Childhood Eye Examination in Primary Care.

Approximately 7% of children in the United States younger than 18 years have a diagnosed eye disorder, and 1 in 4 children between two and 17 years of age wears glasses. Routine eye examinations during childhood can identify abnormalities necessitating referral to ophthalmology, which optimizes children's vision through the early diagnosis and treatment of abnormalities. The U.S. Preventive Services Task Force recommends vision screening at least once in children three to five years of age to detect amblyopia or its risk factors to improve visual acuity. The American Academy of Family Physicians supports this recommendation. The American Academy of Pediatrics recommends screening starting at three years of age and at regular intervals in childhood, and that instrument-based screening (e.g., photoscreening, autorefraction) is an alternative to vision charts for testing visual acuity in patients three to five years of age. Eye examinations include visual acuity testing, external examinations, assessing ocular alignment and pupillary response, and assessing for opacities with the red reflex examination. Common abnormalities include refractive errors, amblyopia (reduction in visual acuity in one eye not attributable to structural abnormality), and strabismus (misalignment of the eye). Rare diagnoses include retinoblastoma (often detectable through loss of red reflex), cataracts (detectable by an abnormal red reflex), and glaucoma (often manifests as light sensitivity with corneal cloudiness and enlargement).

Bell's phenomenon during screening examination for retinopathy of prematurity.

PURPOSE: Bell's phenomenon (BP), which may disturb screening examinations for retinopathy of prematurity (ROP), is known to present infrequently in premature babies. Stress associated with the examinations can influence expression of BP. The authors of the present study evaluated BP during examinations for ROP. METHODS: The present study included 102 eyes of 51 premature babies. Expression of BP was assessed at 3 steps of the examination in the following order: after insertion of a speculum, after illumination of an indirect ophthalmoscope and after scleral depression. The relationship between the expression of BP and the gestational age at the examination was analyzed in each step of the examination. RESULTS: The frequency of BP after the speculum insertion and the illumination was 77% to 92% in infants 32 weeks of age or younger, and decreased significantly to 16% to 57% in infants 42 weeks of age or older (p < 0.005). BP after the scleral depression had no significant association with the gestational age. Frequency of BP increased significantly as the steps of the examination proceeded (p < 0.01). CONCLUSIONS: BP was frequent in premature infants during ROP examination in spite of neurological immaturity. The examiner should take BP into consideration, which frequently occurs in younger infants.

Bell's Phenomenon during Screening Examination for Retinopathy of Prematurity

PURPOSE: Bell's phenomenon (BP), which may disturb screening examinations for retinopathy of prematurity (ROP), is known to present infrequently in premature babies. Stress associated with the examinations can influence expression of BP. The authors of the present study evaluated BP during examinations for ROP. METHODS: The present study included 102 eyes of 51 premature babies. Expression of BP was assessed at 3 steps of the examination in the following order: after insertion of a speculum, after illumination of an indirect ophthalmoscope and after scleral depression. The relationship between the expression of BP and the gestational age at the examination was analyzed in each step of the examination. RESULTS: The frequency of BP after the speculum insertion and the illumination was 77% to 92% in infants 32 weeks of age or younger, and decreased significantly to 16% to 57% in infants 42 weeks of age or older (p < 0.005). BP after the scleral depression had no significant association with the gestational age. Frequency of BP increased significantly as the steps of the examination proceeded (p < 0.01). CONCLUSIONS: BP was frequent in premature infants during ROP examination in spite of neurological immaturity. The examiner should take BP into consideration, which frequently occurs in younger infants.

Pain management during eye examinations for retinopathy of prematurity in preterm infants: a systematic review.

