Screening for hearing and vision disorders in children. Shvets evgeniya nikolaevna Why is ophthalmological screening in infancy so important?

In some countries, including Russia, newborn screening is done. This important diagnostic event is carried out in the first days of life, most often still in the hospital, and allows you to identify in time various diseases in babies.

What it is?

"Screening" in translation from of English language means "triage", but in medical practice this word is used in the meaning of "examination". Screening, for example, is called ultrasound in the second trimester of pregnancy, during which the doctor measures a large number of fetal development parameters.

Newborn screening also includes checking the functioning of several body systems, including hearing, visual organs, neurological reactions, anatomical structure, ultrasound internal organs and a blood test for genetic diseases.

Examining the child during the first day after birth, the doctor assesses the condition skin: whether even and clean, what color they are, whether there is cyanosis; then the pose of the child, which indicates muscle tone. Normally, the baby himself takes the pose of a frog..

Next, the doctor examines and gently probes the head, whether there are small swellings, bruises (they often appear during childbirth). Attention is paid to the condition of the fontanelles - the baby has two of them. The head circumference is necessarily measured and compared with the body length and weight, these indicators are always correlated with each other.

The next step is to examine the nasal passages. The physician must ensure that they are clean and free of breathing, and wide enough to allow the required amount of air to pass through. Oral cavity also becomes an object of attention, including the degree of formation of the palate, the presence or absence of a shortened frenum.

The doctor will check the child's neck, feel it for bulges, seals, examines the collarbone, which fracture is a fairly common occurrence during childbirthdue to the physiological characteristics of the birth of a baby.

Be sure to listen to a child's heart, his rhythm, no noise. With the help of a stethoscope, the doctor will listen to the lungs for wheezing, which may indicate the presence of fluid in them.

Feeling the stomach, the doctor will determine the location of the internal organs, their size, shape, and move on to the genitals. First, the doctor makes a visual examination, assessing their development.

Girls have a small discharge from the vaginal opening, this is considered normal. In boys, the doctor pays attention to whether both testicles are lowered into the scrotum, whether there are inguinal hernias.

During the first examination, the doctor also checks whether the child has a dislocation of the femoral head, the structure of the arms and legs, including the feet, their symmetry and correct position.

For the baby, all these examinations and manipulations are harmless, but they allow doctors in the first days, and sometimes even hours of life, to make sure that the child was born healthy and nothing threatens his life. Even if the screening revealed any deviations from the norm, a more thorough and in-depth examination will be prescribed. If the diagnosis is confirmed, doctors will immediately begin treatment, preventing the disease from developing.

That is why the World Health Organization also recommended that neonatal screening of newborns be carried out, which makes it possible to establish the presence or absence of genetic diseases in a child born into the world.

Kinds

There are several types of newborn screening, depending on what exactly the doctor in the perinatal center pays attention to during the examination: audiological, cardiological, ophthalmic, and genetic.

The audiological test is aimed at checking your baby's hearing. For its implementation, a special device is used - an audiometer. The principle of its operation is based on the fact that the very next day after birth, special cells in hearing aid the child are able not only to catch, but also to respond to the sound signal. The audiometer first sends this signal to the ear canal of each baby's ear, and then hears the response.

To conduct neuroaudioscreen, it is enough just to bring a device that looks like mobile phone, to the child's ear and at the same time insert a thin probe into it. In order to prevent infections, to which newborns are very vulnerable, a nozzle is put on the probe. The probe itself is not inserted deeply, only at the very beginning of the auditory canal.

There is no need to wait for the result of audio screening, the scan results immediately appear on the screen of the device, and the doctor or nurse conducting the test writes down its readings: "+" or "-". The first means that everything is fine with the baby's hearing, the second means that the child cannot hear with this ear. However, this does not mean deafness at all. If the test is negative, it is repeated at the age of 1 month. Most often, by this time, the result is replaced by a positive one. Occasionally, vernix or mucus that has accumulated in the ear canal creates interference.

Carrying out auto-screening in Russia has become mandatory since 2008. Statistics accumulated over this period show that at this stage, hearing problems are detected in only one out of 650 newborns.

In addition to the presence or absence of hearing, the device also shows whether the baby hears the same way. If the screen displays the inscription "AD \u003d AS", it means that the signal in the child's right and left ear is the same.

When checking the child's hearing, the doctor also examines the ear canals, the correctness of their formation. And the form auricle does not affect hearing. In newborns, the ears can be tightly pressed against the skull, but after a few days they straighten, sometimes protruding quite strongly.

The development of the auricle continues until the baby is two years old, and until then, its shape may change.

Ophthalmic screening is usually done during the first examination of the baby within 24 hours of birth. A special flashlight helps the doctor to determine if the child has damage to the eyes, underdevelopment, lens opacity. Sometimes the examination is made difficult by swollen eyelids or ruptured blood vessels, in which case the screening is repeated after a few days.

Ophthalmologic screening of premature babies is receiving even more attention, as babies born ahead of time, underdevelopment of the retina - retinopathy may be found. This pathology occurs only in children who weighed less than 1500 grams at birth. But not necessarily premature baby has vision problems.

In any case, at 3-4 months, each child is assigned a second ophthalmological examination, which is carried out in the children's clinic and includes a fundus check. The kid may be dissatisfied with the examination, but he does not experience painful sensations.

Some clinics use special equipment that allows you to take all the necessary indicators of the condition of the eyes in 30 seconds. Then the device interprets them, and the doctor, comparing them with the indicators of the norm, can draw a conclusion about the health of the organs of vision.

Another type of neonatal screening is also called the heel test, because it requires peripheral blood and the baby's heel is the most suitable place for blood sampling.

On the recommendation of WHO, blood is tested for the most common genetic diseases. In Russia, neonatal screening of newborns has been carried out for 15 years. If you suspect that a child has diseases, including infectious diseases, the doctor prescribes a biochemical blood test. In newborns, blood is also taken from the heel for biochemistry.

In addition, if developmental pathologies were detected in the fetus during ultrasound in the second and third trimesters of pregnancy, then ultrasound screening of the newborn is prescribed. This study shows the presence of dysplasia hip joint and congenital subluxation of the femur, which are easily corrected by timely treatment. Also, through the open fontanelles, the newborn is ultrasound procedure brain.

