CLINICAL SCIENCE

Comparison of the effectiveness of a nondilated versus dilated fundus

examination in the pediatric population

A B S T RAe T :M.W+:*CW-M.'i','.M

A study was performed to compare the clinical effec­tiveness of a nondilated fundus examination to a dilat­ed fundus examination.

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The population consisted of 90 pediatric patients aged 5 to 16 years. Subjects were randomly selected from patients presenting for a routine eye examination at the Eye Institute of the Pennsylvania College of Optometry. Direct ophthalmoscopy was performed on the subjects before pupillary dilation while direct and binocular indi­rect ophthalmoscopy were performed post-dilation

--.--I'+4V Twenty-three patients (25.5 percent) had one or more pos­terior pole anomalies not detected by the nondilated pupil examination. A total of 30 posterior pole anomalies were not detected by the nondilated pupil examination . Forty-six patients (51 percent) had one or more periph­eral anomalies not detected by the nondilated pupil exam­ination. Sixty-nine total periphera l anomalies were not detected by the nondilated pupil examination.

+.',++W'4--M·*:4ii A dilated fundus examination provides a more effective clinical method for evaluating intraocular health in a pedi­atric population .

:--_',1+.1-4·4-9 pupillary dilation. retina. standard of care, direct oph­thalmoscopy, binocular indirect ophthalmoscopy, pediatric retinal disease, pediatric eye examination

Parisi ML, Scheiman M, Coulter RS . Comparison of the efiectivenessof a nondilated versus dilated fundus exam­ination in the pediatric population. JAm Optom Assoc 1996; 67: 266-72.

266

Maria L. Parisi, O.D.a

Mitchell Scheiman, O.D.a

Rachel S. Coulter, O.D.a

The debate about whether to perfoml pupillary dilation on a routine basis continues to be discussed in the opto­metric literature. 1-3 It is suggested that many optometrists do not use pupil­lary dilation on a routine basis.3 A 1989 survey of 259 optometrists found that only 6 percent of respondents routinely used dilation.4 Siegel and col­leagues5 have extensively reviewed the arguments for and against routine dilation and the standard of care issues involved. Common reasons cited for not using dilation on a routine basis include time constraints, patient reluctance, concerns over inconvenience, ocular and systemic side effects of diagnostic agents, and low incidence of peripheral disease in asymp­tomatic patients, especially in the pediatric and young adult healthy pop­ulation.3,6 Reasons to perform routine dilation include inability to assess the peripheral retina with a nondilated examination, enhancement of the detection of posterior pole disease, concern that patients may develop dis­ease between examinations, concern over the legal ramifications of missed lesions, and adherence to a medical standard of care.5

It is well known that diagnostic agents may cause systemic and ocular side effectsJ-loYet the incidence of such adverse effects has been found to be less than 0.208 percent in a study of 12,493 drug applications involving patients from birth to more than 90 years of age.9 Yolton and colleagues'7 study of 15,000 applications of diagnostic pharmaceutical agents to sub­jects ranging from newborns to adults in excess of 61 years of age found no reported cases of systemic side effects, while ocular side effects were transitory and self resolving. Both premature and full-term infants may expe­rience increased adverse reactions and absorption of drugs due to lower body mass, smaller blood volume and immature cardiovascular and ner­vous systems. 11 -14 Concern regarding patient drug side effects may fur­ther deter routine dilation of asymptomatic infants and children. Even so, it may be argued that usage of the lowest dose and volume of drug will help prevent side effects and obtain the desired degree of dilation and cyclo­plegia. 11 ,13,15

With regard to the low incidence of peripheral disease, Siegel and col­leagues,5 in a study of 500 adult subjects aged 20 years and older, found

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CLINICAL SCIENCE

57.4 percent had peripheral anomalies that would have been missed if the patient had not received a dilated fundus examination; 20 of the peripheral anomalies required immediate action. This study5 also found that 51 percent of posterior pole lesions were not detected with a nondilated pupil examination and that 38 percent of the posterior pole lesions that required immediate action were not detected with a nondilated pupil examihation.

