Combination cyclopentolate and phenylephrine for mydriasis in premature infants with heavily pigmented irides

The effects of mydriatic eye drops on cerebral blood flow and oxygenation in retinopathy of prematurity examinations

Mydriatic eye drops used during retinopathy examination have been associated with cardiovascular, respiratory, and gastrointestinal side effects. The aim of our study was to investigate the effects of the drops used for pupil dilatation on cerebral blood flow and cerebral oxygenation. The study included 62 infants who underwent retinopathy screening exams. Vital signs, heart rate (HR), arterial oxygen saturation (SpO2), and mean arterial pressure (MAP) were recorded. Cerebral oxygenation and middle cerebral artery blood flow velocity were evaluated using near-infrared spectroscopy (NIRS) and Doppler ultrasonography, respectively, and the cerebral metabolic rate of oxygen (CMRO2) was also calculated. The mean gestational age of the infants included was 31.29 ± 1.42 weeks, and the mean birth weight was 1620 ± 265 g. Heart rate was found to be significantly decreased after mydriatic eye drop instillation; however, there were no significant differences regarding blood pressure and oxygen saturation levels (HR: p < 0.001; MAP: p = 0.851; SpO2: p = 0.986, respectively). After instillation while cerebral regional oxygen saturation (rScO2) measurements were significantly decreased at the 60th minute (p = 0.01), no significant difference was found in Vmax and Vmean of MCA before and after mydriatic eye drop instillation (p = 0.755, p = 0.515, respectively). Regarding CMRO2 measurements, we also did not find any statistical difference (p = 0.442).    Conclusion: Our study has shown that although eye drops may affect heart rate and regional cerebral oxygen saturation, they do not alter cerebral blood flow velocities and metabolic rate of oxygen consumption. Current recommendations for mydriatic eye drop use in retinopathy exam appear to be safe. What is Known: • Mydriatic eye drop installation is recommended for pupil dilatation during ROP screening exams. • It's known that mydriatics used in ROP examination have affects on the vital signs, cerebral oxygenation and blood flow. What is New: • This is the first study evaluating the changes in cerebral oxygenation and blood flow velocity after mydriatic drop instillation using NIRS and Doppler US concomitantly. • While the eye drops may affect heart rate and regional cerebral oxygen saturation, they do not alter cerebral blood flow velocities and metabolic rate of oxygen consumption.

Low dose or very low dose phenylephrine and cyclopentolate microdrops for retinopathy of prematurity eye examinations (The Little Eye Drop Study): a randomised controlled non-inferiority trial

OBJECTIVE

To determine if very low dose (VLD, 0.5% phenylephrine, 0.1% cyclopentolate) mydriatic microdrop (approximately 7 μL) administration (up to three doses) is non-inferior to low dose (LD, 1% phenylephrine, 0.2% cyclopentolate) mydriatic microdrop administration for ophthalmologist-determined successful retinopathy of prematurity eye examination (ROPEE).

DESIGN

Multicentre, prospective, randomised controlled, non-inferiority clinical trial.

SETTING

Four neonatal intensive care units in Aotearoa, New Zealand from October 2019 to September 2021.

PATIENTS

Infants with a birth weight less than 1250 g or gestational age less than 30+6 weeks and who required a ROPEE.

INTERVENTIONS

The intervention: microdrop (approximately 7 μL) of VLD (0.5% phenylephrine and 0.1% cyclopentolate) to both eyes, or the comparison: microdrop of LD (1% phenylephrine and 0.2% cyclopentolate) to both eyes. Up to three doses could be administered.

MAIN OUTCOME MEASURES

The primary outcome measure was an ophthalmologist-determined successful ROPEE.

RESULTS

One hundred and fifty preterm infants (LD mean GA=27.4±1.8 weeks, mean birth weight=1011±290 g, VLD mean GA=27.5±1.9 weeks, mean birth weight=1049±281 g,) were randomised. Non-inferiority for successful ROPEE was demonstrated for the VLD group compared with the LD group (VLD successful ROPEE=100%, LD successful ROPEE=100%, 95% CI no continuity correction -0.05 to 0.05) and for Māori (95% CI no continuity correction -0.02 to 0.19).

CONCLUSION

VLD microdrops enable safe and effective screening for ROPEE in both Māori and non-Māori preterm infants.

TRIAL REGISTRATION NUMBER

ACTRN12619000795190.

Systemic adverse events after screening of retinopathy of prematurity with mydriatic

Purpose

To evaluate systemic adverse events after screening for retinopathy of prematurity (ROP) performed with mydriatic.

