FP1353 : Pre School Eye Screening Using Bruckner’s Reflex: A Feasibility Study

Dr.Himika Gupta, G11750, Dr. Ravikant Singh, Dr. Sunila Sanjeev

Purpose: Every fifth child on the planet is in India. Though the Bruckners test is employed regularly for paediatric eye screening in many countries, it is non-existent in routine paediatric practice in India, causing a delay in diagnosis of many vision threatening and life threatening conditions. This study evaluates the feasibility of utilizing the red reflex test (Bruckners test) as an eye screening modality for 0-6 yearspaediatric population of India.

MATERIAL AND METHODS:  Two models in four different settings

1. Pre School in Mumbai Suburbs (Urban, population based,withpre-registered lists) 2. Health Centre in Urban Slums of Mumbai (Urban,populationbased,registration on arrival approach) 3. Immunization OPD of Municipal Hospital Khopoli (Rural,opportunistic,registration on arrival) 4. Krantinagar (Khopoli) ‘Anganwadi’ (rural mother and child care centre)

Methods: Four settings(two urban and two rural) were designed to target the low socio economic 0-6year olds. Post-sensitization, pre-registered lists were developed for groups 1 and 4, whereas registration on arrival was followed for groups 2 and 3. Children were screened for red reflex on a designated day in groups 1, 2 and 4; and over a period of three months in group3 (immunization groups) by an ophthalmologist and trained optometrist. Each model was evaluated for yield, efficacy and speed of screening, utility of pre-registration lists and influence of rural versus urban set up.

Results: A total of 298 children(age: 0.25 months- 60 months) were screened with four modalities. Pre-school had the maximum children(153) followed by group 2(67).group 4 (43) and group 3 (35) Twenty six(8.8%) children were found to have an abnormal Bruckners test and s were referred for comprehensive eye examination. The yield of the opportunistic screening model(group 3,N=30,time – three months)was maximum(20%) Time spent to conduct each session ranged from 80 mins-170 minutes. Discrepancy in the pre-registeredname was the commonest challenge, in all the groups. Urban health centre model of registration on arrival, was the most time efficient model (avg 0.74 minutes/child).

Conclusion:  Four different approaches to execute red reflex screening in pre-schoolers in India were evaluated. Single day screening of population based cohort is more time efficient but opportunistic screening using universal immunization programme model had maximum yield.

KEY WORDS- BRUCKNERS TEST, PRE SCHOOL EYE SCREENING

Introduction:

Childhood blindness is one of the priorities in Vision 2020: the right to sight.[1] It is estimated that there are 1.4 million blind children in the world, two thirds of whom live in the developing countries[2]. Early screening for vision abnormalities is critical for the overall development of the child and to prevent childhood blindness. In India, major intervention for prevention of childhood blindness is vitamin A supplementation, Immunization with MMR vaccine and school eye screening programme. Though the benefit of  screening the 0-6 years pre-school children for vision abnormalities is acknowledged, India is not yet geared  up  due to lack of organized primary eye care, lack of sufficient trained manpower, logistics, financial burden and a cataract centric National Programme.

Background-

Bruckners test was described in 1962 [3] (Red reflex test) is a simple test to detect refractive errors, cataract, corneal opacities, squint etc[4]. It is used as a screening tool by ophthalmologists and paediatricians in some countries. As per the American academy of paediatric ophthalmology and Strabismus, Bruckner’s test is recommended once between 0-12 months, then once between 1-5 yrs, then at 5yrs followed by annual eye checkup.[5] The In India, the Existing school screening programmes catering5 to 15 yrs of age includes screening by vision technicians and is broadly refractive error oriented. Currently there is no recommendation for eye screening for 0-6 year olds as they are considered difficult to locate, not readily available in schools, uncooperative for routine vision testing and additional burden as regards to logistics and funding.

However, not all kids reach school. This could be due to adverse socio-economic conditions. Children with developmental delay, special needs or severe vision problems may never make it to schools to benefit from the school vision screening programmes. There are multiple potentially life threatening diseases that affect the under 5 population which, if detected early can save the child’s life. These include the white reflex of retinoblastoma, a retinal tumor, and brain tumor inducing a squint or nystagmus.

With this background a pilot study was conducted to find a working model for India to screen for eye problems in the 0-6 year old children using Bruckners test.

Objectives:

To determine the feasibility of conducting early vision screening in 0-6 year old children using Bruckners test in  different models and effective follow up.

Methodology:

Four different models in two settings (Urban and Rural) were designed to target the 0-6 year old children. Model I and II were in the urban setting and Model III and IV were in the Rural.

Model I: A Pre-school in the suburbs of Mumbai was randomly selected and vision screening was conducted on an appointed day. Prior sensitization of parents and teachers was done 2 weeks prior.Pre-registeredlists were prepared and teachers were present to help for a systematic screening. During the waiting period, health education on hand hygiene was given to all the children.

