Retinopathy Of Prematurity Screening Examinations Research Articles

OMIC: A watchful eye on retinopathy of prematurity

Relevance: This workshop will review and discuss hospital-based programs for screening and follow-up of retinopathy of prematurity (ROP). Based on 2006 U.S. birth statistics, 86,523 live births were very pre-term (<32 weeks) and 63,309 live births were very low birthweight (<1500 g). Relying on this data and current American Academy of Pediatrics ROP screening guidelines, one ophthalmologist estimates that there may be as many as 450,000 ROP screening examinations performed in U.S. NICUs each year. These statistics underscore the fact that ROP screening and follow-up are primarily hospital-based. American Hospital Association data indicates that over 1,100 hospitals in the United States have NICUs. Reflecting a commitment to quality of care and patient-safety, some hospitals are adopting a systematic approach, utilizing one central NICU ROP coordinator (ROPC), to ensure that premature infants receive timely ROP screening and follow-up.

Socioeconomics of Retinopathy of Prematurity In-Hospital Care

To determine if there was any uniform experience across the United States relative to retinopathy of prematurity (ROP) services provided, reimbursement, and malpractice insurance coverage. An online pediatric ophthalmology listserv poll queried pediatric ophthalmologists regarding ROP screening, reimbursement, malpractice insurance, and call and consult coverage. Compensation for providing ROP services is quite variable around the United States. The Southern respondents reported the highest contract income while the Northeast reported the lowest. The mean annual contract income was $63 753 and the median annual contract income was $39 000. There was an even distribution between physicians vs hospitals providing malpractice coverage. There was also a fairly even distribution between physicians who do and do not provide consult and call coverage. Nationwide, there is no standard rate of compensation for ROP in-hospital care, coverage of liability insurance, or providing additional consult or on-call services. Income generation performing ROP screening examinations is roughly half what a pediatric ophthalmologist can generate by seeing patients in the clinic or performing surgery.

ACCURACY OF RETINOPATHY OF PREMATURITY DIAGNOSIS BY RETINAL FELLOWS

The purpose of this study was to measure the accuracy of retinopathy of prematurity (ROP) diagnosis by retinal fellows. An atlas of 804 retinal images was captured from 248 eyes of 67 premature infants with a wide-angle camera (RetCam-II, Clarity Medical Systems, Pleasanton, CA). Images were uploaded to a study Web site, from which an expert pediatric retinal specialist and 7 retinal fellows independently provided a diagnosis (no ROP, mild ROP, type 2 ROP, or treatment-requiring ROP) for each eye. The sensitivity and specificity of each retinal fellow were calculated and subsequently compared with a reference standard of diagnosis by an expert pediatric retinal specialist. For detection of type 2 or worse ROP by fellows, mean (range) sensitivity was 0.751 (0.512-0.953), and specificity was 0.841 (0.707-0.976). For detection of treatment-requiring ROP, mean (range) sensitivity was 0.914 (0.667-1.000), and specificity was 0.871 (0.678-0.987). In general, fellows showed high accuracy for detecting ROP. However, 3 of 7 fellows achieved <80% sensitivity for diagnosis of type 2 or worse ROP, and 2 of 7 achieved <90% sensitivity for diagnosis of treatment-requiring ROP. This could lead to undermanagement and undertreatment of clinically significant disease and raises potential concerns about the quality of ROP screening examinations performed by less-experienced examiners.

The Retinopathy of Prematurity Screening Examination: Ensuring a Safe and Efficient Examination While Minimizing Infant Discomfort

Retinopathy of prematurity (ROP) examinations in the NICU are necessary to protect vision in premature infants, but the examinations are associated with risk and discomfort. ROP examination risks include adverse effects from mydriatic agents, systemic responses to the stress of examination, and nosocomial infection. Infant discomfort may be lessened by limiting examination length and possibly by measures such as topical anesthetic, oral sucrose, and certain nonpharmacologic techniques. A well-organized ROP service facilitates appropriate scheduling of examinations and education of the infant's parents. This article addresses causes of risk and infant discomfort, providing a framework for developing a safe and efficient ROP service while minimizing infant discomfort.

