Mydriasis for retinopathy of prematurity screening in Europe: A cross-sectional online survey

PURPOSE

To compile real-time data on the preferred mydriasis practice patterns for retinopathy of prematurity (ROP) screening in Europe.

METHODS

A cross-sectional online survey was conducted from December 2022 to January 2023, using a self-report online questionnaire which was distributed via email to the members of the European Pediatric Ophthalmological Society and the Greek National ROP Task Force. A six-week period of recruitment was determined, and a reminder email was sent after two weeks. Descriptive statistics were used to explore the data, which was summarized with frequencies and percentages.

RESULTS

Sixty-six responses were recorded (response rate: 29.5%), representing practices in 55 Neonatal Intensive Care Units from 21 European countries. In 94.5%, the applied mydriatic regimen consists of phenylephrine with at least one muscarinic antagonist, either tropicamide or cyclopentolate. The concentration of phenylephrine ranges from 0.5% to 5%, of tropicamide from 0.25% to 1%, and of cyclopentolate from 0.2% to 1%. The most commonly used regimen (43.6%) contains phenylephrine 2.5% and tropicamide 0.5%, administered either combined or separately. About 54.5% of the reported mydriatic solutions are non-commercial, in-house preparations. Systemic adverse events, including oxygen desaturation, bradycardia and cardiopulmonary arrest were reported in 14.5%.

CONCLUSION

There is considerable heterogeneity in the applied mydriatic regimens for ROP screening in Europe, reflecting the absence of universal guidelines. The wide use of in-house preparations underlines the gap in the pharmaceutical industry. Concern should be raised against the wide use of undiluted commercial drugs, that reach adult dose, in the fragile population of preterm infants.

The safety of intracameral phenylephrine - A systematic review

Intracameral phenylephrine is commonly used in ophthalmic surgery as an alternative or supplement to mydriatic eye drops; hence, the importance of an evidence-based understanding of its risk-benefit profile is vital. We performed a comprehensive search in the PubMed, Google Scholar and Cochrane databases for published studies and case reports relating to the use of intracameral phenylephrine. Articles from 1958 to 2021 with the following keywords were used: "intracameral phenylephrine", "intracameral mydriatics", "phenylephrine", "pupil dilation", "complications". Intracameral phenylephrine was first used in 2003 as an alternative to topical mydriatics. Since then, it is being increasingly used with a variety of benefits, including rapid onset of mydriasis, and cost-effectiveness. There are various case reports, however, of ocular and systemic complications associated with intracameral phenylephrine such as generation of free radicals, toxic anterior segment syndrome, inconsistent pupillary dilation during surgery, and ventricular fibrillation. Alternatives to intracameral phenylephrine such as iris hooks, a Malyugin ring, intracameral epinephrine, and intracameral tropicamide were compared with intracameral phenylephrine. Intracameral phenylephrine appears to have a good safety profile.

Alternative mydriasis techniques for retinopathy of prematurity screening

PURPOSE

There is a large variation in mydriatic regimens used in screening for retinopathy in preterm infants. Except for the standard instillation of mydriatic drops in their commercial formulation, other techniques for pupil dilation have also been described. This study aimed to review all techniques that have been used for mydriasis in retinopathy of prematurity eye examination (ROPEE) screening.

METHODS

A comprehensive literature search was performed in PubMed, Cochrane library, Trip database, and Scopus, using the key words: "mydriasis", "techniques", "mydriatics", "dilating drops", "retinopathy of prematurity", "ROP", "phenylephrine", "cyclopentolate", "tropicamide", "smaller mydriatic drops", "reduction in drop size" to February 2019.

RESULTS

Five primary studies were included, assessing the techniques of microdrops, lower conjunctival fornix (LCF) packing and Mydriasert® ophthalmic insert. Reported efficacy was similar to commercial eyedrops instillation. Microdrops appeared to have a superior safety profile. LCF packing and Mydriasert lead to increased blood pressure, without serious complications, necessitating further safety studies.

CONCLUSIONS

Of all alternative mydriasis techniques for ROPEE screening that have been described, microdrops appear to be the safest yet still effective technique in the fragile population of premature infants in risk of ROP.

Accuracy of the Hand-held Wavefront Aberrometer in Measurement of Refractive Error

Purpose

To compare refractive error measured by hand-held wavefront aberrometers with postcycloplegic autorefraction (AR) and cycloplegic refraction (CR).

