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Question: 130

You are treating a former extremely low-gestational age newborn (ELGAN) who was born at 26 weeks’ gestation weighing 700 g. She is now 4 weeks old. Her nurse asks when the eye examination for retinopathy of prematurity (ROP) will be performed and what risk for significant visual impairment exists in this infant.

Of the following, the BEST time to obtain the first ROP screening eye examination in this infant is

A. 4 weeks after discharge from the hospital

B. 4 weeks after weaning from oxygen

C. 5 weeks after birth

D. 5 weeks after the expected delivery date

E. 5 weeks after weaning from the ventilator

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Critique: 130 Preferred Response: C

Retinopathy of prematurity (ROP) is a multifactorial disorder that has been linked historically and epidemiologically to the survival of low-birthweight preterm infants. As the survival of smaller and more immature infants has increased throughout the past 5 decades, the incidence of ROP has shifted toward the smallest, most immature, and sickest babies in neonatal intensive care units (NICUs) in the United States and worldwide. Prospective studies and critical reviews and analyses of extensive data confirm that the greatest known risks for ROP among NICU patients include: very low birthweight (<1,500 g), severity of illness, gestational immaturity (especially <28 weeks' gestational age), intrauterine growth restriction, male sex, and systemic fungal infection. Among the additional possible risks are antenatal dexamethasone exposure (compared to betamethasone) and late treatment with dexamethasone (treatment of infants more than 3 weeks of age for 2 or more weeks). The American Academy of Pediatrics recommends a specific timetable for testing at-risk preterm infants (Item C130). In general, infants should be tested between 31 and 34 weeks gestational age. Accordingly, the infant described in the vignette should be tested 5 weeks after birth. Because most 26 weeks' gestation infants are discharged from the hospital at a gestational equivalent of 34 to 36 weeks, or 8 to 10 postnatal weeks of age, this would be too late for an initial examination, as would one occurring 4 weeks later. Many 26 weeks' gestation infants may have chronic lung disease and be receiving assisted ventilation for days to weeks or be discharged from the hospital on oxygen, so screening is not based on the time of weaning from assisted ventilation or oxygen. Five weeks after the expected delivery date is too late for initial screening.

References:

Bharwani SK, Dhanireddy R. Systemic fungal infection is associated with the development of retinopathy of prematurity in very low birth weight infants: a meta-review. J Perinatol. 2007;28:61-66. Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/18046338

Darlow BA, Hutchinson JL, Henderson-Smart DJ, Donoghue DA, Simpson JM, Evans NJ on behalf of the Australian and New Zealand Neonatal Network. Prenatal risk factors for severe retinopathy of prematurity among very preterm infants of the Australian and New Zealand Neonatal Network. Pediatrics. 2005;115:990-996. Available at: http://pediatrics.aappublications.org/cgi/content/full/115/4/990

Hagadorn JI, Richardson DK, Schmid CH, Cole CH. Cumulative illness severity and progression from moderate to severe retinopathy of prematurity. J Perinatol. 2007;27:502-509. Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/17568754

Karlowicz MG, Giannone PJ, Pestian J, Morrow AL, Shults J. Does candidemia predict threshold retinopathy of prematurity in extremely low birth weight (<1000 g) neonates? Pediatrics. 2000;105:1036-1040. Available at: http://pediatrics.aappublications.org/cgi/content/full/105/5/1036

Lee BH, Stoll BJ, McDonald SA, Higgins RD for the National Institute of Child Health and Human Development Neonatal Research Network. Adverse neonatal outcomes associated with antenatal dexamethasone versus antenatal betamethasone. Pediatrics. 2006;117:1503-1510. Available at: http://pediatrics.aappublications.org/cgi/content/full/117/5/1503

Markestad T, Kaaresen PI, Rønnestad A, et al on behalf of the Norwegian Extreme Prematurity Study

