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Clinical Guidelines (Nursing)

Neonatal eye examination on the Newborn Intensive Care Unit Butterfly Ward

  • Introduction


    Definition of Terms





    Evidence Table


    Neonatal eye examinations are performed to monitor Retinopathy of Prematurity (ROP). Timely treatment of ROP ensures treatment is effective and reduces the risk of vision loss. At risk infants of ROP should be screened by the ophthalmology team. The first exam is determined by their gestational age. Examination by an ophthalmologist is indicated in newborn infants with other abnormalities.


     To provide guidance of nursing care for neonates undergoing an eye examination on the Butterfly Ward.  

    Definition of terms

    Retinopathy of Prematurity (ROP): A disorder resulting in alteration of the normal retinal vascular development, affecting premature infants, which can lead to visual impairment and blindness.

    Very Low Birth Weight: Birth weight < 1500 grams.


    High risk group for ROP
    Other risk factors
    Other indications for eye examinations
    • Infants born with a very low birth weight or gestational age of 32 weeks or less
    • Oxygen supplementation
    • Anaemia
    • Blood transfusion
    • Intraventricular haemorrhage
    • Respiratory distress syndrome
    • Multiple episodes of apnoea/bradycardia
    • Mechanical ventilation
    • Congenital abnormalities or structural abnormalities of the eye
    • Severe eye infections
    • Non-accidental injuries in infants


    If the infant is clinically unstable (determined by medical staff and/or AUM), the procedure will need to be re-scheduled.


    Ophthalmology referral

    Neonatal medical staff identify all infants at risk of ROP and make a referral to Ophthalmology. The Neonatal registrar completes the referral request form in EMR as ‘Ophthalmology Inpatient Consult’. Referrals are found in the Eye Appointment Book in the AUM’s office.

    If the infant is medically unstable and would not tolerate the examination at the time of consultation with the ophthalmologist, this is documented by the ophthalmologist in the Consultation Notes and in the Eye Appointment Book with the reason for not being seen.

    On transfer to another hospital, documentation on the discharge summary of when the next eye review is required should be clearly stated.


    The initial eye examination should be carried out as determined by the table below, and by the neonatal team. 

    Neonatal Eye Exam Table 1

    Source: (Fierson, 2018). 

    Follow up examinations are determined by the ophthalmologist. The date for follow up examinations should be recorded in the Consultation Notes in EMR, and in the Eye Appointment Book by the ophthalmologist.


    The Neonatal Registrar or Fellow should prescribe the eye drops on the MAR.

    • Phenylephrine 2.5% - Cyclopentolate 0.25% 
    • These are manufactured by RCH Pharmacy and stored in the medication fridge on the Butterfly Ward. They are combined together so the baby will get one drop in each eye per dose. 
    • NB: these drops are not being made by Pharmacy during COVID-19.

    If the eye drops above are unavailable:

    • Phenylephrine 2.5% minims and Tropicamide 0.5% minims are to be used instead. 
    • They come in separate packs, meaning the baby will receive 1 drop of each separate medication in each eye per dose.  


    The ophthalmologist will advise the ANUM the time to commence the eye drop administration. The ANUM will inform the bedside nurse and medical team of the commencement time.  

    Administer the eye drops 1 hour prior to the examination. The dose is then repeated 10 minutes after the initial dose, and again 1 hour later.   

    Minims anaesthetic eye drops (Amethocaine hydrochloride 0.5% (Tetracaine) are administered by the treating ophthalmologist. They are administered immediately prior to the examination, and during the examination if indicated. These eye drops are stored in the medication fridge on the Butterfly Ward if additional are required. 

    Nursing care prior to procedure

    • Ensure required dilating eye drops have been administered at the appropriate time
    • Administer oral sucrose prior to the examination if needed

    There are benefits of using oral sucrose in neonatal eye examinations. Refer to the Sucrose (oral) for procedural pain management in infants guideline.

    Nursing care during and post procedure

    • Position the infant supine and wrapped securely in a blanket

    Effective pain management and stress reduction strategies are integral to protecting the infant from adverse consequences of experiencing stress and pain. 
    The following non-pharmacological interventions can be used to help the infant manage pain and stress associated with an eye examination:

    • Facilitated tucking or swaddling/containment
    • Non-nutritive sucking
    • Voice and maternal singing
    • Scent
    • Skin-to-skin care - Infants held in a skin-to-skin position may show quicker return to baseline & decreased cortisol following an eye examination. If this is not possible during the exam the infant should be placed in skin-to-skin immediately after the exam if practicable.

    Assess the infant’s cues and vital signs throughout the procedure; ask the ophthalmologist to pause or cease the examination if the infant is unstable.

    Post procedure documentation and communication

    The ophthalmologist records the results of the examination and further review or appointments in the Consultation Notes in EMR, and in the Eye Examination Book.

    The ophthalmologist will speak to the parents after the examination if parents are available. Otherwise, the managing neonatal team will discuss results with the parents, and if necessary, an appointment will be made with the ophthalmologist if there are any concerns.

    Where possible, parents should be supported and empowered to play an active part in pain management for their infant. For example, use of maternal/paternal voice, scent and skin-to-skin care. These interventions provided by parents are known to support the infant’s behavioural regulation, and decrease stress sooner after a painful intervention, compared with no parental support. This can be empowering for parents, but also may be confronting. Parents should be educated and supported in their choice to be involved with supporting their infant through a painful procedure. 


    Evidence table

    Please remember to read the disclaimer.

    The development of this nursing guideline was coordinated by Lauren Cross RN, Butterfly Ward, and approved by the Nursing Clinical Effectiveness Committee. Updated September 2020.