The argument has been made that patients need not receive pupillary dilation if they are asymptomatic or unless they have defmite indi­cations for dilation. 10 Yet, Siegel and colleagues5

found in their adult study that 14 percent of the anomalies that

ination as compared to a dilated examination. Although a similar study has been performed in the adult population,5 to date no compa­rable study has been performed in the pedi­atric population. The adult study5 established that a dilated fundus examination was more effective in detecting posterior pole and peripheral anomalies, that symptoms were not always reliable indicators for retinal disease, and that retinal anomalies had a relatively high inci­dence. Using methods that were similar,5 the effectiveness of a dilated fundus examination was compared to the effectiveness of a nondilated examination by comparing the number of posterior pole anomalies found with each technique, and determining the

required action were asymptomatic. Silverman 16 describ­ed two cases of asymptomatic pa­tients age 18 and 55 years who received routine pupillary dilation and were found to have a small rhegmatoge­nous detachment and a choroidal melanoma, respec­tively. Likewise, selective dilation of only symptomatic pediatric patients has been the sub­ject of legal opin­ion, most notably in the case of Keir v United States. 1,17

This case suggests

Posterior pole anonlalies detected total

situs inversus

choroidal and scleral crescents

prepapillary vessel loop

macular drusen

macular pigment dot ....... ........... ... ............. .. ...

isol~ted posterior pole drusen

optic nerve glial remnants

· t9rtuou~ . blood vessElI~ assOCiated with prematurity

bear track

that optometrists *multiple occurrences of an anomaly in the same patient were counted once

will be judged according to a med-

nu.nber

ical standard of care and that optometrists should routinely screen for peripheral disease regardless of previous normal fundus exami­nations, family history, associated systemic or ocular disease, or presenting signs and symp-

number of peripheral anomalies found with the dilated examination that were missed with

toms. I7

To investigate these issues in a pediatric pop­ulation, a study was undertaken to determine the effectiveness of a nondilated retinal exam-

a nondilated examination.

Methods Sllbjects The population consisted of 90 pediatric patients aged 5 to 16 years (mean age 9.2 years). Subjects were selected randomly from

of

Table 1

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268

the clinic population presenting for a pediatric eye examination at The Eye Institute of the Pennsylvania College of Optometry. Patients who present to this clinic are randomly assigned to the examining practitioners with­out consideration of history, chief complaint, sex or ethnic background. During the course of multiple clinic sessions, the patients ran­domly assigned to the authors were utilized as subjects. Fifty-three percent of the subjects were male. Seventy-three percent of the sub­jects were black, 21 percent were white, 3 per­cent were Hispanic, 1 percent were Pakistani and 1 percent were Eastern Indian.

Procedures

Direct ophthalmoscopy was performed on each patient before pupillary dilation, while direct and binocular indirect ophthalmoscopy were performed post -dilation. The drops were administered with the standard technique of instillation in the lower cul de sac or filling the medial canthus with the eyes closed and then allowing the eyes to be opened following instil­lation. The assistance of a parent or student intern was used when necessary to guide the patient's ftxation for both the nondilated and dilated examination. Scleral depression was uti­lized when indicated. One practitioner per­formed the nondilated retinal examination while the other performed the dilated retinal examination without knowledge of the pre­vious examiner's findings. Dilation was achieved with the use of one drop of an anes­thetic, one drop of 1 % tropic amide and one drop of 2.5% phenylephrine in each eye.Twen­ty-one percent of the patients required a cyclo­plegic examination, requiring 1 % cyclopento­late to be added to the regimen or substituted for the tropicamide. Three percent of the patients required an additional drop of tropi­camide or phenylephrine because of inade­quate dilation.Two patients received only 1 % tropicamide by oversight.