This procedure provides information about neurological pathologies or their absence.

What can be identified?

In Russia, neonatal screening, or heel test, is used to identify 5 genetic, that is, hereditary diseases.

Of course, there can be much more diseases in newborns. But from them the most common, complex, and also amenable to diagnosis and treatment were selected. These are phenylketonuria, adrenogenital syndrome, cystic fibrosis, galactosemia, congenital hypothyroidism.

Phenylketonuria, abbreviated PKU, is a hereditary deficiency of an enzyme responsible in the body for the breakdown of the amino acid phenylalanine. This amino acid is found in many foods, making it necessary to follow a special diet.

If the disease has not been identified in early age or parents refused to comply with it for some reason, for example, for religious reasons, then as a result of the breakdown of the amino acid, acetone bodies will accumulate in the body.

Intoxication will lead to the appearance in the child of symptoms such as mental retardation, seizures and other signs of central nervous system... This rather rare disease occurs in one out of 15 thousand children.

Cystic fibrosis - also genetic disease, which consists in the malfunction of the organs that produce endocrine secretions. These are sweat glands, as well as special cells in the bronchi, intestines and pancreas. The secretion of these cells thickens, turning into a kind of mucus that disrupts the work of internal organs. Symptoms are especially common in the respiratory and digestive systems.

Often, against the background of dysfunction of organs, infections that cause pneumonia, bronchitis and other serious illnesses join. Cystic fibrosis also leads to the formation of cysts and scar tissue in the pancreas. Hereditary cystic fibrosis is diagnosed in 1 out of 2 thousand newborns.

Adrenogenital syndrome (AGS) is a malfunction of the adrenal glands. These glands produce hormones cortisol and aldosterone. If their number does not correspond to the norm, such pathologies arise, as early sexual development, later - infertility, as well as various kidney diseases.

Congenital hypothyroidism is associated with malfunctioning of the thyroid gland. It helps to correct the disease hormone therapy, moreover, congenital hypothyroidism can be influenced and even completely cured, of course, if measures are taken on time.

Otherwise, a decrease in the production of thyroid hormones leads to disorders of the heart, mental and physical development.

Galactosemia is a disease associated with intolerance to galactose and other carbohydrates in milk, including breast milk.

If you do not follow a special diet and refuse breastfeeding at an early age, then over time diseases of the liver and organs of vision appear, the child begins to lag behind in mental development. However, the use of lactose-free mixtures and an appropriate diet allow you to avoid all these unpleasant consequences.

Even though it is hereditary diseases, if during the examination for their presence in the child and immediately start adequate treatment, you can significantly reduce the likelihood of their development, as well as the severity of the disease. It is also important for parents to be aware of pathologies in order to maintain a diet and balance of physical, emotional and mental stress to ensure optimal conditions for the development of the child.

Neonatal screening for congenital heart defects is carried out for babies with cyanosis of the skin and mucous membranes, signs of respiratory and heart failure, which appear after the birth of a child.

When examined in the first minutes of life, the doctor always listens to the heart in order to exclude the possibility of congenital heart defects - CHD. To do this, the intensity of the pulsation of the peripheral arteries is determined, pulse oximetry is done, a test with inhalation of 100 percent oxygen is mandatory.

Re-examination takes place on day 3-4, most often before the mother and baby are discharged from the perinatal center home. The doctor again does pulse oximetry, measures blood pressure on the arm and leg, counts the breathing rate. The baby is given an ECG to rule out arrhythmia.

According to statistics, 2-3% of newborns are born with heart defects. Cardiac screening of newborns is very important because congenital defects hearts, including critical ones, requiring immediate intervention, possibly surgical, develop in the first days and even hours of life. This way, time will not be wasted.

Cardiac screening is not invasive, does not cause anxiety or inconvenience to the baby, but provides reliable information about the health of the child.

Dates and venue

Neonatal screening of newborns in Russia is mandatory. The time for taking blood for examination in full-term infants is 2–4 days after the birth of the child, and in premature infants - on the 7th day. To obtain a more accurate analysis, it is recommended to take blood for analysis at the age of at least three days, earlier the indicators can be lubricated.

At the same time, they do it no later than up to 10 days of age.

It will take some time until the blood test is ready, so the results will be received by the pediatrician, who will guide the child at the place of residence.

Thus, the test can be done both at the maternity hospital and later at the children's polyclinic. If the heel test was not done in the maternity hospital, a corresponding note is made in the discharge documents.

In some cases, for example, during epidemics of influenza and SARS, the test is carried out at home so as not to expose the newborn child to the risk of infection.

An ultrasound scan for newborns is done at the age of 1 month, and if necessary, repeated at 3 or 5. This is especially important for examining the brain, since by about 6 months the fontanel closes in a child, which makes the study impossible.

How do I prepare for the analysis?

Neonatal screening requires no special training. But before it is carried out, the child is not applied to the breast for 3 hours. This can skew the results.

The technique is as follows: a small amount of blood is taken from the heel of the newborn and immediately applied to a special form. Places where the child's blood should be dripped are marked with circles on it. After the blood has dried in the open air, the child's surname, first name, patronymic, data on his date and time of birth are entered into the form, and marks are made on the state of health based on the results of a doctor's examination. In the maternity hospital, blood sampling for analysis is often done without the presence of the mother.

Each form is placed in a separate envelope and sent for analysis to the medical genetic center, which is located in each region. The analysis is free of charge. Results will be ready in 10 days to 3 weeks.

If a positive result is obtained for at least one disease, these data are transferred to the pediatric clinic for a pediatrician. The child is assigned an examination by a geneticist, who most often prescribes a repeated test and additional examinations to confirm or deny the preliminary diagnosis.

Decoding

Usually, parents do not get their hands on the results of neonatal screening. More often, the geneticist introduces them to the results of the repeated analysis. To understand whether a child's blood counts are normal, there are normal values.

So, when analyzing for PKU, the FA content in the blood of a child under 1 year old should normally be 2–4 mg /%, a value of up to 8 mg /% is acceptable. As a rule, such an indicator is recorded during treatment.

