BJO Online First, published on February 20, 2013 as 10.1136/bjophthalmol-2012-302539 Br J Ophthalmol: first published as 10.1136/bjophthalmol-2012-302539 on 20 February 2013. Downloaded from Clinical science Findings of perinatal ocular examination performed on 3573, healthy full-term newborns Li-Hong Li,1 Na Li,1 Jun-Yang Zhao,2 Ping Fei,3 Guo-ming Zhang,4 Jian-bo Mao,5 Paul J Rychwalski6 1Maternal and Children’s ABSTRACT children who despite screening go undetected with Hospital, Kunming, Yunnan, Objective To document the findings of a newborn eye respect to vision and eye disorders. A careful China 2Beijing Tongren Ophthalmic examination programme for detecting ocular pathology review of Pubmed revealed no published literature Center, Capital University of in the healthy full-term newborn. on the universality, much less the sensitivity and Medical Sciences, Beijing, Methods This is a cross-sectional study of the majority false-negative rate of RRT of normal newborns. China 3 of newborns born in the Kunming Maternal and Child Further, this age group has not been studied exten- Shanghai Xinhua Hospital, Healthcare Hospital, China, between May 2010 and sively and the actual prevalence of ocular abnor- Shanghai, China 4Shenzhen Eye Hospital, Jinan June 2011. Infants underwent ocular examination within malities, transient and permanent, is largely University, Shenzhen, China 42 days after birth using a flashlight, retinoscope, hand- unknown. There are few previous studies looking 5Eye Hospital of Wenzhou held slit lamp microscope and wide-angle digital retinal at the incidence of retinal haemorrhages in healthy Medical College, Wenzhou, image acquisition system. The retinal fundus examination full-term newborns. Smaller series have been pub- China 23 6 utilised the RetCam wide-field digital imaging system lished previously and one study looked at fundus Cole Eye Institute, Cleveland 4 Clinic Foundation, Cleveland, (Clarity Medical Systems, Pleasanton, California, USA). findings only in critically ill children. Ohio, USA The external eye, pupillary light reflex, red reflex, opacity In the People’s Republic of China, there is a of refractive media, anterior chamber and posterior move towards a national health standard for chil- Correspondence to segments were also examined. dren. Neonatal eye examination may play a signifi- Dr Paul J Rychwalski, Mail Code i32, Cole Eye Results A total of 3573 healthy full-term newborns cant role in this process. The Ministry of Health as Institute, Cleveland Clinic were enrolled and examined in the programme. There part of its National Children’s Health Standard Foundation, 9500 Euclid was detection of 871 abnormal cases (24.4%). The encourages newborn examination in detail. This Avenue, Cleveland, OH 44195, majority of abnormal exams were 769 (21.52%) retinal standard has the goal of discovering serious USA; [email protected] haemorrhages. Of these, there were 215 cases of congenital, hereditary and acquired diseases in the significant retinal haemorrhage, possible sight neonatal period of healthy newborns. The present Received 29 August 2012 threatening or amblyogenic, representing 6.02% of the study is, to the authors’ knowledge, the first to Revised 19 November 2012 total. In addition, 67 cases (1.88%) involved macular publish results of a large neonatal eye examination Accepted 21 January 2013 haemorrhage. The other 107 cases (2.99%) with programme. abnormal ocular findings included subconjunctival haemorrhage, congenital microphthalmos, congenital corneal leukoma, posterior synechia, persistent pupillary MATERIALS AND METHODS membrane, congenital cataract, enlarged C/D ratio, Under the umbrella of the Chinese Ministry of http://bjo.bmj.com/ retinal hamartoma versus retinoblastoma, optic nerve Health requirements for general neonatal assess- defects, macular pigment disorder and non-specific ment, the authors devised specifications for neo- peripheral retinopathy. natal eye examination. These exams were optional Conclusion Ocular examination of healthy newborns for the families. The Ministry of Health funded the leads to the detection of a significant number of ocular eye examinations with occasional funding received pathologies. The most commonly discovered ocular from the patient and their insurers. Interested fami- abnormality during examination of the newborns in this lies were educated about the programme and on September 26, 2021 by guest. Protected copyright. study is retinal haemorrhage. The long-term impact of signed an informed consent prior to ophthalmic these findings is unknown. Although presumed by some evaluation. The consent form was reviewed by the to benign, neonatal retinal haemorrhages due to birth hospital and the Ministry of Health ethics and insti- trauma could be involved in altering visual development. tutional review boards and included statements of Further work, including prospective examination of the benefits and modest risks of undergoing the eye newborns with long-term follow-up, is needed and examination. supported by our findings. From the start of the project, maternal health- related