Results Twenty-three patients (25.5 percent) had one or more posterior pole anomalies that were not detected through the nondilated pupil exami­nation (fable l).A total of thirty posterior pole anomalies were not detected by the nondilat­ed examination. Widely accepted criteria were

JOURNAL OF THE AMERICAN OPTOMETRIC ASSOCIATION

used to determine which lesions had the poten­tial for future complications.!8-2! Of the poste­rior pole anomalies not detected by the nondi­lated examination, the only anomalies with potential for future complications were the chorioretinal scar, posterior staphyloma, macular drusen and choroidal nevus. None of these anomalies needed immediate referral or treat­ment and aU findings required only routine mon­itoring. Of the posterior pole anomalies detect­ed by both techniques, only the toxocara canis lesion required immediate referral to a retinal specialist due to peripapillary traction and risk of macular detachment.The retinal specialist rec­ommended photographs, close monitoring and vitrectomy if the traction showed pro­gression. Vitreous liquefaction was noted with the nondilated examination in one subject, but was not observed during the dilated examina­tion.

Forty-six patients (51 percent) had one or more peripheral anomalies not detected through the nondilated pupil examination. A total of 69 peripheral anomalies were not detected by the nondilated examination (fable 2).To determine which peripheral lesions had the potential for future complications, widely used criteria were established and divided into three cate­gories l 8-24(Table 2). In establishing the cate­gories, adult guidelines were used for those dis­orders in which the prognosis was not specillc to children. It might be assumed that there is a better prognosis in the pediatric pop­ulation due to less time for vitreoretinal degen­eration, yet environmental factors such as increased physical activity and trauma may be influential. 18

The fu-st category included conditions generally considered to be benign at any age. Thirty-five benign peripheral lesions (51 percent of all peripheral anomalies), involving 30 patients, were detected. The second category included conditions that generally require routine or peri­odic monitoring, with emphasis on education about the signs and symptoms of progressive disease.Twenty-four peripheral lesions (35 per­cent of all peripheral anomalies) , involving 19 patients, were detected in the second category.

The third category included conditions that generally require close mOnitoring, referral to a retinal speCialist, systemic work-up, treatment,

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or possess additional risk factors l8 for retinal detachment.

The risk factors specific to the pediatric popu­lation considered in this study included vitreous degeneration in the form of vitreous liquefaction or shrinking, patients with myopia over 3 diopters, patients with a strong family history of retinal detachment and patients with sympto­matic breaks. 18 In category three, 10 peripheral lesions (14 percent of all peripheral anomalies), involving eight patients, were found. Of these, only four lesions (5.8 percent), involving three patients, required treatment or systemic work­up. One patient required laser barrier treatment for localized retinal detachments secondary to both an operculated and an atrophic hole, one patient required a systemic work-up for pars planitis and another patient required a systemic workup for venous sheathing.

Sixty-five subjects U2.2 percent) had one or more posterior pole or peripheral anomalies. Multiple areas of an anomaly within the same patient, such as multiple areas of white without pressure, were counted as only one anomaly.

Seven subjects U .7 percent) were noted to be uncooperative for binocular indirect ophthal­moscopy.Two subjects (2.2 percent) had a sus­pected lesion at the ora serrata that could not be viewed with scleral depression due to lack of cooperation, even though the subjects were otherwise cooperative for binocular indirect ophthalmoscopy. The macula could not be viewed with a nondilated pupil examination on one subject with high myopia due to the refractive error and lack of cooperation.

The percentage of anomalies were almost even­ly distributed among the races in comparison to their contribution to the study population. Black subjects U3 percent of subject popula­tion) contributed 77 percent of the retinal anomalies while white subjects (21 percent of subject population) contributed 14 percent of the retinal anomalies. The Hispanic (3 percent of subject population), Pakistani (1 percent of subject population) and Indian (1 percent of subject population) subjects contributed 4.7 percent, 1.9 percent and 1.9 percent of retinal anomalies, respectively. The type of lesions found-in particular, white without pressure-may have been intluenced by the population bias for

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black subjects. In fact, no white subject pre­sented with white without pressure. Of the sub­jects in category three, six were black U5 per­cent), one was white (12.5 percent) and one was Indian (12.5 percent).The only subject who required treatment was white.