In the analysis for congenital hypothyroidism tSH level up to 20 μU / ml is a normal variant... All samples with a hormone concentration above 20 μU / ml are checked. A concentration above 50 μU / ml allows one to suspect a disease, and only if the level of TSH in the blood of a newborn is above 100%, the likelihood of the disease is assessed as high.

Evaluation of the results of neonatal screening for galactosemia is carried out as follows. When the level of total galactose in the blood serum is less than 7.2 mg / dl - negative, from 7.2 to 10 - borderline, over 10 - positive.

Screening for ADH is based on the identification of a specific and sensitive marker of hormonal diagnostics - a high level of 17oxyprogesterone - 17-ONP. In full-term babies born after 37 weeks of pregnancy with a body weight of more than 2 kg, the indicator is normally up to 30 g / mol... With a result of 30 to 90 g / mol, the result is considered doubtful, more than 90 g / mol indicates the presence of a disease in the child. For premature babies, a result of 60 / g / mol is considered normal., up to 100 g / mol - doubtful, above this indicator - positive. However, in children with deep prematurity, the indicator is normally even higher, and a result of more than 150 g / mol is considered positive.

Cystic fibrosis is determined by the level of the enzyme immunoreactive trypsin. A negative result - if the amount of IRT does not exceed 65–70 ng / ml. An analysis in which the IRT is 5-10 times higher is considered positive.

Are there false results?

As with any analysis, the results of the neonatal test may not be correct.

The indicators and the screen will erroneously reflect the presence of the disease, if the child was fed less than three hours before blood sampling, the analysis was taken earlier than 4 days after birth.

The human factor is not excluded, although the protocol for blood sampling and subsequent actions of the medical staff is clearly spelled out, so the probability of error is minimal.

According to statistics, most often false positive results can be for cystic fibrosis. In rare cases, false negative results are also encountered, but the doctor can make a preliminary diagnosis based on other symptoms, and send the child for additional examinations.

and) Why is screening research necessary in pediatric ophthalmology? Young children cannot reliably report vision changes in one or both eyes. Only a limited number of specialists are able to perform eye examinations in children, and their number is steadily decreasing. For these reasons, many eye diseases in children are diagnosed with late treatment. The need for screening became apparent after the emergence of data on the detection of more than 50% of children's ophthalmological conditions affecting the child's vision, as a rule, by pediatricians or family doctors during screening diagnostics.

b) What is screening? “Screening is systematic testing or interviewing to identify individuals at reasonable risk for a particular disorder in order to improve the effectiveness of further screening or immediate preventive measures among patients who did not seek medical help with symptoms of this disorder. " Population screening identifies subjects with a disease before symptoms develop. In addition, screening can be used to detect a risk factor for a future disease or its asymptomatic course.

in) When is a screening test appropriate? The criteria for the significance and feasibility of screening programs have been developed by the World Health Organization. They are divided into groups:

Is screening feasible and acceptable to those participating in the study? (criteria 4, 5, 6). Tests, performed before symptoms develop, are needed to help establish risk factors for the disease or a diagnosis in the asymptomatic stage of the disease. Such tests must have sufficient sensitivity and specificity to be useful, reliable and safe.

Is the disease recognized, is it possible to treat, is there a consensus on whom to treat and how, and are there sufficient technical means for examination and treatment? (2,3,7,8) Understanding and unanimous opinion about the natural course of the disease is necessary to assess the likelihood of progression of its asymptomatic form, detected by screening, to symptomatic. Treatment must be acceptable, affordable and well agreed. Screening for a terminal illness, especially in children too young to consent, carries the risk of significant harm.

Is there a program for widespread and continuous screening? (one) Screening test - complex, which gives hope for its suitability. Differing availability leads to exclusion from screening of those who are most likely to benefit from it.

What is the cost utility of the program as a whole, including follow-up research and procedures, and how does this compare with the resources available for other conditions? (1.9) A cost-benefit analysis is needed. A cost-benefit comparison (cost-benefit analysis) should indicate the superiority of screening over alternatives — public education through information campaigns, medical surveillance for early detection of symptoms, or increased resources for treatment.

d) Screening types:

1. Primary screening... The population as a whole is interviewed, surveyed or tested. This happens at the same time or at regular intervals. As a rule, it is carried out in one or another age group.
Example: Assessment of the red pupillary reflex in newborns.

2. Single-profile (targeted) screening... A test or study is offered to a category of individuals at increased risk of disease or complications.
Example: Screening for Diabetic Retinopathy.

3. Opportunistic screening... A test or study is offered to a patient attending medical institution for a different reason.
Example: assessment of visual acuity or examination of the retina during the assessment of congenital obstruction of the nasolacrimal duct.

4. Cascade screening... Testing of relatives of the patient at high risk of this disease; is the main form of screening in clinical genetics.

The importance of cascade screening is especially great for consanguineous families. In other families, the benefit of screening decreases rapidly as the test taker moves away from the proband, when it represents only a small percentage of the total carriers in the general population.
Example 1: mutation screening in relatives of a proband with retinoblastoma.
Example 2: clinical examination of relatives of a person with Marfan syndrome in order to identify the main and secondary clinical symptoms.

e) Screening vs active surveillance... When the prevalence of the underlying disease at initial screening is low (for example, hundreds of neonatal red pupillary reflex studies need to be performed to diagnose an abnormality), WHO guidelines should justify screening. If the likelihood of positive test results in a particular population is high, active surveillance is used instead of screening.

There is a continuous spectrum from primary screening to clinical care for an individual patient.
Since each category of health care has its own tasks, it is necessary to clearly understand which of them the patient needs.

e) Genetic screening... Specific and variable character genetic screening recognized in the program evaluation criteria. Once costs are reduced, there is pressure from individuals, families, patient support groups, and commercial interest in testing to detect specific gene disorders or complex traits of genetic markers.

The WHO criteria are equally valid for genetic screening, but they have been extended to accommodate specific considerations, such as the interests of other family members who may carry a genetic abnormality incidentally identified during cascade screening, ensuring that participants are fully aware of the limitations of the assay and the effects of genetic changes and also take into account the psychological impact.

g) Screening test analysis... Effective screening requires a test that accurately identifies a risk factor or presymptomatic sign, which in turn is a predictor of the subsequent development of the disease. The test should be trusted by experts and be reliable over time. The optimal threshold between positive and negative quantitative test results (eg, visual acuity) varies with conditions; for example, high sensitivity is required in screening for retinopathy of prematurity due to the severe consequences of each false negative case.

