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

Abstract

Background/objectives Late presentation of congenital cataract in the developing world has led to poor outcomes such that cataract is the leading cause of childhood blindness. Our hypothesis was that, sensitivity of red-reflex testing is greater than sensitivity of torchlight examination. We aimed to compare sensitivity of new red reflex screening tools and assess the feasibility of Arclight red reflex screening in the community. Subject/methods We compared the diagnostic accuracy of four different screening tools for cataract and retinoblastoma performed by ophthalmic nurses, using a clinic based enriched sample of 41 positives and 60 negatives. We then conducted a separate feasibility study, training non-specialist community nurses. Following the training, community nurses examined 2827 children <5 years with Arclight who were attending their clinics for growth monitoring and immunisation. Findings Diagnostic accuracy study: estimated sensitivities were 97.6% for Catcam, 92.7% for Arclight, 90.2% for PEEK retina and 7.3% for torchlight. Estimated specificities were above 90% for Catcam, Arclight and torchlight and 87% for PEEK retina. Feasibility study: twenty-four out of 2728 children screened failed community screening, seven were true positive (six cataract, one retinoblastoma). Prevalence of bilateral cataract was 1.5/1000 (95% CI: 0.40-3.75 per 1000). Conclusions Arclight and CatCam have higher sensitivity than torchlight, are easy to learn and use by primary health care nurses. Red reflex testing should be recommended in the WHO guidelines instead of torchlight examination to help early detection of potential blinding causes including congenital cataract and retinoblastoma.

Evaluation of the red reflex: An overview for the pediatrician

“…The results revealed a significantly higher rate of prompt diagnosis of pediatric cataract, when RRT was performed at maternity wards, in comparison with the absence of RRT. A survey in Tanzania concluded the same results[ 38 ]. The need for implementation of red reflex screening is even stronger in Turkey, the Middle East, Asia and Africa.…”

“…The performance of the RRT, from infancy and at every well child visit, following current pediatric guidelines could prevent childhood blindness[ 3 , 38 ]. Literature data correlated the RRT with early detection of congenital cataract.…”

“…Nowadays, cataract remains one of the most usual reasons of preventable blindness in middle-low income countries, with very poor post-surgery visual outcomes. In these countries, late presentation of patients was very common[ 38 ]. A survey in East Turkey mentioned that 19% of pediatricians did not have an ophthalmoscope or did not know how to use it[ 40 ].…”

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

“…Non-ophthalmic staff who provide care to children, such as pediatricians, staff delivering immunisation programmes and neonatal/obstetric nurses could be trained to perform the BRT both opportunistically and systematically in their daily work. The feasibility of this approach has recently been evaluated in Tanzania demonstrating the Arclight to have sensitivity and specificity of over 90% (15). This could lead to earlier identification of eye conditions benefiting from intervention potentially improving outcomes of treatment and reducing the burden of visual impairment in children.…”

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

“…We are aware of one study in Tanzania which is in press and another unpublished study in Nigeria in which nurses were trained to elicit the red reflex of children to detect eye conditions such as cataract. 15 In one study three devices were assessed, one of which was the Arclight. Both studies demonstrated that nurses can correctly and reliably undertake this screening test (personal communications).…”