Methods

This was a retrospective case series study. Medical records of consecutive patients who underwent screening for ROP with 0.5% phenylephrine and 0.5% tropicamide eyedrops were retrospectively reviewed. The score of abdominal distention (0–5), volume of milk sucked and volume of stool, along with systemic details (pulse and respiration rates, blood pressure and number of periods of apnea) were collected at 1 week and 1 day before ROP examination, and at 1 day after examination. Results were compared between the days before and after examination. Correlation between body weight at the time of examination and the score of abdominal distention was examined. The numbers of infants with abdominal and/or systemic adverse events were compared between pre- and post-examination periods.

Results

Eighty-six infants met the inclusion criteria. The score of abdominal distention increased from 2.0 at 1 day before examination to 2.3 at 1 day after examination (p = 0.005), and the number of infants who had worsened abdominal distension increased after examination (p = 0.01). Infants with lower body weight had a higher score of abdominal distention (p < 0.0001, r = −0.57). The number of infants with reduced milk consumption increased after examination (p = 0.0001), as did the number of infants with decreased pulse rate (p = 0.0008).

Conclusions

Screening for ROP with mydriatic may have adverse effects on systemic conditions. Infants should be carefully monitored after ROP screening with mydriatic.

Randomised controlled pilot trial comparing low dose and very low- dose microdrop administration of phenylephrine and cyclopentolate for retinopathy of prematurity eye examinations in neonates

AIMS

To determine ifVery low dose mydriatic eye microdrop regimen sufficiently dilates the pupil (above 4.1 mm) compared with the currently used low dose mydriatic eye microdrop regimen.Cardiovascular, gastrointestinal and respiratory adverse effects occur following eye drop instillation.

METHODS

Seventeen premature infants were recruited into this prospective, randomised controlled pilot trial in January 2017 to November 2018. Data were collected from the single-centre Neonatal Intensive Care Unit, Dunedin Hospital, New Zealand. The inclusion criteria were birth weight less than 1500 g or gestational age less than 31 weeks, or any premature infant requiring red reflex testing. Infants were randomised to receive either phenylephrine 1% or 0.5% and cyclopentolate 0.2% or 0.1%, 1 microdrop in both eyes. Efficacy outcome measures were pupil size at retinopathy of prematurity eye examination (ROPEE) and ophthalmologist rating of ease of screen.

RESULTS

All participants had sufficient pupillary dilation for a successful ROPEE. Ophthalmologists rated the ROPEE as easy for 90% of all examinations. Pupil dilation measurements at the time of examination, mean±SD, 4.8±0.2 (95% CI 4.5 to 5.2) mm for treatment A and 5±0.2 (95%CI 4.6 to 5.4) mm for treatment B (p=0.61). There were no statistically significant differences between the groups for safety data.

CONCLUSIONS

Very low dose microdrop administration of phenylephrine and cyclopentolate appears to be effective at sufficiently dilating the neonatal pupil for ROPEEs. Low dose and very low dose microdrop mydriatic regimens may also reduce the risk of unwanted adverse effects associated with these medicines.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (reference ACTRN12616001266459p).

Systematic review of mydriatics used for screening of retinopathy in premature infants

INTRODUCTION

Routine retinopathy of prematurity eye examinations are an important part of neonatal care, and mydriatic medicines are essential in dilating the pupil for the eye examination. There are concerns about the level of evidence for efficacy and safety of these mydriatic medicines.

OBJECTIVE

This review evaluates both efficacy and safety evidence of mydriatics used during the retinopathy of prematurity eye examination.

METHOD

Systematic literature review.

RESULTS

There is limited evidence guiding clinical practice for safety and efficacy of mydriatics. The majority of publications are underpowered and with an unclear to high level of bias. There are a wide variety of mydriatic regimens evaluated for efficacy and safety, and multiple regimens are associated with case reports.

CONCLUSIONS

Current international guideline seems unnecessarily high, especially when the reviewed literature suggest that lower doses are effective, albiet from underpowered studies. The lowest effective combination regimen appears to be phenylephrine 1% and cyclopentolate 0.2% (1 drop). Microdrop administration of this regimen would further increase the safety profile, however, efficacy needs to be assessed.

Optimal Dosage of Cyclopentolate 1% for Complete Cycloplegia: A Randomized Clinical Trial

PURPOSE

To determine the optimal dosage of cyclopentolate for adequate cycloplegia with minimal side effects.