Model II:  A vision screening day was fixed (on a Monday) inUrban Health Centre of suburbs of Mumbai. The community and local Anganwadi workers were sensitized regarding the eye screening. The list of the 0-6 year old for the screening was prepared on arrival and the screening was done using the Bruckners test. Those found to have a suspicious or abnormal Bruckners test underwent full ophthalmic check-up and were advised appropriately.

Model III: The Govt. Hospital in Khopoli runs an immunization clinic and paediatric OPD every Monday. The nursing staff was sensitized regarding the early vision screening and the children were sent for eye screening before immunization.

Model IV: All the Anganwadi workers were sensitized regarding importance of early vision screening and the one Anganwadi was picked randomly. All the children enrolled were screened.

Screening was done either by an Ophthalmologist or an Optometrist using Bruckners test. Bruckners test was done in a dark room with the child placed comfortably at 1 metre distance using the Ophthalmoscope. Symmetrical red reflex in both eyes was considered normal. Any asymmetry in the red reflex, absence of red reflex and presence of crescent was interpreted as abnormal test. If the pupils were too small to examine, the child was asleep or red reflex appeared suspicious or variable, then it was categorised into suspicious or indeterminate. All the children who had an abnormal or suspicious test were advised to follow with full ophthalmic examination and appropriate treatment.

OBSERVATIONS and RESULTS

The total children screened were 298 with 154 in group I, 67 in group II, 25 in group III and 47 in group IV. The demographic details and model wise distribution is described in Tables 1 and 2. Four children had obvious eye diseases at the time of screening. The various diseases picked up during the screening programme are mentioned in Table 3.

Group I and IV had more children belonging to 3 years and below. The time taken for conducting the screening session was less in the health centre model and the follow up also was good. In the rural setting the group III had more yield and better follow up.  Out of the total 298 children 33 (11.07%) showed abnormal Bruckners test and 37(12.41%) had a suspicious Bruckners test. The challenges faced were the confusion between pet names and registered names, motivation of the parents for the early vision screening and follow up of the children.

Discussion:

The target population of 0-6 yrs were reached in both urban and rural setting through four different models taking the simple Bruckners test as a screening tool for vision abnormalities and external eye examination. In the urban scenario the maximum number of children could be screened at a pre-school(Group I) however the follow up was better in the community based health centre model (GroupII). Lowry EA[6]  reported that community based follow up was better and cost effective.

In the immunization model(opportunistic screening) of rural area, (Group III) theabnormal Bruckners pick up and the follow up too was better. Since the caretakers of the children coming for immunization are already a sensitized group for preventive care, it was easy to orient them to come for vision screening and hence there was a good follow up.

A study[7] conducted in Brazil for early vision screening during vaccination campaign that it was a simple, rapid and effective opportunistic screening for visual disorders. With the Anganwadi model, reaching out to the target population was easily coordinated, but the challenge was confusion between the pet names and enrolled names for further follow up. It was also observed that the parent or guardian coming for the follow up was difficult because they were daily wage workers.

Studies were conducted to assess the reliability and feasibility to use teachers[8], paramedics or an appropriate tool,[9][10][11]for early vision screening. In our study an optometrist and ophthalmologist conducted the screening. Inter observer disagreement was minimum(less than 1 percent).These cases were categorized as suspicious and advised a detailed eye examination. Hence, a trained ophthalmologist is not needed for the screening purpose. This study helps to understand that integrating the early vision screening with the Universal Immunization Programme in India will not only address the problem of getting the target population but also a better follow up.

The red reflex test is a very important diagnostic tool and its utility is well documented in literature. [12] Refractive error is the most common abnormality picked up and the sensitivity for the same is described to be 91% [13] .

Retinoblastoma is an under five malignancy, if detected early has cure rates as high as 95% and is fatal if untreated. The Bruckners reflex detects the commonest early signs of retinoblastoma, that is leucocoria and strabismus [14] .Ophthalmic abnormality is a common presenting symptom in paediatric brain tumoursand strabismus is the second most frequent presenting sign. [15] Hence the role of Bruckners reflex in these life threatening conditions cannot be over emphasized.

The Bruckners reflex facilitates early detection of vision threatening eye diseases like cataract, corneal opacities, amblyopia, which is associated with lesser disease burden and better outcomes if tackled early[16].

Our screening strategy used a single test, and did not include other tests like cover/uncover test, pupillary reflex-Hirschberg test, which is better at picking up small degree squints and latent strabismus. The waiting time was utilized in health education on proper hand washing techniques.

The current study attempted to establish the feasibility of conducting Bruckners reflex as a vision screening tool in 0-6 yrs in the existing health care system.   Compared to the current recommendation of school screening in 5-15 year olds, this initiative is likely to reach a larger target population and facilitate early detection of vision threatening and life threatening conditions.      Conclusion:  Four different approaches to execute red reflex screening in pre-schoolers in India were evaluated. Single day screening of population based cohort is more time efficient but opportunistic screening using universal immunization programme model had maximum yield.

[1]World Health Organization. Global initiative for the elimination of avoidable blindness. Programme for the Prevention of Blindness and Deafness. Geneva: WHO, 1997 (WHO/PBL/97.61).