Descriptive statistics methods such as the ROC curve can help in making these decisions, to find the optimal balance of sensitivity and specificity. An analysis of previous studies is a prerequisite before the start of the program, followed by its refinement with constant quality control.

h) Preparation of a screening examination... The Government Health Initiative will provide funding and equal access. The key to success is complex and thorough preparation.

1. Setting goals. There are several of them:
and. Improving disease outcomes.
b. Limiting the harmful effects of screening.
in. Expansion of implementation.
e. Informing participants about realistic expectations for screening.
e. Cost limitation.

2. Calculation of the required resources. Quantification is documented covering all aspects of the screening process, including case studies with questionable results and treatment if a disease is detected.
3. Determination of a working strategy. Protocols are created to ensure the integrated operation of the program, the distribution of responsibilities and methods of documentation.
4. Development of a computerized system for identifying and attracting patients / participants that integrates with the systems used to manage selection and referral. Explains what the invitation entails, and provides a realistic view of possible outcomes, including false negative screening results.
5. Providing a screening test. The method and location of the research is determined.

6. Ensuring the conduct of events. Clinical resources should be available prior to starting the program to ensure immediate referral and treatment for the identified disease.
7. Minimization of questionable screening results. Patients with unclear screening results require further treatment, which is often resource-consuming. Choosing the right screening test can reduce the number of questionable results.
8. A screening program requires personnel management, training, communication, coordination and quality management, including audit, research and development.

and) Rationale for screening... Validation requires a large patient population and strict adherence to protocol. Demonstrating the benefits of screening using randomized controlled trials is an important part of preparing for a screening program.

The benefits of an active screening program are assessed using time series trend analysis, ideally with data collection continuing until screening begins. In addition, comparisons can be made simultaneously in a non-screening population, such as between countries.

1. Biased results... Screening studies are prone to bias due to patient selection. Results bias is manifested in support for better results.

Self-selection bias: people who accept a screening invitation are different from those who decline it; only randomized control can completely eliminate the problem.

Runtime bias: Early detection of cases by screening gives the false impression of longer survival or slow progression of the disease.

Duration bias: Screening is more likely to detect slowly progressive or static disease than rapidly progressing cases.

Identifying clinically insignificant cases: not in all cases, pathological changes will continue to develop to a clinically significant disease and, in the absence of screening, remain undiagnosed. Such cases can give the impression of a successful treatment.

Failure to control these influences is suspected when there is insufficient improvement in population treatment success rates established by time series trend analyzes, despite the apparent recovery of the patient based on screening results.

2. Varying screening practice... Optimal screening practice varies with place and time. The age and birth weight of infants with retinopathy of prematurity varies between countries and over time, so the optimal clinical criteria different for the populations targeted for screening. Differences in screening policies are also associated with different beliefs and values.

to) Screening in developing countries... Health systems in developing countries are often underresourced, with overstressed workloads, especially in rural areas. Families, especially mothers, are constrained by welfare and education and are often disadvantaged in rights. Famine, drought, civil unrest, or war can destroy the relief system. However, adequate screening is useful if it targets high prevalence diseases with low screening costs and inexpensive treatments (glasses, vitamins, essential antibiotics) that can be started immediately.

When resources are severely limited, a cost-benefit analysis will make it easier to choose between screening and alternatives such as education, information campaigns, baby-monitoring services, mass vaccinations (eg rubella), or disease prevention (eg oximetry for premature babies).

l) Expected Result... Ideally, screening programs should use objective evidence of benefit and prioritization of resources to achieve the greatest benefit. Other factors influencing the screening strategy are shown in the figure below. The belief in the benefits of pre-symptomatic diagnosis of the disease has led to support from the media, the public, support groups and professionals for some screening programs, which is not supported by evidence.

Social values \u200b\u200binfluence the prioritization of support for screening programs for emotive diseases by the media, the public, support groups and professionals. Commercial interests affect screening policies at various levels.

m) Legal consequences... Screening detects only a certain percentage of cases. When a child becomes ill despite the previous screening, there is palpable family frustration and professional anxiety, even if no mistake is made. This is the difference between screening and an individual approach to the patient; the sensitivity of any optimal screening test is less than 100%, thus avoiding extremely low specificity, which is detrimental to unnecessary testing and treatment.

The elimination of such problems begins before the screening itself by ensuring that the persons invited to screening are fully informed, including the fact that only a part of the persons who need further examination are identified and why this is necessary. In this case, the subject is able to make a conscious decision whether he wants to participate in the program. Be prepared to show retrospectively that informed consent has taken place. The screening service should demonstrate quality control and results that are comparable to the objectives and equivalent programs.

n) Vision screening in children... The main purpose of most screening assessments of vision in children in developed countries is to identify amblyopia. The established procedure varies considerably, including three stages:

Vision screening in preschoolers... The advantage of early diagnosis of amblyopia or risk factors that can lead to amblyopia is counterbalanced by relatively low participation, lack of perfect test, uncertainty about amblyogenic risk factors and their natural development... Vision screening in preschoolers is not widely accepted at this time, but there is ongoing research into criteria, methods and tools that might make it possible.

Vision screening at school age has the benefits of extended recruitment and reasonable consent for testing and treatment. Self-vision is the main result of the test, not a test for possible risk factors. There is reason to believe that amblyopia diagnosed at around the age of five is completely curable. However, it has been suggested that anisometropic amblyopia and strabismus, clouding of the mussel and other causes of amblyopia could have been detected earlier.

Vision screening in schoolchildren is most likely to detect uncorrected ametropia and may be warranted in developing countries, where it is the main cause of visual impairment. After the child has gone to school, further screening for amblyopia becomes ineffective, as new cases of amblyopia do not develop and the condition becomes incurable.

about) Conclusion... Screening is a valuable tool for detecting some childhood eye diseases when treatment is still possible. However, screening is a complex of conflicting aspects. It is important to perform high quality tests prior to implementing a screening program. It is inappropriate to perform inappropriate screening for the benefit of the patient and the general population. Several countries have established National Authorities to optimize and optimize public health screening policies.