METHODS

A prospective randomized clinical trial of patients 3.5 to 20 years of age referred to a strabismus clinic during a 1-year period. Eligible patients were randomly divided into three groups. In Group 1, the cycloplegic effect of one drop of cyclopentolate was compared with two drops; in Group 2, the effect of two drops was compared with three drops; and in Group 3, the effect of one drop was compared with three drops.

RESULTS

This study includes 192 eyes of 96 patients with a mean age of 11.0 +/- 5.7 years. Strabismus was present in 43 patients (44.8%). A total of 146 patients (76%) were hyperopic, 33 (17.2%) were myopic, and 13 (6.8%) were slightly hyperopic or myopic at the two stages of the study. Overall, only 16 eyes, including 9 eyes in Group 1 (16.4%), 2 eyes in Group 2 (3.2%), and 5 eyes in Group 3 (8.6%), had > or = 0.5 D difference in spherical equivalent refractive error at two stages of the study; however, intergroup differences were not statistically significant (p=0.16, chi-square test). Within each group, the percentage of eyes with <0.5 D difference was significantly greater than those with > or = 0.5 D difference (p<0.001 in all three groups, binomial test). Side effects were more prevalent using more frequent drops.

CONCLUSIONS

A single drop of cyclopentolate 1% suffices for cycloplegic refraction. There were less frequent side effects using one drop of cyclopentolate, compared to two or three drops.

Mydriatic insert and intracameral injections compared with mydriatic eyedrops in cataract surgery: controlled studies

Mydriatic eyedrops are the standard method for pupil dilation in cataract surgery, but their limitations have prompted a search for alternative techniques. Two alternatives-an ophthalmic insert containing phenylephrine and tropicamide and intracameral injections of various combinations of lidocaine, cyclopentolate, and phenylephrine, with or without epinephrine in the irrigating solution-have been assessed in prospective controlled studies, including randomized controlled trials (RCTs). We reviewed the safety and efficacy of mydriatic ophthalmic inserts and intracameral mydriatic injections compared with the safety and efficacy of mydriatic eyedrops using a systematic PubMed search (1963 to 2014). We identified 9 prospective studies (7 RCTs, 637 patients) of the mydriatic ophthalmic insert and 15 prospective studies (14 RCTs, 1020 patients) of intracameral mydriatic injections; 7 of the RCTs compared intracameral mydriatic injections and mydriatic eyedrops and 7 RCTs studied the optimum intracameral mydriatic injection protocol. The latter showed that a lidocaine and phenylephrine-based solution, without irrigating epinephrine, was optimum for intracameral mydriatic injections. The mydriatic ophthalmic insert and intracameral mydriatic injections were consistently shown to be safe and as effective as mydriatic eyedrops. Each method has distinct advantages and limitations.

FINANCIAL DISCLOSURE

Dr. Behndig has received fees from Théa Pharma GmbH as a member of the European Team for the Prophylaxis of Infection in Cataract Surgery group. Dr. Korobelnik has received consultancy fees from Alcon Surgical, Inc.; Allergan, Inc.; Alimera, Inc.; Bayer HealthCare AG; Carl Zeiss Meditec AG; Novartis Corp.; Roche Innovatis AG; and Théa Pharma GmbH.

[Serious adverse side effects after pupillary dilation in preterm infants]

PURPOSE

This study aimed at investigating serious side effects of the pupillary dilation protocol used in Caen University Hospital for the screening of retinopathy of prematurity. This protocol includes one drop of phenylephrine 5% and two drops of tropicamide 0.5% instilled at a 5-minute interval.

PATIENTS AND METHODS

This retrospective study included all premature infants with a birth weight less than or equal to 1500 g and/or a gestational age less than or equal to 30 gestational weeks, hospitalized in the neonatal intensive care unit of Caen University Medical Center, having ocular fundus examinations for retinopathy of prematurity screening between 2009 and 2014. The medical records of patients who died or developed necrotizing enterocolitis were reviewed to analyze the imputability of the two eye drops used for pupil dilation.

RESULTS

Five-hundred and twelve infants were included, corresponding to 1033 ocular fundus examinations. No case of death could be ascribed to the use of eye drops. Two cases of necrotizing enterocolitis could be ascribed to the use of tropicamide with a doubtful and plausible intrinsic imputability according to French imputability criteria.

CONCLUSION

The pupillary dilation protocol used in Caen University Hospital for screening of retinopathy of prematurity might be implicated in two cases of necrotizing enterocolitis with an uncertain imputability of tropicamide 0.5% eye drops. No serious side effect could be ascribed to the use of phenylephrine 5% eye drops in this study.

