!DOCTYPE html PUBLIC “-//W3C//DTD XHTML 1.1//EN” “http://www.w3.org/TR/xhtml11/DTD/xhtml11.dtd”>
Noninvasive and Minimally Invasive Surgical Procedures
A broad range of noninvasive and minimally invasive surgical procedures are necessary in the course of managing children with pediatric vitreoretinal pathology. This chapter details the pertinent aspects of these interventions.
Many of these procedures are performed routinely on adults in the clinical setting with topical, subconjunctival, or retrobulbar anesthesia. In general, infants and children will require general anesthesia or monitored sedation for analogous procedures.
EYE EXAMINATIONS IN THE NEWBORN INTENSIVE CARE UNIT
Eye examinations of premature infants at risk of developing retinopathy of prematurity (ROP) are routine events in neonatal intensive care units (NICUs). The health care team for ROP management consists of ophthalmologists, neonatologists, NICU nurses, and the parents. The neonatologist determines whether an individual infant can be safely examined in view of potential systemic complications of the examination. Nurses not only administer mydriatics and assist with the exam but often play a critical role in assembling the infant’s health care team. Parental involvement in keeping the examination schedule, once infants are discharged from the hospital, is critical.
Examination is performed following dilation of the pupils, generally employing a lid speculum and scleral depression, and may increase systemic instability of the infant. Cyclopentolate 0.2% and phenylephrine 1% (combined in Cyclomydril) is administered as a single drop to each eye, with a second application 2 to 5 minutes after the first. When adequate dilation is not obtained, phenylephrine 2.5% (except in the setting of systemic hypertension) and either cyclopentolate 0.5% or tropicamide 1% may be instilled twice, 2 to 5 minutes apart. Special attention should be given to the possibility of bradycardia, arrhythmia, asystole, hypoventilation, apnea, or aspiration. Infants are appropriately monitored, with exams attended by a member of the NICU nursing staff. Examination is interrupted if the infant is not stable and not resumed until the infant is again stable. The examination is terminated if recommended by the NICU nursing staff and physicians.
Equipment required for the eye examination includes an indirect ophthalmoscope with condensing lens (20D, 28D, or 30D), an infant lid speculum, and a scleral depressor. Sterile instruments are used for each examination along. Also, diligent hand washing, use of antiseptic lotions, and changing of gloves between infants are necessary to avoid the transmission of infectious disease from one infant to another.
The infant is swaddled to minimize movement, with an assistant holding the infant to minimize head movement. Topical ophthalmic anesthetic (e.g., proparacaine HCl 0.5%) is used in both eyes. The lid speculum is placed and the right eye is examined first by convention. Each clock hour is examined to the ora serrata. The findings are recorded using the International Classification of ROP (1–3).
DIGITAL FUNDUS IMAGING IN THE NEWBORN INTENSIVE CARE UNIT
The health care team behind a telemedicine approach to ROP surveillance is the same as that described above for monitoring with binocular indirect ophthalmoscopy (BIO). However, in this paradigm NICU nurses typically assume image acquisition responsibilities. The team concept is particularly important in a telemedicine paradigm because the ophthalmologist is no longer onsite face of the evaluation program. Those who acquire images (NICU nurses or other trained personnel) are the front line of the evaluation program. Nurse team members and other interested NICU nurses should be trained in telemedicine techniques (see also Chapter 40).
The only device employed currently is the RetCam (Clarity Medical Systems, Pleasanton, California, USA) family of cameras. For ROP, the 130-degree lens is preferred for wide-angle visualization of the fundus. The external lens is employed for iris and anterior segment imaging. High-magnification imaging (optic nerve or macular pathology) is performed with either a 30-D or an 80-D lens. The RetCam Viewer software allows for image processing capability, including manipulation of contrast, brightness, and color saturation. The discussion that follows assumes reference to the RetCam unless indicated otherwise.
The eyes should be well dilated prior to imaging and is particularly important in darkly pigmented children. The dilation protocol is the same as for binocular indirect ophthalmoscopy (BIO) described above.
Infants should be closely monitored for bradycardia, apnea, and tachycardia after dilation and during the imaging process. There is no evidence to suggest that telemedicine examination is harmful to the infant or more stressful than BIO (4) and some evidence to suggest that it may be less stressful (5). A drop of topical anesthetic is applied to each eye. A wire speculum (Alfonso or pediatric Barraquer) is used to open the eyelids. Because the RetCam is a corneal contact camera, a methylcellulose coupling agent is applied to the cornea or lens surface.
Digital fundus imaging should be performed on all infants at risk for ROP on a dedicated day once weekly (as outlined in the joint statement on ROP from the American Academy of Pediatrics, American Association for Pediatric Ophthalmology and Strabismus, and American Academy of Ophthalmology) (6
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