Methods

The medical records of patients who received refractive measurements using the wavefront aberrometer, postcycloplegic AR, and CR between January 2014 and January 2016 were retrospectively analyzed. The mean differences, 95% confidence intervals, and limits of agreement (LOA) were calculated for the refractive vector components (M, J₀, and J₄₅).

Results

Fifty-one patients (9.0 ± 5.5 years, male 41.2%) were enrolled in this study, and only the right eye of each was included. Refractive errors ranged from −9.25 to +7.25 diopters (D) for spherical equivalent (median, 0.75 D). The M component was not significantly different among the three methods (p = 0.080). However, the J₀ vector component was significantly different (p < 0.001). After post hoc analysis, the wavefront aberrometer obtained more positive values for J₀ compared to the other methods. The J₄₅ component was not significantly different among the three methods (p = 0.143). The mean difference between the wavefront aberrometer and postcycloplegic AR was −0.115 D (LOA, −1.578 to 1.348 D) for M, 0.239 D (LOA, −0.371 to 0.850 D) for J₀, and −0.015 D (LOA, −0.768 to 0.738 D) for J₄₅. The mean difference between the wavefront aberrometer and CR was −0.220 D (LOA, −1.790 to 1.350 D) for M, 0.300 D (LOA, −0.526 to 1.127 D) for J₀, and −0.079 D (−0.662 to 0.504 D) for J₄₅.

Conclusions

The wavefront aberrometer showed good agreement with postcycloplegic AR and CR in spherical equivalents, but tended to produce slightly myopic results. The wavefront aberrometer also overestimated with-the-rule astigmatism. Therefore, we recommend that the device be used for estimations of refractive error, which may be useful for patients who have postural difficulties, live in undeveloped countries, or are bedridden.

Safety and efficacy of a standardized intracameral combination of mydriatics and anesthetic for cataract surgery in type-2 diabetic patients

Background

Cataract surgery in diabetics is more technically challenging due to a number of factors including poor intraoperative pupil dilation and a higher risk of vision threatening complications. This study evaluates the safety and efficacy of an intracameral combination of 2 mydriatics and 1 anesthetic (ICMA, Mydrane) for cataract surgery in patients with well-controlled type-2 diabetes.

Methods

Post-hoc subgroup analysis of a phase 3 randomized study, comparing ICMA to a conventional topical regimen. Data were collected from 68 centers in Europe and Algeria. Only well-controlled type-2 diabetics, free of pre-proliferative retinopathy, were included. The results for non-diabetics are also reported. The primary efficacy variable was successful capsulorhexis without additional mydriatic treatment. Postoperative safety included adverse events, endothelial cell density and vision.

Results

Among 591 randomized patients, 57 (9.6%) had controlled type 2 diabetes [24 (42.1%) in the ICMA Group and 33 (57.9%) in the Topical Group; intention-to-treat (ITT) set]. Among diabetics, capsulorhexis was successfully performed without additional mydriatics in 24 (96.0%; modified-ITT set) patients in the ICMA Group and 26 (89.7%) in the Topical Group. These proportions were similar in non-diabetics. No diabetic patient [1 (0.5%) non-diabetics] in the ICMA Group had a significant decrease in pupil size (≥3 mm) intraoperatively compared to 4 (16.0%; modified-ITT set) diabetics [16 (7.3%) non-diabetics] in the Topical group. Ocular AE among diabetics occurred in 2 (8.0%; Safety set) patients in the ICMA Group and 5 (16.7%) in the Topical Group. Endothelial cell density at 1 month postoperatively was similar between groups in diabetics (P = 0.627) and non-diabetics (P = 0.368).

Conclusions

ICMA is effective and can be safely used in patients with well-controlled diabetes, with potential advantages compared to a topical regimen including reduced systemic risk, better corneal integrity and reduced risk of ocular complications.

Trial registration

The trial was registered at (reference # NCT02101359) on April 2, 2014.

Efficiency and safety of phenylephrine and tropicamide used in premature retinopathy: a prospective observational study

Background

To determine effects and side effects of topical application of phenylephrine 2.5% and tropicamide 0.5% combination in preterm infants.

Methods

In this prospective observational study, 60 infants undergoing retinopathy of prematurity (ROP) screening were prospectively observed. Pupillary diameter, blood pressure, heart rate, and oxygen saturation were monitored before and after up to 24 h during ROP screening examinations.

Results

The mean pupillary diameter 1 h after the instillation of drops was 5.58 ± 0.75 mm for both eyes. The mean systolic and diastolic pressure and oxygen saturation of infants did not change statistically until the end of the study. The average heart rate decreased by a mean of 4.96 beats/minute from the baseline following eye drops instillation. General condition deterioration, fall in oxygen saturation and bradycardia were observed in 4 infants that already had respiratory distress syndrome.

