Catching the glow: the power of red reflex screening

Abstract

Aim: On March 30, 2022, the World Health Organization (WHO) released its inaugural global guidelines for the postnatal period WHO recommendations on maternal and newborn care for a positive postnatal experience, underscoring the importance of comprehensive care for women and newborns during the first six weeks postpartum. Among the landmark recommendations was the inclusion of universal newborn eye screening (NES), marking a significant advancement in pediatric eye health. This initiative calls on national governments to integrate NES into routine maternal and child healthcare services and national health programs, aligning with the United Nations General Assembly’s 2021 resolution, Vision for Everyone.

The primary goal is to promote awareness and empower healthcare providers and communities to prioritize pediatric eye care, particularly the essential red reflex test. This test, a straightforward yet critical screening tool, facilitates the early detection of congenital, vision- and life-threatening conditions such as cataracts, glaucoma, and intraocular tumors, including retinoblastoma, during the critical period of visual development.

Methods: A narrative literature review was conducted to explore relevant sources on maternal and newborn care, as well as pediatric ophthalmic screening. The literature search was performed using PubMed and official WHO bulletins, during 2024, December 1-31. Studies and guidelines were selected based on their relevance to the topic. The extracted references include recommendations from WHO, national healthcare programs, and significant research articles in the field.

Results: On December 21, 2020, Croatia enacted the Plan and Program of Health Care Measures 2020–2022 (Official Gazette, NN 142/2020). Under section 2.2.27 Pediatrics, subsection Neonatology, the measure Vision Screening of All Newborns Using the Red Reflex Test was introduced. The test, conducted with a direct ophthalmoscope—a standard „must“ piece of medical-technical equipment in all pediatric practices (Official Gazette, NN 61/2011)—is performed immediately after birth in maternity hospitals and again at one month of age during routine examinations. This procedure has now become a standard practice.

The red reflex test is a quick and simple procedure. Leading global healthcare organizations, including the American Academy of Pediatrics and the Royal College of Ophthalmologists, recommend it not only as part of neonatal assessments but also at specific intervals throughout early childhood. First described by Brückner in 1962, the test involves observing the reflection of light off the choroid through clear ocular media. Abnormal findings—such as an absent, asymmetric, or irregular reflex—may indicate conditions requiring urgent medical intervention, including cataracts, glaucoma, or retinoblastoma. Prompt diagnosis and treatment during the critical period of visual development, typically within the first six weeks of life, are vital for optimal outcomes.

Congenital cataracts, which account for approximately 10 % of childhood blindness globally, represent a treatable but time-sensitive cause of significant visual impairment. Unlike delays in adult cataract surgery, postponing intervention in infants (ideally intervention should be performed within six to twelve weeks postnatally) can lead to irreversible damage, such as deprivation amblyopia. Furthermore, delayed diagnosis of conditions like retinoblastoma significantly increases risks; an 8-week delay raises the likelihood of local invasion, while a delay of 6 months drastically heightens the risk of extraocular extension.

Conclusions: Integrating the red reflex test into Croatia’s government-directed Plan and Program of Health Care Measures reflects a strategic approach to addressing preventable blindness. Whenever a pathological red reflex is identified, an urgent comprehensive ophthalmological examination must occur within seven days to align with the critical developmental timeframe. Additionally, infants or children at elevated risk of irreversible vision loss or life-threatening conditions—such as those with a family history of retinoblastoma, congenital glaucoma, or other early-onset eye diseases—should undergo a detailed ophthalmological assessment regardless of initial test results.

The red reflex test serves as a pivotal strategy to eliminate preventable childhood blindness, save lives, and enhance quality of life. We advocate for the widespread adoption of this simple, cost-effective measure to protect children’s vision and overall development. By incorporating the red reflex test into routine medical care throughout early childhood, healthcare providers can significantly influence the trajectory of ocular health, ensuring better outcomes for future generations.