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Group. Early death, morbidity, and need of treatment among extremely premature infants. Pediatrics. 2005;115:1289-1298. Available at: http://pediatrics.aappublications.org/cgi/content/full/115/5/1289

Section on Ophthalmology, American Academy of Pediatrics, American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus. Screening examination of premature infants for retinopathy of prematurity. Pediatrics. 2006;117:572-576. Available at: http://pediatrics.aappublications.org/cgi/content/full/117/2/572

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Critique: 130

Reprinted with permission from the Section on Ophthalmology, American Academy of Pediatrics, American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus. Screening examination of premature infants for retinopathy of prematurity. Pediatrics. 2006; 117:572-576.

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Question: 211

A 13-year-old girl comes to your office with a 1-day history of right eye pain and tearing. She denies trauma, but says she rubbed her eyes a lot the day before because it was windy outside. Her right bulbar and palpebral conjunctivae are very injected, and copious clear discharge is present. There is no hyphema, and the pupils are normal. She complains of pain with the eye examination. After applying fluorescein to the eye, you see a single linear abrasion on the cornea. When you evert the eyelid, you find no foreign body.

Of the following, the MOST appropriate management for this condition is

A. oral analgesic

B. oral antistaphylococcal antibiotic

C. tight patching of the eye

D. topical anesthetic drops

E. topical steroid drops

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Critique: 211 Preferred Response: A

Corneal abrasions occur commonly in children as a result of vigorous rubbing of the eye or a foreign body. Symptoms are tearing, photophobia, and pain. The physical examination may reveal injection of the conjunctivae, copious clear discharge, or a dull corneal light reflex. It is important to perform fluorescein dye staining in children suspected of having a corneal abrasion. This dye stains the damaged cornea but is not taken up by intact corneal epithelium. The staining is seen best with a Wood lamp (Item C211), but large abrasions may be visible with regular white light or an ophthalmoscope. The presence of a linear abrasion, as described for the girl in the vignette, suggests the possibility of a retained foreign body underneath the eyelid, and care should be taken to evert the eyelid to evaluate for this. Topical anesthetic drops, such as tetracaine, may be used to facilitate the eye examination and may provide significant relief to the patient, but providing these for home use is not recommended because they may slow healing and mask persistence of symptoms. Oral analgesics usually are all that is needed to control pain while the abrasion heals. Topical nonsteroidal anti-inflammatory drops also may provide relief, but topical steroids are not indicated in the management of uncomplicated corneal abrasions (due to concerns about adverse effects on wound healing and exacerbation of coexisting viral infection). Antibiotic ointment may provide lubrication until the abrasion has healed, but the risk of secondary infection is low, so routine use of antibiotics is not needed. Patching does not speed the healing process and has been shown to interfere with activities of daily living; it no longer is recommended for routine care of simple corneal abrasions. Most corneal abrasions heal within 2 to 3 days, so if symptoms continue beyond this period, evaluation by an ophthalmologist is warranted to rule out secondary infection or retained foreign body.

References:

Calder LA, Balasubramanian S, Fergusson D. Topical nonsteroidal anti-inflammatory drugs for corneal abrasions: meta-analysis of randomized trials. Acad Emerg Med. 2005;12: 467-473. Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/15860701

Michael JG, Hug D, Dowd MD. Management of corneal abrasion in children: a randomized clinical trial. Ann Emerg Med. 2002;40:67-72. Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/12085075

Stout AU. Technical tip: corneal abrasions. Pediatr Rev. 2006;27:433-434. Available at: http://pedsinreview.aappublications.org/cgi/content/full/27/11/433

Turner A, Rabiu M. Patching for corneal abrasion. Cochrane Database Syst Rev. 2006;2:CD004764. Available at: http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD004764/frame.html

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Critique: 211

Corneal abrasion (arrow) demonstrated after flourescein staining and examination with a Wood lamp. (Courtesy of Wake Forest University Eye Center)