Retinoblastoma diagnosed by eye screening.
In some cases, screening reveals a slowly progressive or clinically insignificant disease, which leads to biased results.
The presence of chorioretinal atrophy and intratumoral cystic cavities suggest long-term static size or early spontaneous regression.
The lesion was observed without treatment, and over the next 24 months there was a slow regression.
Screening test planning flowchart.
The screening chart is a standard means by which resources and protocols are planned for proposed or ongoing programs.
All are considered possible ways development of events along with the estimated or actual number of patients after each stage.
Differences in birth weight and gestational age among children with severe retinopathy of prematurity in low, middle and low high level income.
Horizontal and vertical lines represent the usual criteria for screening for retinopathy of prematurity.
It can be seen that many patients in middle- and low-income countries do not meet these criteria.
Factors influencing the screening strategy.

Tereshchenko A.V., Bely Yu.A., Trifanenkova I.G., Volodin P.L., Tereshchenkova M.S.

Kaluga branch of FGU "Eye Microsurgery MNTK" named after academician S.N. Fedorova

Rosmedtechnology ", Kaluga

AN INNOVATIVE APPROACH TO OPHTHALMIC SCREENING OF PREMATURE BABIES

The use of the mobile retinal pediatric video system "RetCam Shuttle" allows not only to examine in detail all parts of the fundus, but also to register the data obtained for subsequent analysis of changes in the state of the retina in dynamics and determination of treatment tactics.

Key words: ophthalmological screening, mobile retinal pediatric video system "RetCam Shuttle"

Relevance

Retinopathy of prematurity (ROP) belongs to a group of diseases that require the most high-tech approaches to diagnosis. This is due to the high specificity of its clinical manifestations, early emergence (the first weeks of a premature baby's life) and a rapid course.

The standard method for diagnosing ROP is considered to be screening examinations of premature babies in the nursing units using an indirect binocular ophthalmoscope. The main disadvantages of this approach are the subjectivity and controversy in the interpretation of research results.

In 1999, the first report was made of the use of the Retinal Digital Pediatric Video System IeYuat for screening premature babies. At present, ophthalmological care for premature babies abroad is organized in such a way that when retinoscopic signs indicating the severity of ROP are detected with the help of IeYuat, children are transferred from the nursing department to a specialized ophthalmological center for appropriate treatment.

In the Russian Federation, there are no national screening programs for ROP, which leads to serious shortcomings in the detection of this pathology and an increase in the number of children with severe and distant forms of the disease.

In 2003, on the basis of the Kaluga branch of the FGU "MNTK" Eye Microsurgery "named after Academician S.N. Fedorov Rosmedtekhnologii ", an interregional service was created, uniting into a single centralized system

measures for early screening, dispensary observation and treatment of children with ROP, based on the introduction of new diagnostic and therapeutic techniques into clinical practice.

Purpose of the study

Evaluation of the capabilities of the RetCam Shuttle mobile retinal pediatric video system in improving the quality of screening examinations of children in prematurity units.

Material and methods

Screening examinations of premature infants were carried out in the nursing departments of premature children's hospitals in Kaluga, Bryansk, Orel and Tula using an indirect binocular ophthalmoscope and a RetCam Shuttle.

In total, 259 children were examined for the first time, 141 were repeated. The percentage of using the "RetCam Shuttle" initial examination amounted to 35.8% (93 children), with repeated examinations - 54.3% (77 children).

The frequency of examinations of children in each of the departments was once every 1-2 weeks. During one examination, from 20 to 50 babies were examined. Screening was carried out starting from the second week of life of infants, with special attention paid to children with a gestational age of less than 30 weeks and a birth weight of less than 1500 grams. The examination was carried out under the conditions of drug mydriasis (double installations of atropine sulfate 0.1%).

The first stage was carried out indirect binocular ophthalmoscopy, when identifying ophthalmoscopic criteria characteristic of an unfavorable course of ROP, digital

XX Russian Scientific and Practical Conference "New Technologies of Eye Microsurgery"

retinoscopy using the RetCam Shuttle. We classified the following as ophthalmoscopic criteria requiring retinoscopy:

1) demarcation line, shaft, extraretinal proliferation in any area of \u200b\u200bthe fundus;

2) a sharp narrowing of the great vessels during vascularization in the 1st and posterior parts of the 2nd zone;

3) a sharp expansion of the great vessels during vascularization in the 1-3rd zones of the fundus;

4) expansion and increased tortuosity of the vessels located on the border with the avascular retina.

The study on the RetCam Shuttle was carried out under local anesthesia (installation of a 0.4% inocaine solution into the conjunctival cavity). 7 fields-circles of the fundus were registered: central, covering the macular zone and the disc optic nerve with vascular arcades, nasal, upper nasal, lower nasal, temporal, upper temporal, lower temporal.

Interpretation of the results of digital retinoscopy was carried out on the basis of the classification developed by us early stages ROP, reflecting the nature of the course of each stage, depending on the morphometric parameters of the retina (with a high or low risk of progression) and allowing to determine the features of monitoring for different courses of the disease, as well as on the basis of the unified international classification of ROP, revised in 2005.

Depending on the results obtained, the tactics of further monitoring and treatment were determined. Upon detection of stages 2 and 3 of ROP with a high risk of progression, as well as posterior aggressive ROP, in agreement with neonatologists, children were transferred to the Kaluga branch of the FGU IRTC "Eye Microsurgery" for laser coagulation of the retina.

Results and discussion

Preretinopathy was initially registered in 84 children (32.4%), with a high risk of further progression in 46 children (17.8%) (of which 11 (23.9%) were at risk of developing posterior aggressive ROP), 1 -th stage

the disease was registered in 63 infants (24.3%), stage 2 - in 28 (10.8%), stage 3 - 10 (3.9%), posterior aggressive ROP - in three children (1.2 %).