Intracameral mydriatics in phacoemulsification cataract surgery -- a 6-year follow-up

PURPOSE

To evaluate the long-term safety of intracameral mydriatics (ICM) in phacoemulsification cataract surgery compared with conventional topical mydriatics (TM).

METHODS

A total of 45 patients were examined 6 years after phacoemulsification cataract surgery. The patients had previously participated in a prospective randomized double-blind study including 60 patients, operated with either ICM or TM. The follow-up included best-corrected visual acuity (BCVA), intraocular pressure (IOP), grade of posterior capsule opacification (PCO), YAG laser capsulotomy rate, pupil size, corneal thickness and endothelial morphology.

RESULTS

No differences in postoperative BCVA, IOP, pupil size, PCO or YAG rate were observed between the groups. Endothelial cell loss, endothelial morphology and corneal thickness were also equivalent.

CONCLUSIONS

Intracameral mydriatics is a safe alternative to topical mydriatics in phacoemulsification cataract surgery with no long-term disadvantages at 6-year follow-up.

A randomized controlled trial to determine the lowest effective dose for adequate mydriasis in premature infants

PURPOSE

To compare the mydriatic efficacy of different numbers of eye drops for retinal examination of premature infants.

METHODS

This pilot study enrolled preterm infants born at <32 weeks' gestational age who were scheduled for retinopathy of prematurity screening examinations. In all study group assignments, the right (treatment reference group) eye received 3 eye drops per current neonatal intensive care unit protocol, whereas the left (test) eye was randomized at each examination to receive either: 0, 1, or 2 drops. Pupils were dilated with the use of a cyclopentolate 0.2% and phenylephrine 1% ophthalmic solution. Pupil size (in mm) was measured by a single examiner at 0 (baseline), 45, 90, and 120 minutes after instillation. Retinal examination occurred at the first opportunity to adequately visualize the peripheral retina. Comparison of the means was calculated using paired t test, t test, or analysis of variance, as appropriate.

RESULTS

A total of 64 eye examinations were performed on 15 enrolled infants (mean gestational age, 28.7 ± 2.6 weeks, 53% white; 40% male). No significant differences existed in mean pupil size between the 1-, 2- and 3-drop groups at baseline, 90 minutes, and 120 minutes. All 1-drop group eyes could be examined by 90 minutes. The 0-drop group maintained baseline size.

CONCLUSIONS

Effective mydriasis was achieved in the test eye with 1 or 2 drops and was sustained to 120 minutes. Therefore, retinal examinations could be completed by 90 minutes in most infants with the use of 1 drop. A larger study is needed to determine the effect of iris color and severity of ROP on these findings.

The retinopathy of prematurity screening examination: ensuring a safe and efficient examination while minimizing infant discomfort

Retinopathy of prematurity (ROP) examinations in the NICU are necessary to protect vision in premature infants, but the examinations are associated with risk and discomfort. ROP examination risks include adverse effects from mydriatic agents, systemic responses to the stress of examination, and nosocomial infection. Infant discomfort may be lessened by limiting examination length and possibly by measures such as topical anesthetic, oral sucrose, and certain nonpharmacologic techniques. A well-organized ROP service facilitates appropriate scheduling of examinations and education of the infant's parents. This article addresses causes of risk and infant discomfort, providing a framework for developing a safe and efficient ROP service while minimizing infant discomfort.

Retinopathy of prematurity in infants with birth weight>or=1250 grams-incidence, severity, and screening guideline cost-analysis

PURPOSE

To determine the incidence and severity of retinopathy of prematurity (ROP) in infants with birth weight (BW) 1250 to 1800 g, to examine the influence of systemic conditions on the development of ROP in this population, and to evaluate the cost-effectiveness of various screening guidelines.

METHODS

We reviewed records from 259 consecutive infants with BW 1250 to 1800 g who were screened for ROP over a 3-year period. Extracted data included presence and severity of ROP, and the following potential risk factors (RF) for ROP development: sepsis, meningitis, necrotizing enterocolitis, intraventricular hemorrhage greater than stage I, pneumothorax, direct bilirubin>2 mg/dl, central line placement, antibiotic treatment>14 days, greater than seven red blood cell (RBC) transfusions, and mechanical ventilation>96 hours.

