title: The detection of simulated retinoblastoma by using red-reflex testing.
abstract: OBJECTIVE
  To determine the ability to detect simulated retinoblastoma by using the red-reflex test.
  
  
  METHODS
  Discs that simulated retinoblastoma lesions were affixed to the retina of model eyes with an 8- or 3-mm pupil. The diameter, height, and location of the discs varied. Five examiners evaluated the red reflex with direct ophthalmoscopy by using straight-on and oblique viewing. The generalized estimating equation was used to assess the effects of pupil dilation and observer viewing orientation on tumor detection.
  
  
  RESULTS
  Significant 3-way interactions between pupil dilation, observer orientation, and tumor diameter (P < .004) or height (P < .02) were detected; these relationships depended on tumor diameter and height. A similar 3-way interaction was found between pupil dilation, observer orientation, and tumor location in degrees from the fovea (P < .001). Oblique viewing and pupillary dilation improved the tumor-detection rate. With straight-on viewing, the degree of detection was <48% (95% confidence interval [CI]: 39%-57%) for even the largest lesions, compared with 96% (95% CI: 93%-98%) for oblique viewing. For peripheral lesions, the percentage detection for straight-on viewing was 35% (95% CI: 21%-50%) for 30 degrees from the fovea and 16% (95% CI: 2%-31%) for 60 degrees from the fovea; these detection rates significantly improved with oblique viewing to 70% or higher (P < .001).
  
  
  CONCLUSIONS
  Detection of simulated retinoblastoma was better when lesions were large and when oblique viewing and dilation were used. Peripheral location was negatively associated with detection. Red-reflex testing to detect leukocoria may be improved with oblique viewing and pharmacologic dilation.
authors.affiliation: Department of Ophthalmology, Cullen Eye Institute, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Li
authors.forename: David K
authors.initials: DK
authors.lastname: Coats
authors.forename: Derrick
authors.initials: D
authors.lastname: Fung
authors.forename: E O'Brian
authors.initials: EO
authors.lastname: Smith
authors.forename: Evelyn
authors.initials: E
authors.lastname: Paysse
mesh_terms: D016001:Confidence Intervals; D006801:Humans; D021621:Imaging, Three-Dimensional; D008953:Models, Anatomic; D015588:Observer Variation; D009887:Ophthalmoscopy / Q000379:methods; D011336:Probability; D012025:Reflex, Pupillary; D019572:Retinal Neoplasms / Q000175:diagnosis*; D012175:Retinoblastoma / Q000175:diagnosis*; D012680:Sensitivity and Specificity