Peds Ophtho Case 4: Additional History & PHYSICAL EXAM

Peds Ophtho Case 4 Index

Answer: Retinopathy of prematurity (ROP)

ROP is a condition that can develop in premature infants. In comparison to other eye conditions, which can be initially screened by general practitioners (i.e. red reflex for retinoblastoma, ocular misalignment with strabismus), ROP requires a dilated fundus and peripheral retinal exam and therefore requires screening by an ophthalmologist.

 

In addition to the baby’s prematurity, which of the following are major risk factors that predispose this newborn to ROP? Select all that apply.
Assisted ventilation
Dexamethasone
Oligohydramnios
Hydrochlorothiazide
Low birth weight
Maternal history of STI
Maternal history of gestational diabetes
Patent ductus arteriosus
Respiratory distress

Answer: Assisted ventilation, low birth weight, and respiratory distress

The leading risk factors for ROP are early gestational age and low birth weight. The American Academy of Pediatrics recommends screening all infants for ROP if they meet the following criteria:

  1. Infants with birth weight ≤1500 or gestational age <30 weeks.
  2. Infants with birth weight between 1500 and 2000 grams or a gestational age >30 weeks who have risk factors for ROP.

Other risk factors for ROP include infants who have ≥1 week of assisted ventilation, respiratory distress, anemia and blood transfusions.

Additional History: 

Allergies: None

Medications:
Dexamethasone
Hydrochlorothiazide 
Acetaminophen
Artificial Tears 

Past Medical History:
Respiratory distress
Prematurity
Oligohydramnios

Past Ocular History: None

Family History: Notable for retinal detachment in patient’s uncle in setting of poorly controlled type 2 diabetes. 

Social History: Non-contributory

Ophthalmic Exam: 

General appearance: Neonate with mechanical ventilation, breathing comfortably. No dysmorphic features.
Vitals: Temp: 37 C, BP: 52/30 HR: 112 bpm, RR 40 on mechanical ventilator with PEEP 6cm, FiO2 92%. Weight: 1420 g (5th percentile);
Visual acuity: Light perception OU
Pupillary reflex: Red pupillary reflex OU
Pupils: PERRL OU
Intraocular pressures (IOP): Soft to palpation OU

External ocular exam:

Eyelids: flat OU, no ptosis OU
Conjunctiva: white and quiet OU
Cornea: Clear OU
Anterior chamber: Formed OU
Iris: Flat without neovascularization OU
Lens: Clear OU

Dilating drops using Cyclomydril (cyclopentolate 0.2%) / phenylephrine 1%) were instilled in both eyes. During instillation, the patient’s heart rate and respiratory status remained stable.

Below are photos of the left eye:

Above Images courtesy of Robin Ginsburg, MD

How would you describe the left fundus appearance?
Sclerotic retinal arteries, intraretinal hemorrhages and macular deposits.
Cotton wool spots with tortuous retinal veins and diffuse intraretinal hemorrhages
Swollen optic disc with macular edema
Detachment of retina with fine pigment floating in the anterior vitreous with neovascularization
 Attenuated blood vessels with pale retina and AV nicking
Wavy and elevated vascularized line (ridge) between vascular and avascular retina with tortuous vessels

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Peds ophtho Case 4 Index
Peds Ophtho Case 4: Introduction