Conclusion

The phenylephrine 2.5% plus tropicamide 0.5% drop is effective and safe as mydriatic combination for retinopathy of prematurity screening. In infants with an additional systemic disease such as respiratory distress syndrome, the side effects of mydriatic drops may be more common. Such babies should be kept under close observation.

Trial registration

The trial was retrospectively registered on 28 February 2018. The ClinicalTrials.gov Identifier is NCT03448640.

Hemodynamic Changes Associated with Mydriatic Eye Drop Administration in Anesthetized Pediatric Patients

Background

Dilating eye drops are routinely used in pediatric retinoblastoma patients during anesthetized ophthalmologic exams. Information on the systemic effects of ocular mydriatics, especially in anesthetized pediatric patients, is limited.

Objective

The primary aim of this study was to analyze hemodynamic changes during mydriatic eye drop administration in anesthetized pediatric patients.

Methods

A retrospective chart review was performed for pediatric retinoblastoma patients who underwent MRI with anesthesia. Baseline blood pressure (BP) and heart rate (HR) were charted for each patient at induction. HR and mean arterial pressure (MAP) measurements were recorded at 5, 10, 15, 30, and 45 min after eye drop administration. Secondarily, we included data from 15 patients who received dilating eye drops while under sevoflurane general anesthetic. All patients were dilated with phenylephrine 2.5 or 10% (depending on age) and tropicamide 1%.

Results

The final analysis included 176 anesthesia encounters. The results demonstrate no statistically significant deviation of more than 20% from baseline for either HR or MAP. Additionally, we did not detect any difference between patients who were anesthetized with propofol versus sevoflurane.

Conclusions

We did not observe significant hemodynamic instability with administration of dilating eye drops during propofol anesthesia.

[Same-eye comparison of pupillary dilation with an intraoperative standardized intracameral combination of mydriatics (Mydrane®) versus a preoperative ophthalmic (Mydriasert®) in standard cataract surgery in non-diabetic patients (French translation of the article)]

INTRODUCTION

Cataract surgery is the most commonly performed surgery in the world, and its success depends in part on the quality of mydriasis.

PURPOSE

To compare, for the same eye, the pupillary dilation obtained with Mydrane® (standardized intracameral solution of 0.02% tropicamide, combined with 0.31% phenylephrine and 1% lidocaine) intraoperatively versus Mydriasert® (0.28mg tropicamide insert and 5.4mg phenylephrine) with a contact time between 45 and 60 minutes in the preoperative period.

METHODS

Single center prospective study from November 2016 to January 2018 at the Laveran Army Instructional Hospital in Marseille. Patients referred for surgery were dilated at the preoperative consultation with Mydriasert®. The pupillary diameter after 45-60 minutes of contact with the insert was manually measured, by two different examiners, through the "iris image" tab of the Pentacam® elevation topography. Patients were dilated on the day of their cataract surgery with 0.2cc of Mydrane® injected in the anterior chamber through a paracentesis. Thirty seconds later, prior to injection of viscoelastic, an eye photograph was taken by screen capture. The pupillary diameter was evaluated by two different examiners with to the Piximeter 5.9 metrology software. The difference in pupil dilation between Mydriasert® and Mydrane® was tested with the paired series Student t-test.

RESULTS

In total, 111 eyes of 82 patients were included. Mydriasert® achieved a mean pupillary dilation of 7.21±0.79mm. The mydriasis obtained with Mydrane® averaged 6.35±0.8mm. This difference of 0.86mm was statistically significant (P<0.001) with a confidence interval of 95% [-0.97; -0.74].

CONCLUSION

On average, Mydrane® dilates the pupil less than Mydriasert®. However, the mydriasis obtained with Mydrane® remains comfortable for the performance of the capsulorhexis. It helps save preoperative time and affords additional anesthetic to the cataract surgery. Nevertheless, the use of Mydriasert® is beneficial when extra mydriasis is required.

