Universal Newborn Eye Screening Nil financial disclosure Samantha Simkin
Paediatric visual impairment 19 million children worldwide are visually impaired 1 1.4 million children are blind 1 Social, economic and emotional impacts The majority of cases can be treated or prevented 1
Red reflex screening? Red reflex test is mandatory in NZ and many other countries X Congenital cataracts 2,3 X Retinoblastoma 4,5 X 4/5 screeners have not had any formal training for red reflex screening. 3 X Sensitivity of 4% for posterior disease 6 American Academy of Pediatrics, Policy Statement, 2008
Telemedicine 7. Dai et al, Retinopathy of prematurity: New Zealand recommendations for case detection & treatment. Journal of Paediatric and Child Health 2015 8. Vinekar et al, The KIDROP model of combining strategies for proving retinopathy of prematurity screening in under served areas in India. Indian Journal of Ophthalmology. 2014;62:41-49 9. Chiang et al, Detection of clinically significant retinopathy of prematurity using wide-angle digital retinal photography: A report by the American Academy of Ophthalmology. Ophthalmology. 2012
Universal Newborn Eye Screening China 10 (Li et al 2013) 3573 infants 24.4% abnormalities India 11 (Vinekar et al 2015) 1021 infants 4.7% abnormalities
Aim: To identify the prevalence of ocular abnormalities, including retinal haemorrhages, in a New Zealand newborn population.
NZ-UNES Method Prospective observational study n = 350 Exclusion criteria 30 weeks gestational age 1250g birth weight Images captured include Anterior eye with red reflex Posterior pole and peripheral retina
NZ-UNES Method Ophthalmology review of all images Detected abnormalities: Retinal haemorrhages were re imaged at 6 weeks 12 Other detected abnormalities were appropriately referred
NZ-UNES Results N = 346 Median age at screening 2 days Indian 9% Māori 7% Pacific Peoples 6% Ethnicity NZ European 50% Chinese 12% 51.5% 48.5% Other 16%
NZ-UNES Results Delivery Modality N = 346 Median age at screening 2 days Ventouse 9% Forceps 4% Normal vaginal delivery 39% Emergency C section 26% 51.5% 48.5% Elective C section 26%
Ocular Abnormalities Incidence 57/346 (16.5%) Haemorrhage 53/346 (15.3%) Other abnormalities 5/346 (1.4%) Congenital cataract Optic nerve hypoplasia Choroidal haemangioma CHRPE
Haemorrhages Presentation Bilateral n = 35 Unilateral n = 16 Optic nerve 49.0% Macular 30.4% Extensive 67.6% Retinal haemorrhages were associated with delivery modality p<0.0005
Retinal Haemorrhages Forty-two infants attended follow up Mean follow up time was 51 ± 15 days Of the cohort two infants did not have complete resolution
Discussion Ocular abnormality rates varied between NZ, China and India Abnormality rate Excluding haemorrhages Haemorrhages China Li et al (n = 3573) 24.4% 2.8% 21.6% India Vinekar et al (n = 1021) 4.7% 2.3% 2.4% NZ-UNES (n = 346) 16.5% 1.4% 15.3% USA Callaway et al (n = 202) 20.3% Retinal haemorrhages were associated with delivery modality 12-14 Birth-related retinal haemorrhages, in particular macular haemorrhages, have unknown long-term outcomes 15
Newborn screening in NZ 0.1% 16.5% 0.2% Ocular abnormalities were identified at a significantly higher rate than other established screenings in New Zealand (16.5%) Cost estimate of $2 million per year for New Zealand
UNES Conclusions Our data shows that wide-field digital imaging of the anterior and posterior eye is an effective tool for universal newborn eye screening UNES detected significant ocular abnormalities including retinal haemorrhage, congenital cataract and optic nerve hypoplasia Further research into the long-term affect of birthrelated retinal haemorrhages is required
Acknowledgements Supervisors: Dr Shuan Dai Dr Stuti Misra Prof Charles McGhee The Screening Team: Marie Hamoy Steven Dakin Holly Willings Sarah Swanevelder And all participating families
References 1. Gilbert & Foster, Childhood blindness in the context of VISION 2020 The Right to Sight. Bulletin of the World Health Organisation. 2001;79(3):227-232 2. Rahi JS, Dezateux C on behalf of the British Congenital Cataract Interest Group. National cross sectional study of detection of congenital and infantile cataract in the United Kingdom: role of childhood screening and surveillance. British Medical Journal 1999;318:362-365. 3. Raoof & Dai, Red reflex screening in New Zealand: a large survey of practices and attitudes in the Auckland region. New Zealand Medical Journal. 2016;129:39-43. 4. Abramson DH, Beaverson K, Sangani P, et al. Screening for retinoblastoma: Presenting signs as prognosticators of patient and ocular survival. Pediatrics 2003;112:1248-1255. 5. Khan & Al-Mesfer, Lack of Efficacy of Dilated Screening for Retinoblastoma. J Pediatr Ophthalmol Strabismus. 2005;42:205-210 6. Sun et al, Sensitivity and Specificity of Red Reflex Test in Newborn Eye Screening. J Pediatr. 2016;179:192-196 7. Dai et al, Retinopathy of prematurity: New Zealand recommendations for case detection & treatment. Journal of Paediatric and Child Health. 2015;51:95-959 8. Vinekar et al, The KIDROP model of combining strategies for proving retinopathy of prematurity screening in under served areas in India using wide-field imaging, telemedicine, non-physician graders and smart phone reporting. Indian Journal of Ophthalmology. 2014;62:41-49 9. Chiang MF, Melia M, Buffenn AN, et al. Detection of clinically significant retinopathy of prematurity using wide-angle digital retinal photography: A report by the American Academy of Ophthalmology. Ophthalmology. 2012;119(6):1272-80. 10. Li et al, Findings of perinatal ocular examination performed on 3573, healthy full-term newborns. British Journal of Ophthalmology. Published Online First 2013; 0:1-4. 11. Vinekar et al, Universal ocular screening of 1021 term infants using wide-field digital imaging in a single public hospital in India a pilot study. Acta Ophthalmologica. 2015;93:372-376 12. Watts et al, Newborn retinal hemorrhages: A systematic review. J AAPOS. 2013;17:70-78 13. Hughes et al, Incidence, Distribution, and Duration of Birth-Related Retinal Hemorrhages: A Prospective Study. J AAPOS. 2006;10:102-106 14. Callaway et al, Retinal and Optic Nerve Hemorrhages in the Newborn Infant One-Year Results of the Newborn Eye Screen Test Study. Ophthalmology. 2016;123:1043-1052. 15. Von Noorden et al, Retinal Hemorrhage in Newborns and Organic Amblyopia. Arch Ophthalmol. 1973;89:91-93