lectures regarding neonatal eye disease were held on a monthly basis for healthcare workers as INTRODUCTION well as for parents. Lectures covering the paediatric The American Academy of Paediatrics recommends ophthalmology, including anatomy, basic pathology red reflex testing (RRT) shortly after birth.1 and disease treatment, were held as continuing Thereafter, children should have their eyes exam- medical education courses for training of physicians, To cite: Li L-H, Li N, ined by their primary care physician on all well nurses and allied personnel involved in the pro- Zhao J-Y, et al. Br J Ophthalmol visits. Formal testing of recognition visual acuity gramme. This approach was designed to raise partici- Published ’ Online First: [please include will typically commence around 3 years of age. pants awareness of neonatal ophthalmic disorders. Day Month Year] With this schedule, it is assumed that the vast For the first 7 months, the ocular examination rate doi:10.1136/bjophthalmol- majority of ocular health issues will be discovered. was 75.54% (1881 examined out of 2490 live births). 2012-302539 Nonetheless, there remain a significant number of For the 7 months following, examination rates Li L-H,Copyrightet al. Br J Ophthalmol Article2013; author0:1–4. (or doi:10.1136/bjophthalmol-2012-302539 their employer) 2013. Produced by BMJ Publishing Group Ltd under licence. 1 Br J Ophthalmol: first published as 10.1136/bjophthalmol-2012-302539 on 20 February 2013. Downloaded from Clinical science increased to 93.90% (2126 examined out of 2264 live births). Between May 2010 and June 2011, there were 4754 live births in the Kunming Maternal and Child Healthcare Hospital, Kunming, Yunnan Province, China. Of those, 4007 (84.29%) infants received a neonatal eye examination either at the hos- pital or returned after discharge within 42 days of birth. This work focuses the analysis on the 3573 healthy full-term infants who underwent an eye examination within 1 week of birth (mean 2.35 days). In our study, a normal newborn is defined as having ≥37 weeks’ gestational age, weighing ≥2500 g. Further, the normal newborn has no evidence of sys- temic disease and an Apgar score of 7 or more. The male to female ratio was 1785 : 1788. Infants whose mothers had known transmitted diseases (eg, STDs, hepatitis B, HIV positive) were excluded. Infants who were premature or were examined after discharge at 42 days of birth with other follow-up were not included in this series. Figure 1 Retinal haemorrhages discovered on newborn digital eye The examinations were performed by a team consisting of an examination. ophthalmologist and assisted, at times, by a nurse. An external examination of the eyes was performed first, which included the anterior segment and pupillary light reflex using a standard DISCUSSION fi fi flashlight. Infants were then dilated with two drops of 1% tropi- Our data reveals, for the rst time, that a signi cant number of camide administered 10 min apart. After mydriasis, the RRT, healthy newborns exhibit ocular abnormalities on digital ocular fi retinoscopy and hand-held slit lamp examinations were examination. Further, the highest proportion of abnormal nd- performed to evaluate the clarity of ocular media. Topical anaes- ings during the study period was retinal haemorrhages, account- thetic was instilled. The anterior segment was examined using ing for 92% of abnormalities. Results of a study of ocular the non-contact wide-angle portrait camera lens. screening of preschool children report that refractive errors Next a sterile eyelid speculum was placed in the eye to be examined. The anterior chamber angle was then evaluated with the 130° lens, tilted appropriately to image the angle in at least four quadrants. Using the RetCam, a wide-angle digital fundus camera examination was then performed in first one eye and then the other. Photos were taken of the posterior pole, includ- ing the optic nerve and macula. The superior, inferior, nasal and temporal retinal fields were imaged when possible. For patients in whom the eye exam revealed an abnormal finding, repeat examination or referral to the ophthalmology clinic was per- formed at a later date. http://bjo.bmj.com/ Data from the examinations were logged onto a spreadsheet and the Pems 3.3 (Package for Encyclopaedia of Medical Statistics) package was used for analysis. RESULTS Of the 3573 healthy full-term newborns who underwent on September 26, 2021 by guest. Protected copyright. newborn eye examination, 871 (24.4%) cases were found to be abnormal. Of the total examined, 769 (21.53%) had retinal haemorrhages (figures 1 and 2). There were no statistically sig- nificant differences based on gender. Of these, 215 cases (6%) were Grade 3 (table 1) retinal haemorrhage and 67 cases (1.9%) involved macular haemorrhage. There were visually threatening ocular abnormalities in 107 cases (2.99%), of whom 28 were associated with retinal haemorrhage. These cases are sum- marised in table 2 below. Additionally, the examinations revealed multiple other ocular pathology of visual and possibly systemic significance.