Visual Problems in Infancy After the NICU

From CHOP Expert Commentary Monte D. Mills, MD Posted: 08/15/2011 Hi, I'm Monte Mills. I'm the Director of Ophthalmology at the Children's Hospital of Philadelphia (CHOP). I'd like to talk about eye and vision problems in babies after they've been discharged from the neonatal intensive care unit (NICU) for prematurity. This is a very relevant problem. Eye and vision problems are common in the former preemie following discharge from the NICU. We know that you, as primary care providers, provide most of the care for these children as they get older and have been discharged from the hospital. Early recognition of these problems can make a difference in long-term outcome. How common are these problems in former premature infants? They're quite common. Approximately 50% of kids will need glasses due to strabismus, amblyopia, or other vision problems after they're discharged from the NICU, even after their retinopathy of prematurity (ROP) has been taken care of. The risk of having problems is related not only to the severity of their ROP, but also to their degree of prematurity. Infants who weight less than 1500 g at birth or are less than 32 weeks' gestational age at birth have the highest risk for eye problems later in life. Ocular abnormalities caused by ROP or CNS injury from prematurity are also highly associated with cerebral palsy and other manifestations of CNS injury. One of the principles of looking at these kids is that their visual development has to be compared with that of children at their same post-conceptual age. That is, their age should be adjusted for the degree of prematurity and not their actual postnatal age. These infants need to be observed for eye and vision problems even after their retinas have become mature and they have either been treated for ROP or their retinas have matured without treatment, and they've been discharged for close follow-up from the pediatric ophthalmology service that has provided their care in the NICU. What examinations do you perform in the office? There are 4 components of office primary care screening for eyes and vision. First, look at the ocular structures and external eye examination. Second, test for visual fixation and visual development. Third, eye alignment and eye movements. Finally, the ophthalmoscopic examination. First, the eye appearance and structures would be just the observations. Are the eyelids opening and closing normally? Do the corneas and visible external and internal surfaces of the eyes appear to be normal? If not, referral needs to be made. Second, visual fixation. The best tool for visual fixation is the examiner's face. Does the child fixate and follow on the face of the mother or the face of the examiner? Horizontal following and fixation occurs earliest and subsequently vertical following. By 2-3 months of adjusted age, the child should have good horizontal fixation and following. Third, eye alignment. Do the eyes align well? Is there nystagmus or rhythmic eye movement? We know that this is very common early on, but if the child is past 3-4 months adjusted age, the child should be referred. Finally, how does the pupil and red reflex look with the ophthalmoscope? Is there a good red reflex, is it symmetric and bright in both eyes? If not, if there's a shadow or an abnormality, the patient should be referred. Look for other common problems in infancy such as tearing disorders, obstruction of a nasal lacrimal duct, or capillary hemangiomas. They may not be specifically related to prematurity, but may occur frequently in these kids. Refer these children appropriately. An early referral and early treatment for amblyopia, strabismus, and refractive errors can result in better outcomes in our infants. Thank you.