SCREENING FOR RETINOPATHY OF PREMATURITY - ARE A LID SPECULUM AND SCLERAL INDENTATION NECESSARY

We wanted to investigate the value of using a lid speculum and scleral indentation in performing binocular indirect ophthalmoscopy (BIO) in neonates at risk of retinopathy of prematurity (ROP). We performed a p rospective masked comparison of BIO examinations using either a lid sp eculum and scleral indentation (SI) or no scleral indentation (NSI), i n our neonatal intensive care unit. We did 57 consecutive BIO examinat ions of infants weighing less than 1500 g and/or having a gestational age of less than 32 weeks. With NSI, zone I ROP was reliably seen in 5 3 of 57 examinations; the superior, nasal, and temporal aspects of zon e II were seen in 45 of 57 examinations; inferior zone II, in 22 of 57 examinations; and zone III in 1 of 57 examinations. SI facilitated co mplete peripheral fundus examination in all cases but had to be abando ned in two infants due to acute changes in oxygen saturation levels. F ive infants developed threshold disease, and in two of them details of the active ROP ridge were missed with NSI. The gentle use of an eyeli d speculum and globe rotation allows rapid and relatively atraumatic a ssessment of the peripheral fundus, even in babies who are being venti lated. Although threshold ROP may be diagnosed by observation of poste rior retinal vessel dilation and tortuosity (''plus'' disease), accura te grading of ROP is likely to require SI. In the absence of clearly d eveloped ''plus'' disease, borderline or prethreshold disease may occa sionally be missed using BIO with NSI. SI is necessary to examine the inferior midperipheral retinal vasculature (zone II) and the far perip heral temporal retina (zone III) and is associated with few complicati ons. BIO with SI allows early identification of neonates with normal r etinal vascularization who require no further ROP screening.