Pain and stress assessment after retinopathy of prematurity screening examination: A comparison study between indirect ophthalmoscopy and digital fundus imaging

UENPS.30 Neonatal pain — What are we afraid of? Paulina Kobiela⁎, Iwona Domzalska-Popadiuk, Anna Kawinska-Kilianczyk, Iwona Janczewska Medical University, Gdansk, Poland

Bell's Phenomenon and Conjunctival Injury in Screening Examination for Retinopathy of Prematurity

Purpose: Bell's phenomenon (BP) was known not to be common in premature babies. If manifested, it may be detected on screening examinations for retinopathy of prematurity (ROP), indicating that conjunctival injury may have occurred. We studied correlations with BP and conjunctival injuries. Methods: Ninety-two eyes of 46 premature babies, ranging from 36 to 38 weeks of gestational age, underwent screening examination for ROP. Rotation of the eyeball was evaluated with an inserted speculum. After observing temporal and nasal ora serrata with indentation, conjunctiva was examined for any possible damage. Results: BP was observed in 50 of 92 subjects (54%). Notable conjunctival hemorrhage was found in 7 of 50 eyes (14%) with BP and in 2 of 42 eyes (5%) without BP. Stronger BP is correlated with severe injury to the conjunctiva (p

Impact of Retinopathy of Prematurity Screening Examination on Cardiorespiratory Indices: A Comparison of Indirect Ophthalmoscopy and Retcam Imaging

To compare the impact of retinopathy of prematurity (ROP) screening examination between a digital fundus camera and conventional binocular indirect ophthalmoscopy (BIO) using cardiorespiratory indices as a measure of distress. Prospective comparative (nonrandomized) interventional study. Eighty-six preterm infants with a birth weight of < or =1500 g or gestational age of < or =32 weeks and undergoing ROP screening were included. Retinopathy of prematurity screening examination with BIO or the digital fundus camera was performed. Cardiovascular indices were recorded before, during, and 1 hour after examination. Race, birth weight, gender, twin status, duration of the examination, gestational age, and postconceptual age were recorded. Heart rate (HR), oxygen saturation, respiratory rate (RR), and mean blood pressure (BP). Thirty-four infants underwent indirect ophthalmoscopy, whereas 52 underwent digital fundus camera examination. The increase in HR and RR was significantly higher in the indirect ophthalmoscopy group than in the digital fundus camera group (P<0.05). There was a significant increase in HR and mean BP during examination in both groups (P<0.05). No clinically significant response persisted at 1 hour. Digital fundus camera examination took significantly longer (P<0.001). Screening for ROP with a digital fundus camera is associated with a significantly lower stress-related response than conventional indirect ophthalmoscopy.

THE EFFECTS OF COMFORT CARE ON THE PAIN RESPONSE IN PRETERM INFANTS UNDERGOING SCREENING FOR RETINOPATHY OF PREMATURITY

The aim of the study was to determine if pain and distress during the retinopathy of prematurity (ROP) screening examination could be ameliorated by providing comfort care. This study was a prospective, randomized, controlled trial of 30 stable preterm infants who underwent initial ROP screening examinations. Fourteen study infants were swaddled, held, and given 24% sucrose solution during the examination. Sixteen controls were examined while lying in their cribs. Vital signs (i.e., pulse rate, respiratory rate, and oxygen saturation), crying time, and time for the vital signs to return to baseline values were recorded at different times during the examination. The vital signs did not vary significantly between the two groups. The participants in the control group had a trend of longer crying time, but this trend did not reach a level of statistical significance. In addition, The time required for the vital signs to return to their baseline values did not vary significantly. ROP screening is very distressful for preterm infants. The routine use of comfort care to reduce pain during the examination could not be supported by this study.

Systemic manifestations in response to mydriasis and physical examination during screening for retinopathy of prematurity

Infant's distress during funduscopic examination has been demonstrated in previous studies. The aim of this study was to determine whether adverse effects manifested via vital sign changes during the screening examination for retinopathy of prematurity (ROP) are because of the pharmacologic properties of the eye drops or to physical manipulation of the eyes. The authors also investigated the relationship between distress during the screening process and the severity of prematurity of the infant. In a prospective observational study, all infants (n = 30) either weighing ≤1500 g or who were ≤32 weeks gestational age at birth and were admitted to the neonatal intensive care unit (NICU) at Northwest Texas Hospital or Baptist St. Anthony's Hospital from June 2002 to February 2003 were enrolled. Blood pressure, pulse, temperature, respiratory rate, and oxygen saturation were recorded at different time intervals during the examination. Infants were excluded from the study if they were on the ventilator, considered acutely ill, born with significant birth defects, or currently taking inotropic drugs, or had received albuterol two hours before the examination. The authors found that oxygen saturation and pulse rate following physical manipulation of the eyes significantly varied from baseline values and the values obtained during the three instillations of topical mydriatics. No significant changes in blood pressure, temperature, or respiratory rate from their respective baseline values were observed throughout the ROP screening examination. Gestational age of the infant did not correlate with level of distress during the examination. The authors conclude that regardless of the severity of prematurity, infants seem to undergo significant distress during the eyelid speculum examination. Thus ophthalmologists should take into consideration the infant's discomfort caused by physical manipulation of the eyes and attempt to perform the examination as quickly and as safely as possible using topical anesthetic.—Valerie Biousse

Screening for Retinopathy of Prematurity: Is It Painful?

