Comprehensive Newborn Eye Exam

What is a COMPREHENSIVE NEWBORN EYE EXAMINATION?

A newborn child does not see as well as an adult or even a young toddler. At best, the baby will look towards light or do facial contortions when exposed to brightness. The normal baby's eyes can also be made to move sideways as its head is turned. Apart from these observations, it is difficult to assess if a baby's equipment for vision is functioning properly.

A pediatric ophthalmologist is an EyeMD who specializes in the diagnosis and treatment of eye diseases in children, basically, a "child EyeMD". During a comprehensive examination of the eye of a newborn baby, the child EyeMD is able to examine the following in the baby's eyes":

• cornea (the clear front part of the eye overlying the colored iris)
• iris (the colored, usually dark, part of the eye)
• pupil (the opening in the middle of the iris which controls the amount of light entering the eye, very much like the aperture of a camera lens)
• lens (the part of the eye which can actively focus light, just like ca camera lens)
• optic nerve (the connection of the eye to the brain)
• retina (the light-sensitive membrane at the back of the eye that receives and processes light, just like the film of a camera)

Each of these is examined for any abnormality or presence of disease.

The refraction of the baby's eye (a person's by temporarily paralyzing the muscles that aid in focusing the eye) the power of the eye to bend and focus light, commonly referred to in relation to eyeglasses as the "grade" of the glasses) can also be measured using eye drops that temporarily relax the muscles of the baby's focusing muscles, a procedure called cycloplegic refraction.

What are the benefits of a COMPREHENSIVE NEWBORN EYE EXAMINATION?

Eye diseases and inborn abnormalities are not ordinarily detected by the traditional routine external eye exam. These problems can be picked up by a more comprehensive examination of your baby's eyes. 

Conditions like cataract (clouding of the normally clear lens), opacities of the vitreous (the normally clear gel that fills the space between the lens and the retina), glaucoma (abnormally high eye pressure causing damage to the optic nerve), tumors within the eye, retinal abnormalities, optic nerve anomalies, problems with production and flow of tears, and even errors of refraction (e.g. near-sightedness, farsightedness, astigmatism) that threaten the normal development of your baby's vision.

Early identification of a problem allows for early intervention that in turn increases chances at successful treatment.

How is a COMPREHENSIVE NEWBORN EYE EXAMINATION done?

A Retcam will be used for this procedure?

During the eye exam, your newborn will be cared for by trained persons assisting the pediatric ophthalmologist. Drops will be applied to the baby to dilate the pupils and to numb the eye's surface. A special device to hold the eyelids open will be used. An ophthalmic gel will be placed on the eye to act as an interface between the Retcam and the eye.

You should inform your baby's pediatrician that you would like your baby's eyes evaluated. Your pediatrician can explain to you the process and will work with a qualified child EyeMD in arranging the examination.

Following a thorough explanation of the eye exam, including its benefits and possible side effects - an only if you understand and agree to the procedure - it is important that you signify your consent. Only a child EyeMD specially trained to evaluate newborn children's eyes will be called upon to perform the eye exam, usually within two days of your request.

Before any manipulation of the baby, anesthetic eye drops (proparacaine) are applied to the baby's eyes to numb the surface of the eye in order to ensure against eye discomfort during the examination. Thirty to forty minutes before the eye exam, the child EyeMD will need to apply several times special eye drops (tropicamide) with or without phehylephrine) in order to widen the pupils of your baby's eyes. This is necessary to allow an adequate view of the back part of the eye. The effect of these eye drops wear off in four to six hours.

The child EyeMD keeps the baby's eyelids open by inserting a sterile instrument called a lid speculum, and may gently manipulate the eye with an instrument called a scleral depressor. Special instruments called a direct and indirect ophthalmoscope are used to view the retina.

Alternately, a more efficient and more reproducible method is through the use of the RETCAM. More and more in advanced centers, the RETCAM, a special mobile camera developed especially to capture digital images of the retina and optic nerve of newborns and young children is used. This has the advantage of having an exact and reproducible image of your baby's retina. The "photography session" can be performed as part of the initial eye examination, or scheduled on another day. Please advise your pediatrician or the child EyeMD if you wish to have a RETCAM examination.

During the eye examination, your baby will be cared for by specially-trained persons who will assist the child EyeMD. They will apply the eye drops to widen the baby's pupils and the drops to numb the surface of the eye to ensure that the baby does not feel pain, as well as an eye gel that will be placed on the eye to cushion the eye during photography with the RETCAM. At the end of the procedure antibiotic eye drops are applied to prevent infection. Because of the special training of the examiners and the anesthetic drops applied, the baby should be able to tolerate the examination without much trouble.

What does the baby experience during the examination?