Upon repeated examination of children after 2 weeks, the distribution by stages of the process changed: preretinopathy was recorded in 44 (31.2%) children (with the risk of developing posterior aggressive ROP and vascularization of only the 1st zone of the fundus - in 5 (11.4%)) , the development of the 1st active stage of ROP from preretinopathy occurred in 17 children (20.2%), from the 1st stage to the 2nd the disease passed in 15 children (23.8%), from the 2nd stage to 3 th - in 11 children (39.3%). Transition of pre-retinopathy to aggressive posterior ROP with initial clinical manifestations was observed in 4 children (4.8%).

As a result, the idea of \u200b\u200bthe timing of the onset and duration of the course of the disease stages has changed. So, in children with a gestational age of 26-28 weeks, preretinopathy was registered already at the 2nd week of life. In children with a gestational age of 30 or more weeks, the 1st stage of ROP was detected at the 2nd week of life (Fig. 1 a, b, colored tab), and the progression to the 2nd stage occurred within 1-1.5 weeks. At the same time, the demarcation line was initially noted not in the temporal segment, but in the upper and lower segments (Fig. 2, color inlay), while in the temporal segment only a vascular break and increased tortuosity of the end vessels at the border with the avascular zone were visualized. Of particular interest was the fact of the development of posterior aggressive ROP from preretinopathy within 2 weeks (in children, on average at 4-5 weeks of life and with the localization of the process inside the 1st zone of the fundus) (Fig. 3 a-d, 4 a-c, color tab).

The data obtained led us to the need to revise the timing of the retinal laser coagulation (LKS). So, in 5 children with stage 2 with a high risk of progression, LCS was performed on average at 3.7 weeks of life, in 12 children with stage 3 with a high risk of progression of LCS - at 4.8 weeks of life, in 3 x children with posterior aggressive RN LKS - at 5.6 weeks of life. Previously, these terms averaged 5.1, 6.3, 7.1 weeks, respectively.

The timing of regression of the disease also shifted towards a decrease: at the 2nd stage, complete regression was observed on average at 5.8 weeks of life, at the 3rd stage - by 6.3 weeks. Have 3 children

Tereshchenko A.V. and etc.

An innovative approach to ophthalmological screening ..

(6 eyes) with posterior aggressive ROP, signs of stabilization of the process were detected on average at the 7th week; at 9.2 weeks of life, 5 eyes (83%) showed complete regression of ROP (Fig. 4d) (at standard terms of LKS, regression observed in 66%), in one case early vitreous surgery was required.

In the technological aspect, when comparing the methods of binocular ophthalmoscopy and digital retinoscopy, the following was revealed. It takes 4-5 minutes on average to examine one child using an indirect binocular ophthalmoscope. In this case, it is possible to examine not all areas of the fundus: it is extremely difficult to visualize the periphery of the retina in the upper and lower segments. In addition, the border of the vascularized and avascular retina in the early manifestations of the disease is not clearly visualized.

The use of "RetCam Shuttle" allows not only to examine in detail all parts of the fundus, but also to register the obtained data for subsequent analysis of changes in the state of the retina in dynamics and determination of treatment tactics. On average, the examination takes up to 5-6 minutes, and half of the time is entering information about the child into the device database. Examination is possible both on the pele-nal table and in the incubator (in case of a severe somatic condition of the child). Fundus visualization occurs in real time, mothers can observe the examination and see changes in the child's fundus, which makes it easier for them to understand the pathology and focus on the need for treatment.

Compared to indirect binocular ophthalmoscopy, RetCam Shuttle allows you to more accurately localize the process in accordance with the fundus zones and obtain more informative examination results.

Conclusion

In the course of the research, it was revealed that two methods - indirect binocular ophthalmoscopy and photo registration using the RetCam Shuttle - complement and expand each other.

The timing of the onset and duration of ROP was revised, depending on the gestational age of the child, and on the basis of this, the timing of laser coagulation of the retina.

In the conditions of the interregional service for the provision of ophthalmological care to premature babies created in the Kaluga branch of the Federal State Institution IRTC "Eye Microsurgery", during mass screening examinations, the use of indirect binocular ophthalmoscopy is convenient and effective. The use of the RetCam Shuttle is also necessary for in-depth diagnostics of complex cases in the field of work with the ability to more accurately predict the course of the disease.

The most expedient seems to be the widespread equipping of nursing units with retinal video systems "RetCam" and training specialists to work with them. The use of innovative digital technologies will contribute to early detection, timely treatment and reduction in the incidence of retinopathy of prematurity.

List of used literature:

1. Tereshchenko A.V. Early diagnosis and monitoring of retinopathy of prematurity / Tereshchenko A.V., Bely Yu.A., Trifankova I.G .; Edited by H.P. Takhchidi. - Kaluga, 2008 .-- 84 p.

2. Tereshchenko A.V., Bely Yu.A., Trifanenkova I.G. Retinal pediatric system "RetCam-130" in the interpretation and analysis of fundus changes in children with retinopathy of prematurity // Ophthalmosurgery. - 2004. - N "4. - S. 27-31.

3. Tereshchenko A.V., Bely Yu.A., Trifanenkova I.G., Volodin P.L., Tereshchenkova M.S. Organization and importance of the interregional service for the provision of ophthalmological care to premature babies in the Central region of Russia // Questions of practical pediatrics. - 2008. - T. 3. - N5. - S. 52.

4. Tereshchenko A.V., Bely Yu.A., Trifanenkova I.G., Tereshchenkova M.S. Working classification of early stages of retinopathy of prematurity // Ophthalmosurgery. - 2008. - N1. - S. 32-34.

5. American Academy of Pediatrics, American Association for Pediatric Ophthalmology and Strabismus, American Academy of Ophthalmology. Screening examination of premature infants for retinopathy of prematurity // Pediatrics. - 2001. - Vol. 108. P. 809-810.

6. Ells A., Holmes J., Astle W. et al. Telemedicine approach to screening for severe retinopathy of prematurity: a pilot study // Ophthalmology. - 2003. - Vol. 110. - N. 11. P. 2113-2117.

7. Gilbert C. Retinopathy of prematurity as a cause of blindness in chidren: Abstract Book World ROP Meeting. - Vilnius, 2006. - P.24.

