Validity of the Bruckner reflex in the detection of amblyopia

Abstract

Purpose: To establish the sensitivity and specificity of the Bruckner reflex (comparison of the fundus red reflexes) in the detection of amblyopia or its risk factors.Methods: A single masked study using a medical student's diagnostic ability against the gold standard of a full clinical examination by a paediatric ophthalmologist. Setting:A university teaching hospital outpatient facility.Patients: Three hundred and one patients consecutively referred for ophthalmic assessment. Results:The sensitivity of the test for the detection of children with amblyopia risk factors was 86% and the specificity was 65%. Of 70 children with a definite diagnosis of amblyopia, the sensitivity of the test was 95%. Conclusions:The Bruckner reflex is a useful screening test for primary eye care personnel. However, there is a significant false-positive rate which will result in unnecessary referrals. We recommend that it form part of a battery of tests, including, for example, the modified base down prism test, which are useful in assessing the vision of preverbal children.Key words: Ambylopia, Bruckner reflex, paediatric ophthalmology.The detection of amblyopia or conditions likely to produce amblyopia such as anisometropia or strabismus is the major task to be undertaken during the examination of a child's eyes. In the younger child who is unable to provide recognition acuity there is a need for simple screening tests to detect amblyopia. In 1962 and subsequently, Bru~knerl-~ described a test using the direct ophthalmoscope which he had found useful for the detection of strabismus and amblyopia or risk factors for their development. He described several separate assessments including: (1) a comparison of the fundus red reflexes when viewed simultaneously at arms' length through the direct ophthalmoscope (the so-called Bruckner reflex4); and ( 2 ) evaluation of the fundus red reflex, pupillary action, and fixation movement with alternate illumination of each eye (the successive illumination test). The assessments together are usually referred to in the English literature as the Bruckner test. ' It is claimed that the simultaneous comparison of the fundus red reflexes (1 above) enables the detection of anisometropia as well as strabismus of three or so prism diopters or more.5 In other words, this assessment alone should detect the common causes of amblyopia. There have been few studies undertaken to determine the validity of the Bruckner test in toto or of the Bruckner reflex in particular as a screening test for ambly~pia.',~ None of the papers by Bruckner which we have cited provided evidence for the efficacy of the recommended tests.Due to an interest in photorefraction, which uses the Bruckner reflexJ4 and the need to

The Brückner test: extended distance improves sensitivity for ametropia

“…The mean correct score was 65% using the Brückner reflex at the traditional distance, versus 82% using a photorefractor [4]. Gole and Douglas reported a sensitivity of 86% and a specificity of not more than 65% for the Brückner reflex when performed by a medical student [16]. In both studies mentioned, the test distance was 1 m. In our patients group, a sensitivity of only 32.5% was achieved at that distance, and a specificity of 93.3%, which is not very reliable due to the small number of emmetropic patients in our group.…”

Task shifting in primary eye care: how sensitive and specific are common signs and symptoms to predict conditions requiring referral to specialist eye personnel?

“…The sensitivity and specificity for several other ocular tests used by non-ophthalmic health personnel including the red reflex, confrontation visual fields, and penlight test for photophobia to detect “serious” pathology has been measured with various results [9-13]. Recognition of the difficulty in determining when an eye is “red” has required investigators interested in conjunctival hyperemia to develop different grading schemes [14,15].…”

Doğumsal göz hastalıklarının erken tanısında kırmızı yansıma testinin (Brückner) etkinliğinin değerlendirilmesi

“…Black spots instead of normal reflection, absence of reflex, a blurred red reflex, a white reflex or nonsymmetrical reflex in the eyes are considered as abnormal red reflex test (8,11). An abnormal test may be the indicator of cataract, intraorbital bleeding, intraorbital tumors, retinal detachment, anisometry and high degrees of refractive error (11,12). Intrauterine infections, metabolic causes, chromosome anomalies and genetic causes have been blamed in the etiology (1,2).…”