Discllssion In this study a dilated fundus examination pro­vided a more effective method than a nondilated fundus examination to evaluate the posterior ocular health in a pediatric population.The dilat­ed retinal examination detected more posteri­or pole anomalies than the nondilated retinal examination, and there was a high incidence of peripheral anomalies detected.

In addition, these findings seem to refute many of the arguments and concerns against routine pupillary dilation. With regard to the low inci­dence of peripheral disease in the pediatric population, it was found that 19 subjects (21 percent) required routine or periodic moni­toring of lesions and education about signs and symptoms of progression. Eight subjects (8.8 percent) required close monitoring, referral, treatment or systemic work-up. It should be emphasized that, despite the high number of peripheral anomalies detected, only one sub­ject (1.1 percent) required treatment and only two subjects (2.2 percent) required a systemic work-up. The sample size was too small to determine the incidence of specific retinal dis­eases in children; this consideration should be addressed in future studies.

The assumption that asymptomatic pediatric patients rarely have retinal disease may also be questioned by the study findings:Although only one patient was symptomatic, there was a high incidence of peripheral anomalies. Ali of the asymptomatic lesions required only monitor­ing, however, and it may be argued that it is unnecessary and time-consuming to examine for lesions that rarely need treatment. Yet, advo­cates of preventive health care may consider the ability to educate parents and children about the signs and symptoms of progressive disease, to provide recommendations for rou­tine monitoring of ocular health, and to pre­scribe protective eyewear (when appropriate) an important part of primary care optometry. It may also be argued that a dilated examina-

269

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tion with binocular indirect ophthalmoscopy may be more appropriate in the asymptomatic pediatric population than in the asymptomatic adult population because children may not report symptoms or inaccurately express subjective complaints. In fact, the symptomatiC patient in this study localized the symptoms to the unaffected eye.

lowing the administration of one drop of an anesthetic, 1% cyclopentolate and 2.5% phenyle­phrine in each eye. The symptoms resolved before the dilated fimdus examination was per­formed.1t is questionable if the symptoms were secondary to the ocular drugs since the patient appeared apprehensive in anticipation of receiving eye drops, struggled with the admin-

istration of the eye

Peripheral anomalies detected drops, and experi­enced the symptoms immediately following

... ~~~~.~~. ~~~.~.~~~ ......... ... ... , .. .. d .. I,d .. ~ .. '.I i&RI~;

... ~~.~~.~~,I.~~.I .. r.~~.i.~~~ .. ~!~~~~~ .. ~~~_~~~!~.I .. ~~~~~~ ....... .. isolated white without pressure

retinal pigment epithelial dropout

asymptomatic vitreous floaters.

isolated peripheral drusen

... ~~~~~ .. ~~.Y~.~~~~~~~ .. ~~~~!~ ................. ,." .. ~ ...... , ... ........... .. operculated asymptomatic holes

lattice degeneration

atrophic holes within lattice without fluid

vitreous tuft without break

chorioretinal dropou~ w/sclerat exposure secondary to perforated globe

chorioretinal scar without break/inflammation

lattice degeneration w/additional risk. factors for rd

atrophic hole within lattice degeneration

w(p~?i.~ional risk .factors for rd .. .... .. . ......

venous sheathing

.. I?c:lrspl .allitisvv/PLJffballsCillcls.Il()\I\I~ank.ill~ ..

6

2

15

4

4

3

2

2

instillation. An emo-tional component may have been causal or contributory to the symptoms. No other ocular or systemic adverse reactions were reported.

The rarity of adverse reactions associated with diagnostic drug use flies in the face of hesitation to use these agents for routine examination (except when contraindicat­ed in an individual patient). Of course, optometrists should always be prepared to manage ocular or systemic side effects of drug use and should use proper judgment on dosage.

*Multiple occurrences of an anomaly in the same patient were counted

Time constraints may be a clinical consider­ation, especially in a pediatric population, because of poor coop­eration. The pediatric Table 2

270

Some clinicians argue that the adverse side effects of mydriatic or cycloplegic drug use may outweigh the advantages of administrating these agents to children on a routine basis. In this study, however, only one patient reported a tran­sient adverse reaction. A healthy 7- year-old white female experienced transient nausea fol-

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dilated fundus exami­nation may at times

require alteration of drug instillation proce­dures. In uncooperative pediatric patients it may be helpful to use a spray technique. 25 It can be very time-consuming to perform binocular indirect ophthalmoscopy when the child is resistant to looking in the directions of gaze required to view the retinal periphery.

