Dilation in Neonates: A Protocol

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Dilation

in Neonates:

A Protocol

Anthony R. Caputo, MD, Robert E. Schnitzer, MD,

Thomas D. Lindquist, PhD, and Shyen Sun, MD

From the Department of Ophthalmology, New Jersey Medical School, and Eye Institute of New Jersey, Newark

ABSTRACT. A protocol for safe and effective dilation in the nursery is presented. This combination has been utilized in numerous nurseries in Newark, NJ and at several institutions around the county. No side effects have been noted after three years of continuous use.

Pediatrics 69:77-80, 1982, pupillary dilation.

There are many indications for pupillary dilation in pediatric practice and a

safe

and effective pro-tocol is needed. Throughout the literature there have been various reports of systemic side effects of the eye drops currently in use. A complete review

of this subject has been published.’ The purpose of this article is to propose a safe and effective

com-bination drop formula for use in the nursery and office.

MATERIALS AND METHODS

Twenty neonates ranging in gestational age from 26 to 42 weeks and with birth weights ranging from

880 to 3,440 gm had their eyes dilated for routine funduscopic examination in the nurseries of United Hospitals Medical Center and College Hospital, CMDNJ, during July 1980. All babies included in

our study had either received oxygen or had some other indication for a dilated examination. Blood pressures and heart rates were monitored by a Dinamap blood pressure and pulse recorder. The combination eye drops used in

our

study have been used for the past three years by the pediatric

oph-thalmology staff at the Associated Eye Residencies Program of New Jersey. These “Caputo drops,” as they have become known, are prepared by

our

pharmacist in a 15-mi dropper bottle as follows:

Received for publication Sept 16, 1980; accepted March 5, 1981.

Reprint requests to (A.R.C.) 15 South Ninth St, Newark, NJ

07107.

3.75 ml of Cyclogyl 2%, 7.5 ml of Mydniacyl 1%, and 3.75 ml of Neosynephnine 10%. The

final

solution contains: Cyclogyl 0.5%, Mydriacyl 0.5%, and

Neo-synephnine 2.5%.

The babies were arbitrarily divided into two groups. Group I consisted of ten neonates who received only one drop in each eye. Group II con-sisted of ten neonates who, after receiving a drop in each eye, were given a second instifiation after

approximately ten seconds. In both cases, the

eye-lids

were held apart long enough to prevent reflexed forced closure and possible expulsion of the drop from the conjunctival sacs.

In all cases the infants were supine and resting quietly. Base line heart rates and blood pressures were recorded several times before the drops were

administered; average values were used as individ-ual control measurements. Following the

instilla-tion of eye drops, blood pressures and heart rates were recorded at 5, 10, 15, 30, 45, and 60 minutes. Pupil sizes were then measured with a small plastic

ruler in ambient lighting and under the intense beam of a halogen transilluminaton. This was done to simulate the conditions of an indirect ophthal-moscopic examination. Subsequently, routine ocu-lar evaluations were conducted.

RESULTS

Group I

This group received one drop in each eye. After

60 minutes the average dilation in room lighting was 7.3 mm. When exposed to the light beam, pupils constricted to an average of 6.1 mm. Four of the infants in this group had either blue, gray, or hazel irides. Their pupil size remained at 7.0 mm.

Group II

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In neither group were there any significant

changes in heart rates or blood pressures. (See Figs 1 and 2 and Tables 1 and 2).

DISCUSSION

During the past decade many reports of systemic effects of mydriatic eye drops have appeared in the

literature.2#{176} Currently, more attention is being di-rected to choosing the proper dilating drops. This is especially true in nurseries in which hypertension has been reported following the use of 10% phenyl-ephnine”9’2’ and a death occurred following the use

of 1% cyclopentolate.22

It has been shown that these medications can

enter the systemic circulation rapidly via capillaries of the eye or via the lacrimal drainage system. Here

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the absorption may occur through nasal mucosa or by way of the gastrointestinal tract.23

As it is now well documented that these routine eye drops may be harmful in normal adult

concen-trations, the formulation of either new nontoxic

drugs

or combinations at lower concentrations has

been necessary. The combination of a weak anti-cholinergic drug with a weak sympathomimetic drug synergistically acts on the iris musculature to produce maximal mydriasis which resists intense light.24

It is generally accepted that 7 mm of dilation is

required to view the peripheral fundus adequately.25 In

our

study we have found that one drop of our combination solution provides adequate dilation for examination of the ocular media, posterior pole, and retina using the indirect ophthalmoscope. Greatest dilation was observed in the infant with blue, hazel, or gray irides.

This

fact has been re-ported in the literature.26’27 With widen dilation viewing the peripheral retina was easier.

In

the group with two instifiations we observed consistent dilation of 7 mm on greaten. In all cases,

the peripheral retina was easily examined.

CONCLUSION

By using a solution of weak mydriatics we pro-duced safe and adequate dilation for funduscopic examination of nursery patients. With infants hay-ing blue irides, one drop in each eye is adequate. In all other cases, a second instillation within five to ten seconds ofthe first provides consistent adequate dilation without observable systemic effects.

ACKNOWLEDGMENT

This work was supported by a grant from Fight for Sight, mc, New York, to the Fight for Sight Children’s Eye Center of the Eye Institute of New Jersey.

REFERENCES

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-80 DILATION IN NEONATES

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(Cyclogyl) toxicity in the newborn infant. J Pediatr 82:501, 1973

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THINK ABOUT IT

Atomic bombs are no respecters ofbuildings or ofpeople: “ofthe 298 mobilized doctors in Hiroshima City, 270 became A-bomb victims. Casualty rates among

pharmacists and nurses ranged between 80 pen cent and 93 pen cent. Death rates among all medical personnel were high. For all practical purposes, the

well-prepared medical care system was rendered totally useless.” In Nagasaki “The city’s preparations for medical relief were wrecked from top to bottom.” The TNT equivalents of these two bombs were only 12.5 and 22 kilotons, respectively.

Submitted by Student

From Ijjima 5, Imahori 5, Gushima K (eds): Hiroshima and Nagasaki: The Physical, Medical and

Social Effects of the Atomic Bombings, for the Committee for the Compilation of Materials on Damage Caused by the Atomic Bombs in Hiroshima and Nagasaki, Ishikawa E, Swain DL (trans). London, Hutchinson; New York, Basic Books; 1981, pp 706.

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1982;69;77

Pediatrics

Anthony R. Caputo, Robert E. Schnitzer, Thomas D. Lindquist and Shyen Sun