8. International committee for the Classification of Retinopathy of Prematurity. The International Classification of Retinopathy of Prematurity revisited // Arch. Ophthalmol. 2005; 123 (7): 991-9.

9. Lorenz B., Bock M., Muller H., Massie N. Telemedecine based screening of infants at risk of retinopathy of prematurity // Stad Heals Technol Inform. - 1999. - Vol. 64 .-- R. 155-163.

10. The Committee for the Classification of retinopathy of prematurity // Arch. Ophthalmol. 1984; 102: 1130-4.

The cost"Plusoptix screening test" - 150 UAH - without a doctor's examination

Cost "Plusoptix Screening Test" - UAH 175 with a professional examination by a doctor

All parents wish their children health... As you know, preventing the development of a disease is much easier than treating it. To rid kids and their parents out of trouble a comprehensive preventive examination will help with health. For this purpose, for the first year of a child's life, once a month it is necessary to visit certain specialists. And it is no coincidence, because the first year is a very important period in the life of a baby, since it is at this time that all organs and systems of the body are formed. In our state health care system, a pediatrician examining a child monthly, sends him for a consultation to specialized specialists only if he suspects any pathology. But is it always possible to see the problem with the “naked eye”?

As it turned out, not always! It is about the development and formation of the child's visual system. Within the walls of our clinic, we often encounter situations when, upon hearing this or that ophthalmological diagnosis, parents ask the question: “How long have we had this problem?”, And are very surprised when they hear in response: “This problem is not three weeks old, and not even a few months, this is a congenital pathology. " And often we see the amazed and confused look of dads and moms. And when we start asking when did they visit the ophthalmologist, we get many answer options, such as:

- "Why do this before school?"
- "We were - we were told with age, everything will pass."
- “We were assured that it is impossible to examine a child until the age of 3,” and so on.

How to check the vision of a child of the first year of life?

Now in our center in Kharkov, thanks to the "Plusoptix, Gemany" apparatus, we can accurately test the vision (visual acuity) of a child under one year old.

This is the procedure for checking visual acuity:

• Doctor within 15-30 seconds measures the device "Plusoptix"
• Further, depending on the result of the examination, the doctor gives further recommendations and gives to the patient examination result.

Why is it so important to consult a pediatric ophthalmologist in infancy?

The peculiarity of eye diseases is such that they are not accompanied by painful sensations (except for injuries), so the child is not able to realize that he sees poorly and cannot inform his parents about it.

First visit to an ophthalmologistneed to plan at 3-4 months... It is at this age that the correct position of the eyes is established and possible pathologies are already visible. The doctor evaluates the condition of the optic nerve and retinal vessels, which are an indicator of the tone of the cerebral vessels. At this age are visible signs of such serious diseases as:

• congenital glaucoma(increased intraocular pressure),
• cataract(cataract),
• ptosis (drooping of the upper eyelid),
• malignant neoplasmsrequiring urgent surgical intervention.

If still add paralytic strabismus and some refractive errors, which can no longer only be diagnosed, but also successfully corrected before the age of one year, it becomes obvious how important is early inspection pediatric ophthalmologist .

No doubt is that a preventive examination is necessary for all babies. But there is a certain risk group, which is shown to visit an ophthalmologist almost urgently.
In what cases visit to the optometrist so necessary:

• pregnancy took place against the background of preeclampsia of any severity (preeclampsia, eclampsia)
• case of intrauterine chronic hypoxia
• with rapid or, conversely, protracted labor with a long anhydrous period
• cesarean section
• umbilical cord entanglement
• birth trauma
• premature birth before 38 weeks of gestation
• premature placental abruption
• apgar score less than 7-8 points
• IUGR (intrauterine growth retardation)
• TORCH - infection (congenital rubella, chlamydia, mycoplasmosis, herpes infection)
• aggravated family history according to ophthalmologists: - myopia (myopia) - hyperopia (farsightedness) - astigmatism - strabismus - cases of congenital cataract, glaucoma, optic nerve atrophy.

Let's summarize:

1) When is the first visit to the ophthalmologist necessary? - 3-4 months
2) What is needed for this? - The child must be full and not want to sleep
3) How difficult is the examination? - In the absence of pathology, it does not require expensive equipment or much time
4) What information content? - 100%, since at 3 months the child is not yet afraid of the doctor, follows the toy well and is calm during the entire examination
5) What will it give us if pathologists are detected? - Timely identification of the problem opens up the possibility of early conservative treatment.
6) How can an infant wear glasses? - We assure you that children even at this age will be able to wear glasses, and the sooner they start solving this problem, the more chances that the child will go to school with a completely healthy and prepared for the load of the visual system.

• Did your baby startle from loud noises in the first 2-3 weeks? life?
• Does the fading of the child appear in the voice at the sound of someone's voices? at the age of 2-3 weeks?
• Does the child turn around at the age of 1 month. to the sound of a voice behind him?
• Does the child turn his head at the age of 4 months? towards a sounding toy or a voice?
• Does the child revive at the age of 4 months. at the sound of your mother's voice?
• Does the child at the age of 1.5-6 months respond? shouting or opening your eyes wide to harsh sounds?
• Is there humming in a child aged 2-4 months?
• Does humming turn into babbling in a child at the age of 4-5 months?
• Do you notice in the child the appearance of new (emotional) babbling as a reaction to the appearance of parents?
• Does a sleeping child worry about loud sounds and voices?
• Do you notice in a child aged 8-10 months. the emergence of new sounds, and what?

The use of such questionnaires allows you to more accurately determine the pathology of hearing in the early childhood or even during the neonatal period, which means to outline preventive measures.

Hearing screening

Early identification of audiological problems allows early initiation of interventions aimed at increasing communication, social and educational skills in these children. For many years, there has been debate about the value of selective hearing screening and universal audiological screening during the neonatal period.

Unfortunately, only half of newborns with significant hearing impairment are identified using a selective screening strategy based on the presence or absence of risk factors for hearing impairment: a family history of hearing impairment in childhood, a history of congenital infections, anatomical malformations of the head, neck or ears, weight at birth less than 1500 g, a history of hyperbilirubinemia exceeding the critical level, severe asphyxia at birth, bacterial meningitis; history of ototoxic drug use; long-term mechanical ventilation; the presence of a congenital / hereditary syndrome or its stigma associated with sensorineural hearing loss.