RESULTS

The overall incidence of ROP in this population was 4.2%. Two infants had stage 3 ROP, one with plus disease. Infants with stage 3 ROP had significantly lower BW (1299 versus 1484 g, P=0.013) and gestational age (GA) (28 versus 31 weeks, P=0.002) than those with no ROP. No infant with BW>1500 g developed treatable ROP. Conditions that best predicted ROP development in the 1501 to 1800 g BW group were sepsis, ventilation >96 hours, antibiotic use >14 days, RBC transfusions greater than seven units, and central line placement (P=0.001, P=0.001, P=0.012, P=0.014 and P=0.035, respectively). All infants with BW>1500 g who developed ROP had greater than or equal to two of these RF.

CONCLUSIONS

All cases of high-risk ROP would have been identified by current screening guidelines. Modified screening criteria of infants with (1) BW<or=1500 g or (2) BW 1501 to 2000 g and greater than or equal to two significant RF results in a $587.85 benefit per infant screened.

Rétinopathie du prématuré : résultats de l’examen du fond d’œil chez 94 enfants à risque

PURPOSE

The purpose of this study was to evaluate the incidence and severity of retinopathy of prematurity (ROP) in infants of birth weight less than 1.500 g and/or under 32 weeks'gestation.

METHODS

Ninety-four preterm infants were examined following the Royal College of Ophthalmologists guidelines and retinopathy was graded using the International Classification of ROP. Screening limits were 1 500 g birth weight or 32 weeks'gestational age. Fundus examinations for ROP were performed at 5 weeks'chronological age from birth. Pupil dilation was obtained with instillation of 1% tropicamide three times at 15-minute intervals.

RESULTS

The 94 infants examined for ROP had a median gestational age of 292.3 weeks and a median birth weight of 1 110340 g. ROP was diagnosed in 21 of 94 subjects (22.3%) by fundus examination. ROP stage 3 developed in one preterm infant, ROP stage 2 developed in five preterm infants, and ROP stage 1 developed in 15 preterm infants. No premature babies developed stage 4 or stage 5 ROP. The disease regressed spontaneously in all cases and none of the infants required cryo/laser therapy. In the most premature infants, 23-26 weeks'gestation, 57% developed ROP and one developed severe ROP (stage 3). No disease more posterior to peripheral zone 2 was observed. The incidence of ROP was higher in infants exposed to greater than 21% oxygen (24.2%) than in infants who did not receive oxygen (17.8%). Oxygen, blood transfusion, and cardiopathy appear to be associated with an increased incidence of retinopathy of prematurity.

CONCLUSIONS

ROP continues to be a common problem associated with prematurity in France. This study found a similar incidence of prethreshold ROP when compared to recent studies. The data showed that blood transfusion and cardiopathy may play a role in the development of ROP in premature infants.

Intracameral mydriatics in phacoemulsification cataract surgery

PURPOSE

To evaluate intracameral injection of mydriatics in phacoemulsification cataract surgery and compare the results with those of conventional topical mydriatics.

SETTING

Department of Clinical Science/Ophthalmology, Umeå University Hospital, Umeå, Sweden.

METHODS

This prospective randomized double-blind study included 60 patients who were given topical (topical group) or intracameral (intracameral group) mydriatics. The topical mydriatics comprised 3 drops of cyclopentolate 1% and phenylephrine 10% given 15 minutes apart and 150 microL intracameral lidocaine hydrochloride 1% (Xylocaine) and the intracameral mydriatics, placebo eyedrops and 150 microL intracameral cyclopentolate 0.1%, phenylephrine 1.5%, and Xylocaine 1%. The pupil size was recorded preoperatively, throughout surgery, and 1 day and 1 month postoperatively. Preoperative and postoperative corneal endothelial morphology, corneal thickness, intraocular pressure, visual acuity, aqueous cells and flare, phacoemulsification energy, duration of surgery, pulse, blood pressure, and intraoperative sensation of pain and glare were also recorded.

RESULTS

With intracameral mydriatics, mydriasis reached 95% +/- 3% (SD) of its final value within 20 seconds. In the intracameral group, the pupils were smaller than in the topical group (mean 6.7 +/- 1.0 mm versus 7.7 +/- 1.0 mm, P<.001) but did not contract intraoperatively. The pupils in the topical group tended to contract, and the difference between groups was significant (P =.0020). The intracameral group reported less glare during the procedure (P<.001). There was no difference in endothelial cell loss, inflammatory reaction, postoperative corneal swelling, or surgical performance between the groups.

CONCLUSIONS

Intracameral mydriatics were a rapid, effective, and safe alternative to topical mydriatics in phacoemulsification. Their use can simplify preoperative routines and in certain high-risk groups, may reduce the risk for cardiovascular side effects.