Background: Screening programmes for retinopathy of prematurity have shown to reduce unfavourable visual outcome and to be cost-effective. Following present recommendations, almost 1% of all newborn babies should therefore be screened and undergo at least one ophthalmologic examination. This is a skilled procedure that requires drug instillation and manipulation of the ocular globe with scleral indentation. The objective of this study is to describe the side effects of this ophthalmic exam with special focus on the occurrence of pain. Methods: This was an observational study with a before-after analysis where all neonates undergoing an ophthalmologic exam during a 4-month period in a third level hospital were included. CRIES pain score was determined before the exam, 5 min after and 24 h after the screening manoeuvre. Blood pressure and pulse rate were determined in addition to the mentioned measurements 30 min after the ophthalmologic examination.Minimum oxygen saturation, apnoeas, gastrointestinal side effects (like vomiting and gastric aspirates), the need for respiratory assistance or for intensive care unit admission were recorded within 24 h before and after the procedure. Results: 27 preterm neonates underwent an ophthalmologic examination and were included in the study. CRIES pain score was significantly higher 5 min after and 24 h after the screening procedure than before. This difference was also observed after stratification for birth weight and gestational age. No other study variable modified this time effect. No significant changes in blood pressure and pulse rate were shown after the ophthalmic exam. Vomiting was present in 4% of the newborns, gastric aspirates in 22% and apnoeas in 41% after the examination. Ten percent of the explored preterm babies needed increased respiratory assistance and 4% had to be transferred from the intermediate care unit to the intensive care because of severe apnoeas. Comments: An increase in pain score was shown after retinopathy of prematurity screening examination. Physiologic variable changes do not last long enough to evaluate the impact of certain procedures. Multivariate pain scores (like CRIES) should be used in everyday practice. It seems that the ophthalmologic examination in preterm babies might be painful and further studies should identify the best strategy to prevent pain during the retinopathy of prematurity screening manoeuvre.

Severe retinopathy of prematurity: longitudinal observation of disease and screening implications.

To test the effectiveness of our Canadian retinopathy of prematurity (ROP) screening guidelines as applied to high-risk premature infants. Retrospective longitudinal cohort study. A total of 969 infants were examined longitudinally between 1991 and 2000 and 46 of these infants screened were treated for severe ROP. Data from weekly ROP screening examination results were collected from a geographical area and analysed. The average incidence of severe ROP requiring treatment in the population of premature infants eligible for screening was 48.3 per 1000. In all, 46 infants were treated in this cohort. The mean gestational age (GA) was 25.5 weeks of age and the mean birth weight was 750 g. The mean chronological age (CA) and postmenstrual age (PMA) at the time of first screening was 36 days and 30.7 weeks, respectively. The first identification of any ROP in this group was at a mean CA 60 days and PMA of 34.1 weeks. The mean CA and PMA of the first observation of stage 3 were 74 days and 36.3 weeks. The mean CA and PMA at the time of treatment were 86 days and 37.7 week. Our observations and analysis indicate the following ROP screening recommendations: infants of 28 weeks of GA or less, infants with a GA between 28 weeks and 30 weeks should have a single 'spot examination' at approximately 37 weeks of PMA (or prior to discharge from hospital) to include possible outliers; infants born with a birth weight of 1250 g or less; initial screening examination should be at 31 weeks of PMA or 4 weeks of CA, whichever is later; in the presence of any active ROP, the infant should be followed every 1-2 weeks; and stage 3 should be followed at least every 7 days.

Systemic manifestations in response to mydriasis and physical examination during screening for retinopathy of prematurity.