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For many of the patients in this study the assis­tance of a parent or a student intern was used to guide the patient's fixation in the appro­priate positions of gaze.With this assistance the peripheral retina could be viewed without dif­

ficulty in 92 percent of the patients studied. The high percentage of missed posterior pole anomalies without dilation may have been par­tially due to difficulty in maintaining the child's fixation, which is critical with a small pupil. In the pediatric population, it is more effective and may be more time-efficient to perform a dilated fundus examination because fixation is not as critical when the pupils are large.

Patient reservations and inconvenience have often been expressed as concerns. No parent in this study refused dilation. In a pediatric population there is little concern about risk of injury after dilation, as opposed to an adult population where there is risk of injury after dilation while driving or operating machinery. When necessary, a child may return to school with instructions for the teacher regarding visu­allimitations. If the child must return to school for a written test or sports activity, the dilated fundus examination may be rescheduled for a day or time that is more convenient.

The optometrist must also consider the legal risks of not performing a dilated retinal examination with binocular indirect ophthal­moscopy. Optometrists have been held legal­ly responsible for the failure to diagnose ocu­lar pathology in young patients. The standard of care to be applied in such cases is likely to be medical, as has been demonstrated in the case of Keir v United States 17 and in other cases. A recent study recommends that pedi­atricians examine newborns through a dilated pupil shortly after birth to promote early inter­vention for ocular disease and avoid delay of visual stimulation during the critical period.25

If it becomes the standard of care for pedia­tricians to use dilated fundus examinations on healthy newborns, it will become difficult for optometrists to justify not using pupillary dila­tion on a routine basis.

A limitation of this study is the bias toward black subjects.As discussed in the results, the percentage of anomalies was almost evenly dis­tributed among the races in comparison to their contribution to the study population. But

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CLINICAL SCIENCE

racial bias may influence the type of lesions detected, as reflected for example by the high incidence of white without pressure.The types of lesions found in this study may be reflective of a large metropolitan population. It should also be noted that the dilated fundus exami­nation was always performed after the nondi­lated examination, creating a risk that the sub­jects may have learned the art of being an examination subject. This risk was not con­sidered a Significant factor, however, because pediatric subjects generally have a short attention span, tire easily and become more uncooperative at the end of the examination.

The effectiveness of a dilated fundus exami­nation should certainly influence a clini­cian's decision to routinely perform such exam­inations on pediatric patients. Yet, in an increasingly cost-conscious health care system, cost effectiveness and efficiency should also be considered. Clinicians should seek to combine thoroughness with efficiency whenever pos­sible.An initial thorough dilated fundus exam­ination should be followed by a dilated exam­ination every few years (dependent on age) unless the initial examination was difficult to perform, ineffective, or revealed pathology that requires monitoring. In addition, the onset of new signs or symptoms, ocular trauma, or a change in health status would require addi­tional examination. This protocol is in accor­dance with the recently published Optomet­ric Clinical Practice Guideline for Pediatric Eye and Vision Examination. 26

The guideline suggests all school-age children have comprehensive eye and vision examina­tions before the first grade and every 2 years thereafter. 26 It also maintains that some chil­dren may require more frequent care depend­ing on the nature of any diagnosed eye or vision disorder. 26 These guidelines should be reviewed by all optometrists who provide care to a pediatric population.