[Emphasizing the standardized use of cycloplegics in the epidemiological studies of myopia]

The prevalence of myopia in China is extraordinarily high, and much attention has been paid to the epidemiological studies related to myopia. Epidemiological investigations can be used to understand the incidence and prevalence of myopia, its epidemiological characteristics and the related risk factors. At present, there are many articlespublished in China on epidemiological surveys of myopia. However, the criteria for cycloplegic regimes are not uniform, the age limit is not definite, and cycloplegics are even not used in some researches. Lack of or insufficient cycloplegia is associated with overestimation of the prevalence of myopia and underestimation of hyperopia and leads to inaccurate assessment of risk factors. In this article, we propose standardized methods for cycloplegia in the epidemiological investigations of myopia in China by reviewing different types of cycloplegic regimes commonly used and the effects on different age groups. This will help to obtain the accurate incidence and prevalence of myopia, promote the interconnection and increase comparabilityof research data, improve the accuracy of assessing related risk factors and provide scientific evidence for the prevention and control of myopia. (Chin J Ophthalmol, 2019, 55: 561-564).

[An investigation on professional performance of optometric refraction in spectacles stores in Anyang city of Henan Province]

Objective: To investigate the methods of optometric refraction adopted for adolescents in spectacles stores in Anyang city of Henan Province and the professional performance of optometric refraction. Methods: Cross-sectional study. Maps and yellow pages were used to collect the information of 131 spectacles stores in Anyang city. A questionnaire was used to investigate spectacles stores that had optometry equipment and can provide refraction prescription and spectacles in this city. The questionnaire covered (1) the process of optometric refraction, including whether cycloplegic refraction was conducted for adolescents and children if it was their first-time optometry and the type of cycloplegics,and (2) the opticians' knowledge on optometric refraction for adolescents and children, such as necessity of cycloplegic refraction for adolescents and children and age cut-offs. According to whether they used a comprehensive refractometer, the optometry methods were divided into conventional optometry and medical optometry. Results: Of 131 spectacles stores in Anyang city, 127 were enrolled. A total of 127 questionnaires were distributed and returned with an effective rate of 100%. Conventional optometric refraction was performed in 53 stores (41.73%), and medical optometric refraction was performed in 74 stores (58.27%). Cycloplegic refraction was conducted in only 4 spectacles stores (3.15%) for adolescents and children upon their first-time optometry. The fogging method of refraction was adopted in 31 stores (24.41%), while optometric refraction was directly conducted in 92 stores (72.44%) without controlling accommodation. As for the use of cycloplegia at initial optometric refraction of children, cycloplegia was objected to in 4 stores,and thought to be no need in 28 stores including 6 stores in which the fogging method was used to replace cycloplegia. In 68 stores, cycloplegia was performed if wanted, or children could go to a hospital for it. In 12 stores, the use of cycloplegics was determined by children's vision and diopters. In 5 stores, children were suggested to go to a hospital for cycloplegic refraction. Cycloplegic refraction was required in only 4 stores. As to the age cut-offs of cycloplegic refraction, 6 years old, 12 years old, and 18 years old were considered as the boundary in 7 stores, 33 stores, and 9 stores, respectively.In 11 stores, age was only considered for amblyopia and hyperopia, and in 67 stores, it was not realized. Conclusions: Cycloplegic refraction was found to be conducted for adolescents and children in only 3% of the spectacles stores in Anyang city. Moreover, most of the spectacles store opticians did not support to use cycloplegia before optometric refraction for adolescents and children and lacked knowledge on the age cut-offs of cycloplegic refraction.Standardized training of cycloplegic refraction should be further strengthened. (Chin J Ophthalmol, 2019, 55: 576-581).

[Impact of mydriatic eyedrops on distance visual acuity in patients with exudative age-related macular degeneration]

PURPOSE

To demonstrate a decrease in distance visual acuity (VA) following instillation of mydriatic eyedrops in eyes with exudative age-related macular degeneration (AMD).

MATERIALS AND METHODS

A prospective assessment in clinical practice was conducted in our ophthalmology department at the University Hospital of Tours from 7/19/2018 to 8/29/2018. Distance (ETDRS) and near (Parinaud) VA were assessed before and after instilling one drop each of tropicamide 0.5% and phenylephrine 10% in the 40 included eyes with exudative AMD.

RESULTS

The mean difference in distance VA before and after pupillary dilation (PD) was 0.06 LogMAR (SD=0.14) (P<0.01), i.e. -3.05 letters read (SD=7.52) on the ETDRS chart (P=0.01). For near VA, the mean difference was 0.16 LogMAR (SD=0.16) (P<0.001), i.e. -1.58 paragraphs read (SD=1.63) on the Parinaud chart (P<0.001).

DISCUSSION

The absence of a clinically significant loss in post-dilation distance VA for exudative AMD could be explained by negligible glare coming from the ETDRS chart, milder photophobia, low pre-dilation VA's and a balance between higher order optical aberrations and diffraction. The opposite result for near VA could essentially be explained by greater glare induced by the light illuminating the Parinaud chart.

