Diagnostic Test Accuracy of the Red Reflex Test for Ocular Pathology in Infants: A Meta-analysis

Abstract

Importance: Red reflex testing is a simple and inexpensive method implemented in many countries as an important part of infant screening for ocular pathologies.

Objectives: To review the literature on the diagnostic accuracy of the red reflex test in infant screening for ocular pathologies and to perform meta-analyses to provide summary estimates.

Data sources: The following literature databases were searched for English-language, peer-reviewed literature, published until April 19, 2020: Cochrane Central, PubMed/MEDLINE, Embase, Web of Science Core Collection, BIOSIS Previews, Current Contents Connect, Data Citation Index, Derwent Innovations Index, KCI-Korean Journal Database, Russian Science Citation Index, SciELO Citation Index, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and ClinicalTrials.gov.

Study selection: Eligibility criteria were defined according to population (studies of consecutively screened infants), exposure (red reflex or Brückner test as the index test), comparator (any ophthalmological examination), and study type (any study with diagnostic test accuracy data).

Data extraction and synthesis: The Preferred Reporting Items for Systematic Reviews and Meta-Analysis of Diagnostic Test Accuracy Studies (PRISMA-DTA) guidelines were followed. Data were extracted independently by 2 authors. For summary estimates of diagnostic test accuracy, the hierarchical summary receiver operating characteristics curve was used. Prevalence of ocular pathologies was introduced for a prevalence meta-analysis, which was then used in calculations of diagnostic accuracy of the red reflex test when applied in infant screening.

Main outcomes and measures: True-positive, false-positive, true-negative, and false-negative findings; sensitivity; specificity; and positive and negative predictive values.

Results: In this meta-analysis, 8713 unique infants from 5 unique studies were eligible for qualitative and quantitative review. All studies used the red reflex test without pupillary dilation and were compared with a reference test performed with pupillary dilation. For any ocular pathology, an estimated sensitivity of 7.5% (95% CI, 7.4%-7.5%) and specificity of 97.5% (95% CI, 97.5%-97.5%) was found. Focusing on ocular pathologies that required a medical or surgical intervention, sensitivity improved to 17.5% (95% CI, 0.8%-84.8%) and specificity remained high at 97.6% (95% CI, 87.7%-99.6%).

Conclusions and relevance: These findings suggest that an abnormal red reflex finding most likely reflects an underlying ocular pathology. However, a normal red reflex finding during screening does not exclude ocular disease.

Figure 1.. Flow Diagram of Study Selection Process

Figure 2.. Performance Evaluation of the Red Light Reflex for Detection of Ocular Pathologies

Based on summary estimates of the diagnostic test accuracy, we plotted the association between the disease prevalence (x-axis) and the positive predictive value (PPV, ie, percentage with disease given that the test result is positive) and the negative predictive value (NPV, ie, percentage not having disease given that the test result is negative) (y-axis). The dotted line shows the calculated prevalence among infants of any ocular pathology (A) and any medical or surgical intervention–demanding ocular pathology (B).