Avoiding use of lid speculum and indentation reduced infantile stress during retinopathy of prematurity examinations

Abstract

To study the safety and efficacy of indirect ophthalmoscopy with (Sp) or without (speculum free, SpF) the use of lid speculum and scleral indentation for retinopathy of prematurity (ROP) screening. Methods: In this crossover randomized controlled trial, preterm infants received either the Sp on their first and the SpF technique on their second examination a week later or vice versa. Video recordings of the infants' reactions were assessed by two observers, using Premature Infant Pain Profile-Revised score and the crying score of the Bernese Pain Scale for Neonates. Fundoscopy adequacy, its duration and adverse events within the first 24 hr postscreening were also recorded. Results: Thirty-seven infants with median (interquartile range) gestational age of 28.7 (28.0, 30.2) weeks and mean (standard deviation, SD) birth weight 1225 (377) grams were enrolled. The mydriasis-induced stress was similar between the Sp and SpF exam

Analgesia for retinopathy of prematurity screening: A systematic review

“…9 Sources of pain during ROP screening include insertion of an eyelid speculum to provide access to the pupil, bright light to illuminate the fundus, and scleral indentation due to manipulation of the eye during examination. 8,[10][11][12] Exposure of neonates to painful procedures may have implications for future health and development, [13][14][15][16][17] and screening for ROP has been specifically associated with physiological stress and increased rates of apnoeic episodes. 18 As ROP screening is conducted regularly, until retinal vascularization progresses over a sufficient portion of the retina, 5 offering safe and effective analgesia for the procedure is important.…”

“…Sources of pain during ROP screening include insertion of an eyelid speculum to provide access to the pupil, bright light to illuminate the fundus, and scleral indentation due to manipulation of the eye during examination 8,10–12 . Exposure of neonates to painful procedures may have implications for future health and development, 13–17 and screening for ROP has been specifically associated with physiological stress and increased rates of apnoeic episodes 18 .…”

Skin Conductance Measurement as a Selective and Continuous Pain Assessment Method During Eye Examinations for Retinopathy of Prematurity

“…Our visual observational findings are in line with previous studies that report significant changes in observational pain scales during ROP screening. 14,32,33 Cohen et al have also described a clinically significant pain response after applying mydriatic eye drops (Tropicamide 1% and Phenylephrine 2.5%), using the PIPP scale before and after instillment of the drops. 32 In a study by Moral-Pumarega et al, a short-term stress response was seen both during fundoscopy and WFDRI when measured by PIPP and CRIES scale.…”

“…33 In a recent study, Mataftsi et al compared the stress induced during fundoscopy with and without the use of an eye lid speculum and scleral indentation, and found lower Premature Infant Pain Profile-Revised (PIPP-R) scores in infants examined without eyelid speculum and scleral indentation. 14 The authors argue that the use of a speculum and indentation should be limited to patients with suspicion of severe disease. 14 In our study a significant increase of skin conductance from baseline was seen during both the instilment of anesthetic eye drops and insertion of the eyelid speculum.…”

“…13 ROP screening starts at a postnatal age of 6 weeks, but the first examination is postponed to postmenstrual age (PMA) 31 weeks in infants born < 26 weeks' (25+6) GA. 13 Eye examinations for ROP screening are sometimes painful and stressful, and is dependent on the ophthalmologist's investigative level of skill. [14][15][16] The methods currently applied for pain relief during ROP screening, such as topical anesthetic eye drops, oral sucrose and non-nutritive sucking, seem to be inadequate. [16][17][18] Pain management in preterm infants is important to prevent both short-and long-term adverse effects of pain.…”