The baby experiences some smarting when the drops are instilled. Once the topical anesthetic is instilled, the baby's eyes are numbed and should feel no pain. Despite this however, most babies will cry during the procedure and will appear to resist opening of the eyelids, the bright light of the indirect ophthalmoscope, and the manipulation of the eye. Having the baby drink milk or glucose water is usually effective in appeasing the baby. It is important to keep in mind that the baby feels no pain and is merely reacting in the only way it can - by crying - to unfamiliar stimuli.

What are the risks of the examination?

Side effects due to the tiny amounts of eye drops are absorbed into the baby's system are seen infrequently. These uncommon side effects include skin rash, discomfort, feeding intolerance, increased heart rate, and elevated blood pressure. Even less commonly seen are apnea (stoppage of breathing), gastric dilatation (stomach distension), ileus (non-mechanical intestinal obstruction), and others. Occasionally, the stress of the examination itself can cause systemic side effects in the baby, such as an increased heart rate and even apnea.

For babies who develop side effects, the eye exam is deferred and repeated with precautions when the baby is slightly bigger and more mature in age. Dose adjustment, closer monitoring, and occluding the eye's tear drainage to prevent systemic absorption of the eye drops may be all that is necessary to increase tolerance to the examination.

Following the eye exam, the baby may show some swelling and redness of the eyelids and eyes. This generally subsides in a few hours. Some develop eye discharge and may require topical antibiotic for a few days. To prevent this, The Medical City protocol includes prophylactic antibiotic instillation at the conclusion of the eye exam.

What are the risks and complications of NOT having the examination?

Fortunately, the great majority of babies are born with normal eyes. However a few may be born with problems. Delay in diagnosis means delay in treatment. Should the baby have a vision-threatening or even a life-threatening disease, such as retinoblastoma (in Filipinos, the most common tumor within the eye), there is risk of blindness, amblyopia (poor vision due to poor development of the eye despite having normal structures, commonly called "lazy eye"), strabismus (crossing or splaying of the eyes, i.e. "dulling" or "banlag"), delayed visual development, and even death (from malignant eye tumors).

When is the COMPREHENSIVE NEWBORN EYE EXAMINATION done?

As soon as the baby is stable, the initial eye examination can be done while in the nursery or bedside when roomed-in with his/her mother before discharge.

When will the result of the examination be known?

The result of the examination is immediately known after completion of comprehensive newborn eye examination. The official report will be available in 24-48 hours and the findings can be diagnosed with the child EyeMD.

What are the additional examinations and relevant treatment options?

Additional procedures and relevant treatment options are decided by the eye findings on initial examination. However, a normal initial eye examination does not mean the eyes will be normal forever. Some eye diseases are not apparent until the baby is much older. A regular visit to your child's EyeMD is necessary to ensure continued good eye health. Typically, a second examination is best done around the child's sixth month of life, or sooner if anything “unusual” is noticed.       

How does The Medical City help?

Facilities. The Medical City uses the latest technology, the RETCAM, which enables not only accurate assessment but also digital image documentation of the baby's retina. It is the only hospital in the Philippines that does compuunding of anti-VEGF medications for use in severe cases of retinopathy of prematurity (ROP: retinal disease of preterm babies) and other retinal diseases. Its facilities for vitreo-retinal surgery, as well as ocular tumors, are unsurpassed by any facility in the country.

Manpower. The Medical City has on its staff a most impressive roster of the leading pediatric ophthalmologists in the Philippines. All are eminently qualified and experienced in screening, diagnosing and treating children's eye diseases. Moreover, the TMC's OB-GYN and Pediatric physician staffs are among the most skilled and respected in the country.

Culture of patient partnership. The Medical City is a leader in maternal and child health advocacy. Recognizing that the children are our future and that good vision is critical to a child's development, The Medical City is one of the few hospitals in the country that espouses comprehensive vision screening for all newborns as well as expanded indications for retinopathy of prematurity.

REFERENCES:

1. Li Li-Hong, Universal Eye Screening in Healthy Neonates. RETINA TODAY, March 2013; p 50

2. China evaluates newborn eye exams. http://www.claritymsi.com/us/newsletter may.html#china

3. Linder B. is it time for Universal Newborn Eye Screening? Mini Focus, Caring for the Pediatric Patient, in Advanced Ocular Care, April 2014, pp 28-30.

4. Vinekar A, Mahendradas P, Avadhani K et al. Look what else we found! Clinical entities serendipitously detected on RETCAM imaging during routine ROP screening. Presented at the WORLD ROP Congress 2012.

For more information, please call:

CENTER FOR PATIENT PARTNERSHIP

Tel. no.: (632) 988-1000 / (632) 988-7000 ext. 6444

Note:   This information is not intended to be used as a substitute for professional medical advice, diagnosis or treatment.   If you or someone you know have any of the symptoms mentioned above, it is advisable to seek professional help.