San Francisco, Calif.: American Academy of Ophthalmology; 2007.
  10. ↑ Tongue, Andrea Cibis; Cibis, Gerhard W. (1981). "Brückner Test". Ophthalmology. 88 (10): 1041–1044. doi:10.1016/S0161-6420(81)80034-6. PMID   7335307.
  11. ↑ 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.
  12. ↑ 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.
  13. ↑ 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.
  14. ↑ 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.CS1 maint: multiple names: authors list (link)
  15. 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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