It is crucial to achieve good pupillary dilation in order to allow examination of the retinal periphery in addition to the posterior pole. Recommended eye drops are tropicamide 0.5 % together with phenylephrine 2.5% applied two to three times every 5-10 min. As an alternative, custom-made atropine 0.1% eye drops applied also two to three times every 5-10 min may be used, as they provide good mydriasis for about 3 h, thus requiring a less stringent planning of the exact consultation time by the ophthalmologist in charge of the screening. In order to avoid potentially harmful light exposure, the incubator should in this case be covered by a cloth. The nurses are asked to check pupil size, and to repeat the application of cycloplegic agents whenever needed. Immediately prior to the ophthalmic examination, local anesthetic eye drops are instilled (e.g., oxybuprocaine), and a sterile lid speculum for premature infants is gently inserted. The examination is best performed in a darkened room using a binocular indirect ophthalmoscope (BIO) together with a 28-diopter (D) lens (for a good peripheral view and to classify the disease by zones) and a 20-D lens (for more detailed evaluation). To visualize the peripheral retina out to the ora serrata, rotation of the globe together with gentle indentation is needed, e.g., with a squint hook or a lens wire loop. It is advisable to have a nursing staff member present during the examination to assist in physically restraining the infant, and to monitor the infant's vital signs and airway. Bradycardia due to the oculocardiac reflex is a recognized complication of the examination . The examination should be thorough yet rapid. It is not sufficient to only examine the temporal periphery, as in particular in zone I and posterior zone II disease, acute ROP may be more advanced in the nasal periphery, and also in the upper and lower periphery . An important sign is the presence of plus disease. Prior to the formation
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