The average age at which a child with significant hearing impairment is identified, for example, in the United States, is 14 months. Limitations in screening technologies that lead to inconsistent test interpretation and high frequency false positiveslogistics problems related to availability and performance ended in the United States in 1999 with the reaffirmation of a universal neonatal hearing screening policy with the goal of identifying significantly impaired infants by 3 months of age so that interventions begin by 6 months of age. Ideally, the first screening should be done before discharge from the hospital. Newborns up to 6 months are traditionally investigated using brainstem response testing.

A newer physiological technique - testing for otoacoustic emissions or evoked brain potentials - holds great promise as a simple screening technique. However, problems with specificity and logistical problems with the consistent use and interpretation of this test raise questions regarding the introduction of this method for universal screening.

Some pediatricians advocate a two-step screening strategy whereby children who are deficient in otoacoustic emission testing are referred for screening using a brain stem response test. Until an optimal screening method emerges, the specific methodology for screening newborn hearing is limited to these tests.

Children over 6 months. can be investigated using behavioral, auditory brainstem responses, or otoacoustic emission testing. Regardless of the technique used, screening programs should be capable of detecting a hearing loss of 30 decibels or more in the 500-4000 Hz region (speech frequency) - the level of deficit at which normal speech development may be impaired. If hearing impairment is identified, the child should be referred in a timely manner for further evaluation and early assistance in the form of guided education and socialization.

In addition to performing a rough hearing assessment and asking parents about hearing problems, formal hearing screening should be performed on all children at each dispensary visit. Risk factors that necessitate formal screening outside the neonatal period are: parental concerns about hearing impairment and / or delayed speech development; a history of bacterial meningitis; neonatal risk factors associated with hearing loss; a history of head trauma, especially with involvement in the fracture process temporal bones; the presence of syndromes associated with sensorineural hearing loss; frequent use of ototoxic drugs; neurodegenerative diseases and infectious diseases such as mumps and measles, which are associated with hearing loss.

Visual impairment

The most common type of visual impairment in children is refractive error. Through careful history taking, examination and visual testing, visual impairments can be detected early and their manifestations reduced or completely eliminated.

Risk factors for developing eye pathology include:

• prematurity, low birth weight, hereditary diseases in the family;
• BHV infection, rubella, herpes and sexually transmitted diseases in the mother during pregnancy;
• diathesis, rickets, diabetes, kidney disease, tuberculosis in a child; family history of ophthalmic diseases (amblyopia, hyperopia, strabismus, myopia, cataract, glaucoma, retinal dystrophy);
• a family history of diseases that may affect vision (diabetes, multiple sclerosis, collagenosis);
• the use of medications that can affect vision or cause a delay in the development of vision (steroid therapy, streptomycin, ethambutol, etc.);
• viral infections, rubella, herpes in a child.

Vision screening

Routine vision screening is an effective way to identify otherwise non-manifest problems that need to be corrected. Since the normal development of vision depends on the brain receiving clear binocular visual stimulation, and the plasticity of the developing vision system is limited in time (the first 6 years of life), early identification and treatment of various problems that impair vision are necessary to prevent permanent and irreversible vision deficit.

Routine age assessment of vision should be carried out at every dispensary visit of a pediatrician primary carestarting with the study of newborns and at any age, include a review of adequate anamnestic information regarding visual problems and family history, a rough examination of the eyes and surrounding structures, observation of pupil symmetry and reactivity, assessment of eye movements, identification of the "red reflex" (to detect opacification and asymmetry of the visual axis) and age-related methods for assessing eye preference, adjustment and visual acuity. Special ophthalmoscopic examinations are carried out at 1, 3, 5, 6, 7, 10, 12 and 14 years old, then annually up to 18 years old as part of the annual clinical examination of children or in the direction of a pediatrician.

In newborns, eye condition, adjustment and visual acuity can be roughly assessed by observing the child's ability to visually follow an object. In doing so, any behavioral signs of eye preference are noticed by alternately closing each eye when showing the object of interest and observing the symmetry position of the light reflected from the corneas when the light source is held several centimeters in front of the eyes (corneal light reflex). Visual adjustment (look with both eyes) should be constantly present by 4 months. life. It is especially important to evaluate the "red reflex" during the neonatal period. Identification of the absence of defects or asymmetry of the "red reflex" is the key to the timely identification and treatment of opacities of the visual axis and many anomalies in the back of the eye.

In infants and preschoolers, visual preference and adjustment can also be assessed by a more complex one-eye closure test. It involves closing and opening each eye while the child is looking straight ahead at an object about three meters away. Observation of any movement of the unclosed eye when the opposite eye is closed, or of the closed eye when the occluser is removed, indicates a potential misalignment of the eyes (squint) and requires discussion with the ophthalmologist about the plan for further examination. Regardless of the etiology, strabismus that remains untreated ultimately leads to cortical suppression of visual impulses from the non-dominant eye and a lack of spatial vision, making early diagnosis and critical therapy.

By 3-5 years of age, stereoscopic vision can be assessed using a stereoscopic test or stereoscopic screening devices. Formal visual acuity testing should begin at age 3 with age-appropriate techniques. Approximately 20-25% of children have identifiable refractive errors, usually premyopia or myopia (nearsightedness) by the time they reach adulthood. Picture tests such as the LH test and Allen picture cards are most effective in screening preschoolers. By the age of 5, most children can be successfully screened using standard alphabet cards, the Upside Down Test.

Schoolchildren, including adolescents, should have annual visual acuity tests. The examination of preschoolers should be continued if the visual acuity of any eye is reduced. In children 5-6 years old, if it is impossible to read most of the lines, further examination is necessary. At any age, more than one line difference in visual acuity measurement between eyes requires further evaluation.

Periodic examinations of the organ of vision and examination of visual functions should be carried out by family doctors at regular intervals: upon discharge from the hospital; at the age of 2-4 months; at the age of 1 year; at the age of 3-4 years; at the age of 7; at school - once every 2 years. Children at risk of developing eye pathology should be examined annually. Newborns and infants from risk groups are examined quarterly during the first two years of life.