To determine whether adverse effects manifested via vital sign changes during the screening examination for retinopathy of prematurity (ROP) are due to the pharmacologic properties of the eye drops or to physical manipulation of the eyes. The authors also investigated the relationship between distress during the screening process and the severity of prematurity of the infant. A prospective observational study was designed that enrolled all infants either weighing < or =1500 g or who were < or =32 weeks gestational age at birth who were admitted to the neonatal intensive care unit (NICU) at Northwest Texas Hospital or Baptist St. Anthony's Hospital from June 2002 to February 2003. Thirty participants were enrolled in this study. Blood pressure, pulse, temperature, respiratory rate, and O2 saturation were recorded at different time intervals during the examination. Infants were excluded from the study if they were on the ventilator, considered acutely ill, born with significant birth defects, or currently taking inotropic drugs, or had received albuterol 2 hours before the examination. Oxygen saturation and pulse rate following physical manipulation of the eyes significantly varied from baseline values and the values obtained during the three instillations of topical mydriatics. No significant changes in blood pressure, temperature, or respiratory rate from their respective baseline values were observed throughout the ROP screening examination. Gestational age of the infant did not correlate with level of distress during the examination. Regardless of the severity of prematurity, infants seem to undergo significant distress during the eyelid speculum examination. Thus ophthalmologists should take into consideration the infant's discomfort caused by physical manipulation of the eyes and attempt to perform the examination as swiftly, yet safely, as possible using topical anesthetic.

Retinopathy of prematurity in infants with birth weights greater than 1250 grams

Purpose To determine whether severe retinopathy of prematurity (ROP) occurs in infants whose birth weights exceed 1250 g. Methods We retrospectively reviewed the medical records of 1118 premature infants with birth weights > 1250 g, who were referred for screening examinations for ROP, to determine the severity of ROP observed. We then cross-tabulated these data with each infant’s estimated gestational age and birth weight. Finally, we applied currently recommended screening guidelines retrospectively to determine whether they would have identified infants who had developed severe disease and who were subsequently treated. Results Stage 3 ROP was detected in infants with estimated gestational ages up to and including 32 weeks and birth weights up to and including 1874 g. A total of 26 of the participants received laser treatment for threshold ROP. Seven of these infants would not have been referred for screening according to current guidelines. Conclusions Current screenings guidelines may fail to detect severe ROP in larger, more mature infants.

Pharmacology Review

The American Academy of Pediatrics, in a joint statement with the American Association for Pediatric Ophthalmology and Strabismus and the American Academy of Ophthalmology, recommends that all infants who have birthweights less than 1,500 g or gestational ages of 28 weeks or less, as well as selected infants whose birthweights are between 1,500 and 2,000 g and who have unstable clinical courses should receive fundus examinations after pupillary dilatation to evaluate for retinopathy of prematurity (ROP). Most infants have at least two examinations. Despite more than 100,000 examinations being performed annually on preterm infants, there are relatively few data regarding the frequency and severity of adverse systemic effects caused by the examination or the medications used for the examination. Ocular stimulation causes alterations in cardiac rhythm or rate via afferent impulses through the ophthalmic division of the trigeminal nerve via the reticular formation to the visceral motor nuclei of the vagus nerve. Traction on the ocular muscles and pressure on the globe are among the stimuli that cause bradycardia and ectopic beats in some patients. Clarke and associates documented positive oculocardiac reflexes in 17 of 54 preterm infants (31%) undergoing ophthalmoscopic screening examinations for ROP. Instillation of eye drops, introduction of the speculum, scleral depression, and traction on the rectus muscles all were associated with heart rate decreases of greater than 10%. All episodes lasted fewer than 15 seconds after removal of the stimulus. Ramet and colleagues demonstrated that the heart rate response to ocular pressure progressively increased with decreasing postconceptional age; infants at 32 weeks’ postmenstrual age (PMA) demonstrated electrocardiographic RR interval prolongation that was two to three times greater than infants at term PMA and older. A later study by the same authors demonstrated that RR interval prolongation induced by ocular stimuli during REM sleep was significantly greater …

Screening guidelines for retinopathy of prematurity: the need for revision in extremely low birth weight infants.

To determine whether significant retinopathy of prematurity (ROP) can be detected before 31 to 33 weeks' postmenstrual age (PMA) in extremely low birth weight (ELBW) infants. Medical records of all ELBW infants (<1000 g at birth) admitted to our regional perinatal center between April 1995 and January 1999 were reviewed retrospectively. Screening examinations for ROP were routinely performed at 4 to 6 weeks' chronological age (CA) from birth and followed at least every other week. Data were collected for infants who developed ROP. We determined the PMA at which the first screening eye examination demonstrated prethreshold disease and the subsequent examination that showed threshold disease (if it occurred). The percentages of infants who developed prethreshold ROP diagnosed at </=31 weeks' PMA and of those who progressed to threshold ROP before 34 weeks' PMA were determined. All 258 ELBW infants were screened for ROP. Seventy-eight infants (30%) were diagnosed with prethreshold ROP. Twenty-seven of these infants (35%) progressed to threshold ROP. Ten infants who progressed to threshold ROP were <34 weeks' PMA at the time of this diagnosis. Of these 10 infants, 3 were diagnosed at 31 weeks' PMA, 4 at 32 weeks', and 3 at 33 weeks'. More than 80% of ELBW infants who developed prethreshold disease in this cohort were </=33 weeks' PMA. The joint statement screening option of independently using 31 to 33 weeks' PMA for the first eye examination would have led to a diagnosis of threshold ROP on first examination in as many as 13% (10/78) of our patients. Early identification of prethreshold ROP is important for providing timely intervention in this rapidly progressive disease. Therefore, ELBW infants should receive initial ROP screening using the CA guideline of 4 to 6 weeks rather than the 31- to 33-week postconceptional age guideline.