[2]World Health Organization. Preventing blindness in children: report of WHO/IAPB scientific meeting. Programme for the Prevention of Blindness and Deafness, and International Agency for Prevention of Blindness. Geneva: WHO, 2000 (WHO/PBL/00.77).

[3]Tongue AC, Cibis GWBrückner testOphthalmology. 1981 Oct;88(10):1041-4.

[4]Cagini C, Tosi G, Stracci F, Rinaldi VE, Verrotti 2.Red reflex examination in neonates: evaluation of 3 years of screening.Int Ophthalmol. 2016 Nov 7. [Epub ahead of print]

[5] https://aapos.org/terms/conditions/107

[6]LowryEA,de Alba Campomanes AG. Cost-effectivenessof school-based eye examinations in pre-schoolers referred for follow-up from visual screening.JAMA Ophthalmol.2016 Jun 1;134(6):658-64.

[7]Poterio MB, Cardillo JA, De Senne F, Pelegrino R et al. The feasibility of introducing a visual screening test for children during vaccination campaigns.JPediatr Ophthalmol Strabismus. 2000. Mar-Apr,37(2):68-72.

[8]Rewri P, Nagar CK, Gupta V. Vision screening of younger school children by school teachers: A pilot study in Udaipur City, Western India. J Ophthalmic Vis Res 2016;11:198-203.

[9]Cotter, S. A., Cyert, L. A., Miller, J. M., Quinn, G. E., Russ, S. A., Block, S. S., Wallace, D. K.. Vision screening for children 36 to G72 Months: Recommended practices. Optometry and Vision Science.2015, 92(1):6-16.

[10]Cibis Tongue A. Refractive errors in children. PaediatrClin North Am 1987;6:1425-37

[11]Arnold RW. Vision screening in Alaska: experience with enhanced Bruckner test. Alaska Med 1993;35:212-

[12]Shafiq A .Seeing red in young children: the importance of the red reflex.Br J Gen Pract. 2015 Apr;65(633):209-10. doi: 10.3399/bjgp15X684625.

[13]Mihir T K. Can the Bruckner test be used as a rapid test to detect significant refractive errors in children? Indian  J Ophthalmol . 2007;55:213-5.

[14]Rao R, Honavar SG.Retinoblastoma.Indian J Pediatr. 2017 Jun 16. doi: 10.1007/s12098-017-2395-0. [Epub ahead of print]

[15]Alswaina N, Elkhamary SM, Shammari MA, Khan AO.Ophthalmic Features of Outpatient Children Diagnosed with Intracranial Space-Occupying Lesions by Ophthalmologists.Middle East Afr J Ophthalmol. 2015 Jul-Sep;22(3):327-30. doi: 10.4103/0974-9233.159739.

[16]Eventov-Friedman S et al.The red reflex examination in neonates: an efficient tool for early diagnosis of congenital ocular diseases.,Isr Med Assoc J. 2010 May;12(5):259-61.

TABLE 1 –
	Total No. of Children screened	Bruckners test – Normal	Bruckners test – Abnormal	Bruckners test -Suspicious
Group I (Pre-school)	153 (100%)	126 (82.35%)	22 (14.37%)	5    (3.26%)
Group II (Health centre)	67(100%)	48 (71.64%)	4   (5.97%)	15 (22.38%)
Group III  ( Municipal Hospital , Khopoli)	35(100%)	20 (57.14%)	6 (17.14%)	9  (25.71%)
Group IV (Anganwadi)	43 (100%)	34 (79.06%)	1   (2.32%)	8  (18.60%)
Total	298 (100%)	228 (76.51%)	33 (11.07%)	37 (12.41%)

TABLE 2

	Group I (Pre-school) N=153	GroupII (Health centre) N=67	GroupIII ( Municipal Hospital , Khopoli) N=35	Group IV (Anganwadi) N-43
AGE
3years and below	84 (54.90%)	2 (2.98%)	19 (54.28%)	27 (62.79%)
Above 3 years	69 (45.09%)	65 (97.03%)	16 (45.71%)	16 (37.20%)
Sex
Male	92 (60.13%)	40 (59.70%)	23 (65.71%)	24 (55.81%)
Female	61 (39.86%)	27(40.29%)	12 (34.28%)	19 (44.18%)
Pre-sensitization	Done	Done	Done	Done
Time taken for screening	170 min	50 min	NA	120 min
Average time taken per child	1.11 min	0.74 min	Na	2.7min
Pre-registered list	Present	Absent	Absent	Present
Abnormal  & Suspicious Test	27 (17.64%)	19 (28.35%)	15 (42.85%)	9 (20.93%)
Follow Up ( out of the abnormal & suspicious test)	2 (7.40%)	16 (84.21%)	9 (60%)	4 (44.44%)

TABLE 3 – DISEASES PICKED UP ON SCREENING

REFRACTIVE ERROR

PTOSIS

SQUINT

STYE

NEVUS OF OTA