The result of our study found that 34% of infants had abnormal ocular findings, and it was higher than the expected range of 4 to 25% in other studies (3-5). Ocular abnormalities detected in this study were subconjunctival haemorrhage, iris nevus, retinal haemorrhages, vitreous haemorrhage and congenital hypertrophy of retinal pigment epithelium (CHRPE). Compared to larger studies, we did not find any sight-threatening or life-threatening diseases such as congenital glaucoma, cataract and ocular tumours (3-5, 9, 12, 13). This suggests that such diseases are uncommon. Nonetheless, they require urgent treatment if detected.
We evaluated some of the maternal, infant and birth factors which may contribute to risk for ocular abnormalities. However, we found no significant difference in gender, race, maternal gravida, birth weight and maturity of pregnancy between both groups, except there was a larger proportion of newborns delivered by SVD in the abnormal ocular group (p<0.001) compared to newborns with normal ocular findings. We further sub-analyse the SVD group to compare 1st and 2nd stages of labour and episiotomy. In terms of duration of 1st stage and 2nd stage of labour, there was no significant difference between both groups. However, amongst newborns delivered via SVD, we found that episiotomy was more common in the group with abnormal ocular findings compared to normal findings (p=0.023).
In this study, the commonest abnormality was in the posterior segment, with 29.6% of infants having retinal haemorrhages. This result fell within the reported incidence of neonatal retinal haemorrhages between 2.6 to 50% (14). The wide range of incidence reported may be due to sampling biases (15) and timing of examination (16). Bilateral retinal haemorrhage was more common compared to unilateral (53.3% versus 46.6%), and this finding was similar to a systematic review by Watts et al. (16). The retinal haemorrhages detected in this study were 47 and 45 in the right and left eyes respectively, suggesting that chances of retinal haemorrhages were similar for both eyes.
In recent years, many authors tried explaining mechanisms and risk factors for retinal haemorrhage and proposed that the likely cause was birth-related trauma (3, 17). Yanli et al. proposed that compression of the foetal head during delivery causes deformation, which leads to elevated intracranial venous pressure, peripheral vascular congestion, expansion, or rupture, resulting in retinal haemorrhage (17). So far, no studies have suggested otherwise.
Overall, there were no statistically significant findings in terms or gender, race, maternal gravida, birth weight, term and age of the infant when correlation was made to determine the risk factors for retinal haemorrhages. However, many studies have reported that the mode of delivery was an associated risk factor for retinal haemorrhage (9, 16, 17). There are several other identified risk factors correlated to retinal haemorrhages such as maternal age, gravida, prolonged 2nd stage of labour and neonatal intracranial haemorrhage (17). In our study, we looked into some of the risk factors reported in those studies. A multiple logistic regression analysis indeed found that SVD remained the greatest risk factor which has nearly 3.5 times higher risk of newborns developing retinal haemorrhage compared to LSCS (OR=3.43; 95% CI 1.73, 6.78; p<0.001). A systematic review by Watts et al. found that instrument delivery had a higher risk compared to SVD (16, 18). However, we did not compare the risk of assisted/instrumental delivery as there were only 5 cases of vacuum-assisted delivery (however 3 out of 5 cases were associated with retinal haemorrhage).
Subsequently, this study also found that for every 1 minute increment in the duration of 2nd stage of labour, there was 6% more likely to have retinal haemorrhage (OR=1.06; 95% CI 1.01, 1.11; p=0.025). Yanli et al. explained that during the second stage of labour, the cervix is fully dilated, the foetal head is descended, and contractions are much stronger. At the same time, the foetus is compounded by other stresses such as intrauterine ischaemia and hypoxia. Therefore, the longer the second stage of labour, the more serious the damage to the retinal vein and vascular endothelial cells, causing increased neonatal retinal haemorrhages (17).
At our centre episiotomy is routinely performed on most primigravida mothers who deliver via SVD. This procedure involves a surgically planned incision on the perineum and the posterior vaginal wall during the second stage of labour. The aim is to enlarge the vaginal introitus to ease and facilitate safe delivery of the foetus, to minimise overstretching and rupture of the perineal muscles and fascia, to reduce the stress and strain on the foetal head, and to shorten the second stage of labour. A result in our study showed that SVD with episiotomy had 2.5 higher odds of associating retinal haemorrhage in newborns compared SVD without episiotomy (OR=2.50; 95% CI 1.16, 5.40; p=0.020). However, it was statistically not significant after adjusting all the variables using Multiple Logistic Regression. Emerson et al also found that the incidence of retinal haemorrhages was not associated with episiotomy (14). This suggest that episiotomy may even be protective against retinal haemorrhages as it is performed to reduce the duration of second stage of labour.
Many of these haemorrhages resolve spontaneously within 1–2 weeks without clinically significant long-term visual impairment (4, 16). Some recover by one month (18). Only a few of those cases required intervention (12). Retinal haemorrhages rarely persist beyond six weeks, except in isolated cases, up to 58 days (16). Therefore, the early detection of retinal haemorrhages can help distinguish between newborn ocular abnormalities and non-accidental injuries such as shaken baby syndromes (18). Choi et al. reported a case of vitreous haemorrhage, which resolved after 3 months (19). Some authors have postulated that long-standing; dense haemorrhage obscuring the macula may limit normal optical development, potentially resulting in visual disturbances such as anisometropia and amblyopia later in life (4, 19).
The ICON Paediatric fundus digital imaging system used in this study was able to produce clear images of the fundus for the detection and identification of posterior ocular abnormalities. Images taken can be used in the form of visual education to parents. Many earlier studies reported similarly using the Retcam, and in some studies, these cameras were operated only by trained technician (3-5, 12, 13, 17, 20). Therefore, examination using the fundus camera provided an alternative to indirect ophthalmoscopy by the Ophthalmologist. Technicians can be adequately trained to manage these cameras and subsequently stationed in places of demand. This translates to better ophthalmology services, can simultaneously reducing the workload and address the issue of shortage of Ophthalmologist.
Evidence of earlier successful telemedicine programs for diabetic retinopathy and ROP suggested that it can also be extended to a universal eye screening for all newborns. Imaging of fundus abnormality allows us to record and monitor treatment and disease progression (21). Images can also facilitate the transfer of information between clinicians (21). Now, with the advent of 5G technology, examination and management of our patients can be done in real-time. However, the cost of purchasing these cameras is substantial, and the economic value has to be assessed further. A study by Goyal P. et al. attempted to prove that there was a net monetary gain when taken into consideration, for example, the potential financial loss incurred by treating a blind child (3).
In our study, there was no reported adverse effect from the screening procedure conducted on these healthy term newborns. However, if present, previous studies showed that the systemic effects were mild and resolved spontaneously (2, 20, 22). Early detection of eye diseases is important, and therefore, an eye examination should be done within 24-72h after birth for all newborn unless they are unfit. In such scenario, the examination may be delayed. Further assessment by a family physician or general practitioner at six weeks of age is likely to enhance the detection rate further (7).
This study has several limitations. The simple sampling method used and relatively small sample size reduced the probability of detecting rarer ocular abnormalities. A multicenter study would give a better representation of the true proportion and types of abnormalities detected in the newborn population.