Differential effects of the retinopathy of prematurity exam on the physiology of premature infants

Tan, John B C; Dunbar, Jennifer A.; Hopper, Andrew; Wilson, Christopher G.; Angeles, Danilyn M.

doi:10.1038/s41372-019-0331-z

Cited by 12 publications

(10 citation statements)

References 29 publications

(35 reference statements)

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“…Nevertheless, no difference was found between the positive vs. non-positive pressure support groups on the frequency of or level of intervention needed for A/B/Ds post-ROP examination. This differs from findings in other studies where infants on oxygen support responded with more tachycardia to the mydriatic eye drops (cyclopentolate) and with subsequent bradycardia with the examinations compared to those on room air ( 27 ). The oxygen support group was found to have higher levels of circulating cyclopentolate compared to those in room air, although the same dose was administered ( 44 ).…”

Section: Discussioncontrasting

confidence: 99%

“…It is well established that ROP examinations including mydriatic administration, speculum insertion, and scleral depression cause pain and stress. Consequently, ROP examinations have been associated with adverse events including apneas, bradycardias, desaturations, elevated pain scores, and delayed gastric emptying (27)(28)(29)(30)(31). Despite evidence that ROP examinations are painful, and existence of standard criteria for ROP screening (3,(32)(33), there is no consensus on pain relief for the ophthalmologic examination.…”

Section: Discussionmentioning

confidence: 99%

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Autonomic measures identify stress, pain, and instability associated with retinopathy of prematurity ophthalmologic examinations

Onuagu¹,

Gardner

Soni

et al. 2022

Front. Pain Res.

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BackgroundRetinopathy of prematurity (ROP) ophthalmologic examinations cause stress and pain. Infants’ stress and pain can be measured non-invasively using skin conductance (SC) and high frequency heart rate variability (HF-HRV), reflecting sympathetic-mediated sweating and parasympathetic activity, respectively.ObjectivesTo test the utility of SC to detect sympathetic activation during ROP examination, and the contribution of HF-HRV to predict stability post-examination.MethodsIn this prospective, single center study, we measured SC continuously pre-, during, and post-examination, and HRV at 24 h pre-ROP examination. Clinical data included stability [apneas, bradycardias, and desaturations (A/B/Ds)], and interventions post-examination.ResultsSC increased 56% above baseline during ROP examination (p = 0.001) and remained elevated post-examination (p = 0.02). Post-hoc analysis showed higher illness acuity, represented by need for respiratory support, was associated with lower HF-HRV at 24 h pre-ROP examination (p = 0.001). Linear regression indicated lower HF-HRV at 24 h pre-examination contributed to the need for higher intervention (i.e., stimulation to breathe, oxygen support) particularly among infants with higher illness acuity [F(1, 15) = 5.05, p = 0.04; β = −1.33, p = 0.04].ConclusionROP examination induced a 2-fold increase in sympathetic activation which remained above baseline in recovery. Also, we propose that the low parasympathetic tone associated with autonomic imbalance contributes to instability and need for higher intervention to assure stabilization with A/B/D events. Our findings provide insight into the underestimation of adverse events associated with ROP examination and identification of infants who may be more vulnerable to potential sequelae following ROP examinations.

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Section: Discussioncontrasting

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Autonomic measures identify stress, pain, and instability associated with retinopathy of prematurity ophthalmologic examinations

Onuagu¹,

Gardner

Soni

et al. 2022

Front. Pain Res.

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“…18 Infants receiving supplemental oxygen may be at particular risk of cardiac disturbance during exams. 19 Heart rate variability as an indicator of autonomic nervous system function may be an independent risk factor for Type 1 ROP. 20 General anesthesia utilized with strabismus surgery is a substantial difference when compared to awake ROP Exams.…”

