Ophthalmologic Examination Of The Newborn

I. Examination of the Eyes should take place

A. During the initial routine examination (1st day of life) of all infants (by the pediatrician/neonatologist) to exclude obvious anomalies (must include bilateral red reflexes).

B. Following an initial period of stabilization (1st week of life) in all preterm infants < 1250 grams at birth (by the pediatrician/neonatologist) to exclude obvious anomalies and to assess gestational age.

C. Following an initial period of retinal development (from 4 to 6 weeks of life) in all preterm infants <1250 grams at birth (by an ophthalmologist trained to screen retinopathy of prematurity [ROP]):

1. To initiate regular ophthalmologic examinations until inner retinal vascularization is complete (may not be to the ora serrata).

2. To follow the progression and regression of ROP.

3. To determine the need for surgical therapy, which is usually necessary from 32 to 42 weeks postconceptual age (gestational age + postnatal age), thus ROP occurs early in larger (higher gestational age) infants and later in smaller (lower gestational age) infants.

4. To follow for the development of refractive errors, strabismus, amblyopia, etc. (all of which are more frequent in preterm infants).

D. At any time when any of the following are suspected or proven (by an ophthalmologist):

1. congenital intrauterine infections;

2. genetic syndromes;

3. family history of eye disease in parents or siblings;

4. severe central nervous system abnormalities;

5. maternal drug use or abuse;

6. obvious eye abnormalities or failure to obtain bilateral red reflexes.

II. Examination Techniques and Normal Findings

A. The use of direct ophthalmoscopy and dilating drops (cyclopentolate 0.2% and phenylephrine 1%) is safe and effective without causing hypertension or bradycardia in all but the smallest and most unstable infants. Hold the eyelids open for a few seconds; blot away excess.

B. A functional examination — for visual acuity, visual field, motility, and refraction — is not part of the routine initial examination. Note that good fixation and following and consistently straight eyes may not be present until 6 months of age; however, if there is no visual interest, nystagmus, bilaterally dull red reflexes, asymmetrical red reflexes, or a consistently crossed eye, an examination by an ophthalmologist is recommended.

C. During an orderly structural examination, note obvious orbital abnormalities (overview) and then proceed from the anterior to the posterior parts of the eye: an external examination includes the eyebrows, lids, lashes, lacrimal system; an internal includes the conjunctiva, sclera, cornea, iris (note pupils), anterior chamber, lens, vitreous, fundus (especially optic nerve and macula). Look for symmetry of ocular structures and clarity of optical media (clear cornea, lens, vitreous). The red reflex should be bright and symmetrical.

D. Be aware of the urgency of ophthalmologic examinations:

1. To prevent progressive ocular damage (e.g., glaucoma, retinopathy of prematurity, etc.).

2. To prevent unilateral deprivation amblyopia due to any unilateral obstruction to the visual axis (lid tumor, ptosis, corneal clouding such as glaucoma, corneal injury such as forceps, cataract, vitreous hemorrhage, etc.). Immediately patch both eyes to prevent irreversible severe amblyopia from developing, and refer to an ophthalmologist as soon as the obstruction is recognized.

3. To prevent bilateral deprivation amblyopia due to any bilateral obstruction to the visual axes (especially cataracts). Cataract surgery and refractive correction must be completed by 6 weeks postnatal age (in a term infant) to obtain optimal visual results. Other bilateral obstructions (corneal and vitreal) are less amenable to surgical correction with optimal visual results; however, refer to an ophthalmologist as soon as the obstructions are recognized. Note: asymmetrical refractive errors can cause relative unilateral refractive amblyopia; bilateral large farsighted refractive errors can cause relative bilateral refractive amblyopia.

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