References ,. Classe JG. Pupillary dilation. An eye-opening problem JAm Optom Assoc 1992; 63( 10)733-41

2. Whitmer L To see or not to see routine pupillary dilation. J Am Optom Assoc 1989; 60(7):496-500.

3. Cole RM III. Make dilation part of your routine. Rev Optom 1992; 129(7)47 ·50.

4. Anonymous. Panelists tread lightly with DPAs and TPAs. Rev Optom 1989; 126(1)6-7

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5.Siegel BS, Thompson AK, Yolton DP, et al. A comparison of diagnos­tic outcomes with and without pupillary dilatation. J Am Optom Assoc 1990; 61 (1)25-34

6. Gottschalk G. The case for routine dilation. Rev Optom 1989; 126(1)27-8

7. Yolton DP, Kandel JS, Yolton RL Diagnostic pharmaceuti cal agents side effects encountered in a study of 15,000 applications. J Am Optom Assoc 1980; 51 (2) 113-8

8. Jennings BJ, Sullivan DE. The effect of topical 2.5% phenylephrine and 1 % tropicamide on systemic blood pressure and pulse. J Am Optom Assoc 1986; 57(5)382-9

9. Applebaum M, Jaanus SO. Use of diagnostic pharmaceutical agents and incidence of adverse effects. Am J Optom Physiol Opt 1983; 60(5)384-8

10. Alexander LJ, Scholles J Clinical and legal aspects of pupillary dila­tion. J Am Optom Assoc 1987, 58(5)432-7

11. Wheatcroft S, Sharma A, McAllister J Redu ction in mydriatic drop size in premature infants. Br J Ophthalmol 1993; 77(6)364-5

12. Palmer EA How safe are ocular drugs in pediatrics? Ophthalmolo­gy 1986; 93(8)1038-40

13. Bolt B, Benz B, Koerner F, BosSI E. A mydriatic eye-drop combina­tion without sys temic effects for premature infants: a prospective double­blind study J Pediatr Ophthal Strabismus 1992; 29(3)157-62

14. Jaanus SO, Pagano VT, Bartlett JD. Drugs affecting the autonomic nervous system. In Bartlett JD, Jaanus SO, eds. Clinical ocu lar pharma­cology. Boston Butterworth, 198437-130.

15. Caputo AR, Lingua RW The problem of cycloplegia in the pediatric age group a combination formula for refraction. J Pediatr Ophthalmol Stra­bismus 1980; 17(2)119-28

16. Silverman MB. The dilation dilemma (Letter) J Am Optom Assoc 1987; 58(5)372

17. Cia sse JG. The eye-opening case of Keir v United States JAm Optom Assoc 1989; 60(6)471-6

18. Alexander LJ . Primary care of the posterior segment. East Norfolk, C1 Appleton & Lange,198914,16,20,23-5,84-5,11 0-2, 165-8,176-8,220-233,235-9,2 44 -6 ,250-2,262 -5.

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19. Harley RD. Pediatric ophthalmology, 2nd ed. Philadelphia WB. Saun­ders Co ,1983 527-833

20. Helveston EM, Ellis FD. Pediatric ophthalmology practice, 2nd ed. St. Lou is C.v Mosby CO,1984 25,222,253,255

21. Taylor D. Pediatric ophthalmology. Boston Blackwell Scientific Pub­lications,1990 286,291 -241 7,421 ,426-9,431,445-6,463

22. Nelson LB, Calhoun, JH, Harley RD. Pediatric ophthalmology, 3rd ed Philadelphia WB. Saunders CO,1991 306-8.

23. Tasman W Retinal diseases in children . New York Harper & Row,1971: 30,110-2,116,121·5,213-4

24. Bell FC, Stenstrom WJ Atlas of the peripheral ret ina. Philadelphia WB. Saunders CO,1983 18-20,30-5,96-7,144-5

25. Adler R, Lappe M, Murphree AL Pupil dilation at the first well baby examination for document ing choroidal light reflex J Pediatr 1991; 118(2)249-52

26. American Optometric Association. Optometric clinical practice guide­line pediatric eye and vision examination . St. Louis: American Optomet­ric Association, 1994 27-9

Footnote a. Pennsylvania College of Optometry, Philadelphia, PA

Submitted 2/94; accepted 9/95

Maria L. Parisi. 0 .0. Pennsylvania College of Optometry

1201 West Spencer Street Philadelphia. Pa 19141

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