Section: Discussionmentioning

confidence: 99%

<p>Oculocardiac Reflex During ROP Exams</p>

Schumacher¹,

Ball²,

Arnold³

et al. 2020

OPTH

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Point your SmartPhone at the code above. If you have a QR code reader the video abstract will appear. Or use: https://youtu.be/XB2uu1ca7kQ Purpose: Reducing physiologic stress including bradycardia during staging eye exams for retinopathy of prematurity (ROP) is desirable. We observed heart rate change during routine retinopathy of prematurity eye examinations and compared the response with our ongoing study of oculocardiac reflex (OCR) elicited by uniform EOM tension during strabismus surgery. Patients and Methods: Electrocardiograph was prospectively monitored during ROP exams featuring indirect ophthalmoscopy with Alfonso lid speculum and see-through scleral depressor without topical anesthesia. Clinical data were retrieved from ROP-Check software. OCR was defined as maximally changed heart rate (HR) as a percent of baseline. Strabismus surgery patients under general anesthesia served as controls. Results: From 10/2017 to 9/2020, 281 infants had ROP exams, and the median OCR was 55.9% of baseline HR (IQR 41.4% to 72.6%), the kurtosis 0.93 and skewness 1.01 representing a drop from HR 169 ± 16 bpm to 102 ± 39 bpm. In comparison, 1493 adult and pediatric strabismus surgery patients had less OCR median bradycardia 87.8% (IQR 72-98%), kurtosis 1.60 and skewness −1.18. ROP %OCR correlated with birth gestational age (%OCR = 2.5 (GA)-11, r(279)=0.33, p<0.01) and with birthweight (%OCR = 0.02 (BW) + 38, r(279) =0.35, p<0.01). The duration of bradycardia induced by ROP exam averaged 92 ± 34 seconds (range 34-240 seconds). Conclusion: Bradycardia is common during eye exams in the smallest premature infants with greater degree, more rapid onset and longer duration than OCR during strabismus surgery.

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“…At baseline, except for respiratory rate, these were comparable between OCT and BIO. Observers noted widely fluctuating respiratory rates at baseline and throughout imaging for 61 OCT (86%) and 48 BIO sessions (68% and second eye (163 [20] and 166 [19] beats per minute, respectively) vs BIO (180 [16] and 187 [16] beats per minute, respectively) (first eye: 95% CI, −21.89 to −13.60; second eye: 95% CI, −24.66 to −17.77; P < .001 for all at both time points). Mean respiratory rate was higher for OCT vs BIO at baseline (95% CI, 0.82-11.54; P = .02) and during the first (95% CI, 2.70-13.72; P = .003) and second eye OCT/BIO sessions (95% CI, −0.07 to 6.48; P = .05).…”

Section: Primary Stress Factorsmentioning

confidence: 99%

Preterm Infant Stress During Handheld Optical Coherence Tomography vs Binocular Indirect Ophthalmoscopy Examination for Retinopathy of Prematurity

et al. 2021

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urvival and neurodevelopmental outcomes in preterm infants, including periviable infants (22-25 weeks' gestational age), have improved over the past 20 years. However, despite these achievements, long-term neurodevelopmental outcomes for these infants remain a concern. [1][2][3] Prolonged exposure to early-life stress while in the intensive care nursery (ICN) causes alterations in the neural connectome leading to cognitive deficits later in life. [4][5][6] Stressors in the ICN include physiological stressors such as sepsis, environmental stressors such as excessive light, and experiential stressors such as blood draws. 4,7,8 Retinopathy of prematurity (ROP) examination by a trained ophthalmologist usually entails placement of an eyelid speculum, mydriatic drops, retinal illumination by the bright light of a binocular indirect ophthalmoscope, and pressure on the outer surface of the eye. 9 Binocular indirect ophthalmoscopy (BIO) is a repeated experiential stressor/ painful procedure for infants [10][11][12][13] and can produce changes in heart rate, both tachycardia and bradycardia, and apnea during and after examination. 11,14-16 Use of oral sucrose and intranasal fentanyl have been reported to reduce pain associated with retinal examination without increasing the risk of respiratory depression; however, their safety and efficacy need to be verified. 17,18 Approximately 70 000 infants per year in the United States receive 1 or more BIO examinations for ROP screening. 19IMPORTANCE Binocular indirect ophthalmoscopy (BIO) examination for retinopathy of prematurity (ROP) is a well-known cause of repeated preterm infant stress. OBJECTIVE To compare stress during investigational optical coherence tomography (OCT) imaging to that during BIO for ROP. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study examined infants at the bedside in the intensive care nursery. Consecutive preterm infants enrolled in Study of Eye Imaging in Preterm Infants (BabySTEPS) who had any research OCT imaging as part of the study. Patients were recruited from June to November 2019, and analysis began April 2020. MAIN OUTCOMES AND MEASURES Infant stress was measured using modified components of a neonatal pain assessment tool before (baseline) and during OCT imaging and BIO examination of each eye. RESULTS For 71 eye examinations of 16 infants (mean [SD] gestational age, 27 [3] weeks; birth weight, 869 [277] g), change from baseline to each eye examination was lower during OCT imaging than during BIO and the difference between OCT imaging and BIO at each eye examination was significant for the following: infant cry score (first eye examination: mean [SD], 0.03 [0.

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Differential effects of the retinopathy of prematurity exam on the physiology of premature infants

Cited by 12 publications

References 29 publications

Autonomic measures identify stress, pain, and instability associated with retinopathy of prematurity ophthalmologic examinations

Autonomic measures identify stress, pain, and instability associated with retinopathy of prematurity ophthalmologic examinations

<p>Oculocardiac Reflex During ROP Exams</p>

Preterm Infant Stress During Handheld Optical Coherence Tomography vs Binocular Indirect Ophthalmoscopy Examination for Retinopathy of Prematurity

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