AIM: To assess whether non-pharmacological and/or pharmacological measures lead to decreased pain during an eye examination in preterm infants. METHODS: . DESIGN: Systematic review. SUBJECTS: Premature infants meeting the criteria for screening eye examination for retinopathy. INTERVENTION: Databases were searched through the Ovid interface. Randomized and quasi-randomized controlled trials were included. Data were assessed independently by three reviewers. MAIN OUTCOME MEASURES: Pain assessed by Premature Infant Pain Profile (PIPP) or physiological changes. RESULTS: Eight studies were included and grouped according to intervention: oral sucrose (group 1), anaesthetic eye drops (group 2) and non-pharmacological measures (group 3). For group 1, the mean PIPP score with sucrose was 1.38 (WMD) (95% CI: 0.41-2.35) lower than that of placebo (p = 0.005). For group 2, one study showed a reduction of two points on the PIPP score with topical proparacaine, whereas another showed no benefit. For group 3, developmental care improved developmental scores and salivary cortisol in one study. CONCLUSION: Sucrose reduced pain during the eye examination, whereas the efficacy of proparacaine was not consistent in the studies included. However, PIPP scores remained relatively high in all the studies; thus further research is required to delineate better pain reduction strategies.

Lower stress responses after Newborn Individualized Developmental Care and Assessment Program care during eye screening examinations for retinopathy of prematurity: a randomized study.

OBJECTIVE: Screening examination for retinopathy of prematurity is distressing and painful. The aim of the present study was to investigate whether a Newborn Individualized Developmental Care and Assessment Program intervention during a retinopathy of prematurity examination results in less adverse behavioral, pain, and stress responses as compared with standard care. METHODS: The first 2 eye examinations in 36 preterm infants were evaluated. The infants were randomly assigned at the first eye examination to receive either Newborn Individualized Developmental Care and Assessment Program care or standard care. At the second examination, crossover of subject assignment was performed. The assessments included behavioral responses; recordings of heart rate, respiration, and oxygenation; pain scores (premature infant pain profile); and salivary cortisol at defined time points up to 4 hours after the eye examination. The nursing support given during the eye examinations (intervention score) were scored using predefined criteria. RESULTS: Altogether, 68 examinations were evaluated. Newborn Individualized Developmental Care and Assessment Program care was associated with better behavioral scores during the examination but there was no difference in heart rate, respiratory rate, oxygenation, or premature infant pain profile score between the 2 care strategies before or after the eye examination. Salivary cortisol increased from baseline to 30 minutes after the eye examination independent of care strategy and decreased significantly between 30 and 60 minutes when infants were subjected to Newborn Individualized Developmental Care and Assessment Program care but not after standard care. During the study period the intervention score for standard care increased and approached the score for Newborn Individualized Developmental Care and Assessment Program care at the later eye examinations. CONCLUSION: A Newborn Individualized Developmental Care and Assessment Program-based intervention during eye examination does not decrease pain responses but results in faster recovery, as measured by lower salivary cortisol 60 minutes after the examination. The differences were seen despite the influence from the Newborn Individualized Developmental Care and Assessment Program intervention on the standard care treatment that occurred during the study period.

Systemic effects of screening for retinopathy of prematurity.

AIMS: To detect systemic complications of screening for retinopathy of prematurity (ROP), paying particular attention to the physical examination. METHODS: Oxygen saturation, pulse rate, and blood pressure were monitored before, during, and after 110 ROP screening examinations. RESULTS: Following topical mydriatics diastolic blood pressure was elevated by a mean of 6 (SD 7.2) mm Hg. Immediately after the examination there was a further rise in both systolic and diastolic pressure of 4.3 (14.5) mm Hg and 3.3 (11.6) mm Hg, respectively. Oxygen saturation and pulse rate remained stable during the control period and administration of eyedrops. Saturation fell by a median of 3% (95% confidence interval plus or minus 1.2%) after the examination while there was rise in pulse rate of 7 (SD 23.1) beats per minute. This change in pulse rate was not observed in infants on concurrent methylxanthine therapy. No infant had clinically significant changes at the end of the study. CONCLUSION: The initial changes in blood pressure may represent side effects of topical mydriatics but the later changes following the physical examination may be an additional response to the stress of ROP screening.