Evaluation of the red reflex: An overview for the pediatrician

Table 1 Search terms

RRT and neonate/newborn	RRT congenital cataract
RRT and complications	RRT retinoblastoma
RRT and necessity	RRT and glaucoma
RRT and sensitivity and specificity	RRT and blindness
RRT and differential diagnosis	RRT and leukocoria
RRT guidelines	RRT and prematurity

RRT: Red reflex test

Table 2 Quality assessment

Ref.	Year	Selection bias	Study design	Confounders	Blinding	Data collection methods	Withdrawals and drop-outs	Global rating
Nye[1]	2014	Moderate	Weak	Strong	Moderate	Weak	NA	Weak
De Aguiar et al[2]	2011	Strong	Weak	Strong	Moderate	Strong	NA	Moderate
Eventov-Friedman et al[3]	2010	Moderate	Weak	Strong	Moderate	Strong	NA	Moderate
AAP[4]	2008	Moderate	Weak	Strong	Moderate	Weak	NA	Weak
Litmanovitz et al[5]	2010	Moderate	Weak	Strong	Moderate	Weak	NA	Weak
Cagini et al[6]	2017	Strong	Weak	Strong	Moderate	Strong	NA	Moderate
Loh et al[7]	2018	Moderate	Weak	Weak	Moderate	Weak	NA	Weak
Donahue et al[8]	2016	Moderate	Weak	Weak	Moderate	Weak	NA	Weak
Li et al[11]	2010	Weak	Weak	Weak	Moderate	Weak	NA	Weak
Gurney et al[12]	2018	Weak	Weak	Weak	Moderate	Weak	NA	Weak
Levin[13]	2015	Weak	Weak	Weak	Moderate	Weak	NA	Weak
Sloot et al[14]	2015	Moderate	Weak	Weak	Moderate	Weak	NA	Weak
Wan et al[15]	2014	Weak	Weak	Weak	Moderate	Weak	NA	Weak
Tuli et al[16]	2011	Moderate	Weak	Weak	Moderate	Moderate	NA	Weak
Ozkurt et al[17]	2018	Strong	Weak	Strong	Moderate	Strong	NA	Moderate
Bell et al[19]	2014	Moderate	Weak	Weak	Moderate	Weak	NA	Weak
Balmer et al[20]	2007	Moderate	Weak	Weak	Moderate	Weak	NA	Weak
Mansoor et al[21]	2016	Moderate	Weak	Weak	Moderate	Weak	NA	Weak
Popoola et al[22]	2019	Moderate	Weak	Weak	Moderate	Weak	NA	Weak
Abramson et al[23]	2003	Moderate	Weak	Weak	Moderate	Strong	NA	Weak
AAP et al[24]	2002	Moderate	Weak	Weak	Moderate	Weak	NA	Weak
Li et al[25]	2013	Strong	Weak	Strong	Weak	Strong	NA	Weak
Butros et al[26]	2002	Moderate	Weak	Weak	Weak	Weak	NA	Weak
Sun et al[28]	2016	Strong	Weak	Strong	Weak	strong	NA	Weak
DerKinderen et al[29]	1989	Moderate	Weak	Strong	Weak	Strong	NA	Weak
Goddard et al[30]	1999	Moderate	Weak	Strong	Weak	Strong	NA	Weak
Bhatti et al[31]	2003	Moderate	Weak	Weak	Moderate	Moderate	NA	Weak
Rajavi et al[32]	2016	Moderate	Weak	Weak	Moderate	Weak	NA	Weak
Gogate et al[33]	2011	Weak	Weak	Weak	Moderate	Weak	NA	Weak
Haargaard et al[34]	2015	Moderate	Weak	Strong	Moderate	Weak	NA	Weak
Atiq et al[35]	2004	Weak	Weak	Strong	Moderate	Weak	NA	Weak
Meier et al[36]	2006	Moderate	Weak	Strong	Moderate	Weak	NA	Weak
Donahue et al[37]	2016	Moderate	Weak	Weak	Moderate	Strong	NA	Weak
Mndeme et al[38]	2010	Moderate	Weak	Strong	Moderate	Strong	NA	Moderate
Magnusson et al[39]	2013	Moderate	Weak	Strong	Moderate	Strong	NA	Moderate
Özkurt et al[40]	2019	Moderate	Weak	Weak	Moderate	Strong	NA	Weak
Ulanovsky et al[41]	2015	Strong	Weak	Strong	Moderate	Moderate	NA	Moderate
Raoof et al[42]	2016	Weak	Weak	Weak	Moderate	Strong	NA	Weak
Wall et al[44]	2002	Weak	Weak	Weak	Moderate	Strong	NA	Weak
Gupta et al[45]	2019	Weak	Weak	Strong	Moderate	Weak	NA	Weak
Munson et al[46]	2019	Moderate	Weak	Weak	Moderate	Moderate	NA	Weak
Chen et al[52]	2019	Moderate	Weak	Weak	Moderate	Strong	NA	Weak
AAP[53]	2003	Moderate	Weak	Strong	Moderate	Weak	NA	Weak
Anderson[54]	2019	Moderate	Weak	Weak	Moderate	Weak	NA	Weak

NA: Not applicable.

Table 3 Data extracted from the eligible articles

	Total number of articles	Ref.
Emphasis on the importance of RRT	44	[1-8,11-17,19-26,28-42,44,46,52-54]
Retinoblastoma	20	[3,6,11,12,15-17,19-23,26,28-30,36,38,40,54]
Congenital cataract	16	[3,5,6,12,15-17,19,21,31-35,38-40]
Retinopathy of prematurity	4	[2,3,16,20]
Specificity and/or Sensitivity of RRT	10	[3,5,6,11,12,22,25,28,32,38]
Compliance of health care providers with current screening protocols	12	[2,3,5,6,14,22,23,32,39,40,42,44]
Limitations of RRT	9	[1,4,6,11,12,23,26,28,41]
Comparison of RRT with other techniques	7	[17,25,28,34,38,45,46]

RRT: Red reflex test.

Table 4 Anatomical approach for an abnormal red reflex test[4,12]

Tear film	Mucus or other foreign bodies
Cornea	Dysgenesis of the anterior segment (Peters anomaly), congenital glaucoma, birth trauma
Lens	Cataract
Vitreous	Persistent fetal vasculature, vitreous hemorrhage or inflammation
Retina	Retinoblastoma, retinal detachment, Coat’s disease, chorioretinalcoloboma, toxocariasis
Other	Anisometropia, strabismus