CONCLUSION

Our primary goal was not achieved. A study presuming the absence of a clinically significant decrease in post-dilation distance VA would be necessary to consider directly measuring post-dilation VA in eyes with exudative AMD in our daily practice.

[It is essential to diagnose and correct children's ametropia after cycloplegic refraction]

It is essential to diagnose and assess children's ametropia after cycloplegic refraction. The use of cyclopentolate 1% eyedrops in children is safe and effective for cycloplegic refraction. An accurate prescription should be based on the actual eye position and accommodation, as well as cycloplegic refraction in children. (Chin J Ophthalmol, 2019, 55: 86-88).

Budget impact model of Mydrane®, a new intracameral injectable used for intra-operative mydriasis, from a UK hospital perspective

BACKGROUND

During cataract surgery, maintaining an adequate degree of mydriasis throughout the entire operation is critical to allow for visualisation of the capsulorhexis and the crystalline lens. Good anaesthesia is also essential for safe intraocular surgery. Mydrane® is a new injectable intracameral solution containing two mydriatics (tropicamide 0.02% and phenylephrine 0.31%) and one anaesthetic (lidocaine 1%) that was developed as an alternative to the conventional topical pre-operative mydriatics used in cataract surgery. This study aimed to estimate the budget impact across a one year time frame using Mydrane® instead of topical dilating eye drops, for a UK hospital performing 3,000 cataract operations a year.

METHODS

A budget impact model (BIM) was developed to compare the economic outcomes associated with the use of Mydrane® versus topical drops (tropicamide 0.5% and phenylephrine 10%) in patients undergoing cataract surgery in a UK hospital. The outcomes of interest included costs and resource use (e.g. clinician time, mydriasis failures, operating room time, number of patients per vial of therapy etc.) associated with management of mydriasis in patients undergoing cataract surgery. All model inputs considered the UK hospital perspective without social or geographical variables. Deterministic sensitivity analyses were also performed to assess the model uncertainty.

RESULTS

Introduction of Mydrane® is associated with a cost saving of £6,251 over 3,000 cataract surgeries in one year. The acquisition costs of the Mydrane® (£18,000 by year vs. £3,330 for eye drops) were balanced by substantial reductions in mainly nurses' costs and time, plus a smaller contribution from savings in surgeons' costs (£20,511) and lower costs associated with auxiliary dilation (£410 due to avoidance of additional dilation methods). Results of the sensitivity analyses confirmed the robustness of the model to the variation of inputs. Except for the duration of one session of eye drop instillation and the cost of Mydrane®, Mydrane® achieved an incremental cost gain compared to tropicamide/phenylephrine eye drops.

CONCLUSIONS

Despite a higher acquisition cost of Mydrane®, the budget impact of Mydrane® on hospital budgets is neutral. Mydrane® offers a promising alternative to traditional regimes using eye drops, allowing for a better patient flow and optimisation of the surgery schedule with neutral budget impact.

Effect of Homatropine eye drops on pain after photorefractive keratectomy: A pilot study

PURPOSE

To assess the effect of homatropine eye drops on pain after photorefractive keratectomy (PRK).

METHODS

This randomized, double masked, interventional study included 15 patients (30 eyes) who underwent bilateral PRK. After operation, patients received homatropine eye drops, 4 times daily in only one eye (homatropine eye). The level of pain was evaluated using visual analogue scale (VAS), verbal rating scale (VRS) and pain rating index (PRI) at 0.5, 24 and 48 h after operation.

RESULTS

The level of pain was statistically similar between the two eyes half an hour after operation, however, homatropine eyes had significantly less pain 24 h after operation compared to fellow eyes (2.5 ± 1.9 vs 5.3 ± 2.5, P = 0.004 for VAS, 2.0 ± 1.2 vs 3.2 ± 0.9, P = 0.023 for VRS, and 9.4 ± 5.7 vs 16.0 ± 9.0, P = 0.031 for PRI). Also, 48 h after surgery, the pain scales were less in the homatropine eyes (2.3 ± 1.7 vs 4.0 ± 2.1, P = 0.014 for VAS, 1.6 ± 1.0 vs 2.5 ± 1.0, P = 0.038 for VRS, and 6.8 ± 5.7 vs 12.0 ± 8.9, P = 0.005 for PRI). No delayed epithelial healing was observed.

CONCLUSION

Homatropine eye drops may be useful for reducing pain after Photorefractive keratectomy.