Mydriatics slow gastric emptying in preterm infants

Objective: Preterm infants are more likely to have episodes of abdominal distention, emesis, and gastric residuals 24 hours after their first screening examination for retinopathy of prematurity (ROP) than on the day preceding the examination. Because these feeding problems reflect abnormalities in motor function, the purpose of this study was to compare antral and duodenal motor activity and gastric emptying in preterm infants before and after the instillation of mydriatics. Study design: Using a low compliance continuous perfusion manometric system, we recorded antral and duodenal fasting motor activity in 11 preterm infants before and after the instillation of mydriatics for their first screening examination for ROP. Gastric emptying was compared before and after the eye examination. Results: Although the number of antral motor contractions remained relatively constant throughout the study, duodenal motor contractions decreased nearly fourfold after the instillation of mydriatics versus that seen before (P <.01). Gastric emptying was significantly delayed after the completion of the eye examination compared with that seen before the examination (P <.05). Conclusion: Current doses of mydriatics inhibit duodenal motor activity and delay gastric emptying, and these gastrointestinal effects of mydriatics may underlie the feeding difficulties seen in preterm infants on the day of screening examinations for ROP. (J Pediatr 2000;137:327-30)

Retinopathy of prematurity in infants of birth weight > 2000 g after haemorrhagic shock at birth

BACKGROUND: The risk of retinopathy of prematurity (ROP) is associated with low birth weight and low gestational age. For ROP screening examination is recommended in infants weighing 1500 g (n = 149) and who required additional oxygen supplementation or underwent surgery with general anaesthesia before estimated term. RESULTS: Unexpectedly, three infants with birth weights between 2080 and 2325 g and a gestational age of 32 or 33 weeks developed stage 2 or 3 ROP. One of these underwent cryocoagulation. In three infants, preterm birth was induced by sudden placental abruption with severe prenatal blood loss followed by haemorrhagic shock. The umbilical cord packed cell volume was reduced to 0.14-0.19 (normal 0.43-0.63). All three infants underwent surgery with general anaesthesia within the first weeks of life. Of the remaining 449 infants none with a birth weight > 1650 g developed any stage of ROP. CONCLUSION: Severe prenatal blood loss requiring blood transfusions and surgery with general anaesthesia may induce higher stages of ROP even in infants with birth weights exceeding the usual screening criteria.

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.

Retinopathy of prematurity in infants of birth weight &gt; 2000 g after haemorrhagic shock at birth.

The risk of retinopathy of prematurity (ROP) is associated with low birth weight and low gestational age. For ROP screening examination is recommended in infants weighing < or = 1500 g or of less than 32 weeks' gestational age. From 1991 ROP screening was performed in 452 premature infants with either a birth weight < or = 1500 g (n = 303) or a birth weight > 1500 g (n = 149) and who required additional oxygen supplementation or underwent surgery with general anaesthesia before estimated term. Unexpectedly, three infants with birth weights between 2080 and 2325 g and a gestational age of 32 or 33 weeks developed stage 2 or 3 ROP. One of these underwent cryocoagulation. In three infants, preterm birth was induced by sudden placental abruption with severe prenatal blood loss followed by haemorrhagic shock. The umbilical cord packed cell volume was reduced to 0.14-0.19 (normal 0.43-0.63). All three infants underwent surgery with general anaesthesia within the first weeks of life. Of the remaining 449 infants none with a birth weight > 1650 g developed any stage of ROP. Severe prenatal blood loss requiring blood transfusions and surgery with general anaesthesia may induce higher stages of ROP even in infants with birth weights exceeding the usual screening criteria.

Systemic effects of screening for retinopathy of prematurity.

To detect systemic complications of screening for retinopathy of prematurity (ROP), paying particular attention to the physical examination. Oxygen saturation, pulse rate, and blood pressure were monitored before, during, and after 110 ROP screening examinations. 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. 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.