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Clinical Guidelines (Nursing)

Neonatal eye examination on the Newborn Intensive Care Unit Butterfly Ward

  • Introduction


    Definition of Terms




    Special Considerations


    Evidence Table


    Neonatal eye examinations are primarily performed to monitor for the presence and progression of Retinopathy of Prematurity (ROP), once considered an untreatable condition leading to blindness. Research has shown that careful screening of the retina of infants at risk, beginning at 30-32 weeks corrected gestational age, can help reduce the occurrence of posterior retinal traction folds and/or retinal detachments, as early laser or cryotherapy may be performed where indicated.
    In addition, examination of the eye by an ophthalmologist is indicated in newborn infants with other abnormalities, as ocular involvement may occur in several dysmorphic syndromes.


    This guideline specifically provides guidance for care of the infant during neonatal eye examinations for ROP, however the management of neonatal eye examinations is the same for indications other than ROP.

    Definition of terms

    Retinopathy of Prematurity (ROP): An alteration of the normal retinal vascular development, mainly effecting premature infants, which can lead to visual impairment and blindness


    High risk group for ROP

    • Infants born with a birth weight of below 1500 grams and / or gestational age of 32 weeks or less

    Other potential risk factors

    • High oxygen levels
    • Anaemia
    • Blood transfusion
    • Intraventricular haemorrhage
    • Respiratory distress syndrome
    • Chronic hypoxia in utero
    • Multiple spells of apnoea / bradycardia
    • Mechanical ventilation
    • Seizures

    Other indications for eye examinations

    • Congenital abnormalities or structural abnormalities of the eye
    • Severe eye infections
    • To check for ocular manifestations of 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 to a more appropriate time.


    Ophthalmology referral

    Neonatal medical and nursing staff need to identify all infants at risk of ROP and ensure that a referral to Ophthalmology is made. The Neonatal registrar is required to complete the referral request form in EMR as “Ophthalmology inpatient consult referral”.

    For infants on Butterfly Ward, referrals are kept in the Eye Appointment Book in the AUM’s office.

    • If the infant is medically unstable at the time of the consultation with the ophthalmologist and would not tolerate the examination, this should be documented in the Consultation Notes and in the Eye Appointment Book with the reason for not being seen, and dated and signed by medical staff
    • If the infant is transferred to another hospital, it should be documented on the discharge summary whether or not ophthalmologic follow up is required and the timing of next review


    • An ophthalmologist with experience in the examination of preterm infants carries out the examination
    • The initial examination should be carried out at 30-32 weeks corrected gestation as determined by the neonatal team. Ventilated infants and infants on nasal CPAP are included in the screening process unless they are deemed too unwell
    • Follow up examinations are best determined by the finding at the first examination using the International Classification of Retinopathy of Prematurity. A general guide is that examinations are performed every 1-2 weeks until the retina is fully vascularized at about 40 weeks corrected age, or at the discretion of 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% and Cyclopentolate 0.25% eye drops are used to dilate both pupils prior to examination. These are stored in the medication fridge on the Butterfly Ward
    • The time of administration will be determined by the ophthalmologist who will usually contact the ward in advance


    The neonatal eye examination is not thought to cause pain to the infant, however it may cause distress, and some analgesia may be appropriate.

    Amethocaine Hydrochloride 0.5% (Tetracaine) topical anaesthetic eye drops

    • Amethocaine hydrochloride 0.5% eye drops (1 drop in each eye) should be ordered on the MAR and administered by the treating ophthalmologist
    • Administer immediately prior to the examination, and during the examination if indicated
    • Amethocaine hydrochloride 0.5% eye drops are stored in the medication fridge on the Butterfly Ward

    Oral sucrose

    The evidence supporting the benefit of using oral sucrose, in addition to topical anaesthetic eye drops, in neonatal eye examinations, is not conclusive. It may be indicated if the infant is unsettled prior to, or after the procedure. Refer to the Sucrose (oral) for procedural pain management in infants guideline.

    Ideally sucrose should not be given during an eye examination. It is more effective when administered in advance, and there is a small risk of eye injury if the infant is stimulated during the procedure.
    When administering oral sucrose:

    • Administer dose prior to the commencement of the procedure
    • Do not delay or disrupt the procedure to administer further doses after the commencement of the procedure
    • Do not administer if the infant is asleep (some infants remain asleep during the examination)

    Nursing care during and post procedure

    • Administer the first dose of Phenylephrine 2.5% and Cyclopentolate 0.25% (1 drop in each eye) one hour prior to the examination. The dose is repeated 10 minutes after the initial dose and again 1 hour later. Infants with dark coloured eyes may require an extra dose
    • Ensure that the instruments for the eye examination are available (sterile eye retractor and vectis) - the ophthalmologist will bring these; on Butterfly Ward the instruments may also be found in the Consumables  store room
    • Ensure required dilating eye drops have been administered at the appropriate time
    • Wrap infant securely in a blanket (with arms at sides) and administer oxygen as required
    • Administer oral sucrose prior to the examination, not during the examination (for more information about sucrose administration, refer to Oral Sucrose information above)
    • Position the infant to allow adequate viewing of the retina by the ophthalmologist
    • The infant needs to be held securely to minimise head movement and prevent any eye injury occurring during the examination
    • Use a dummy if infant is more settled with it
    • Assess the infant’s vital signs throughout the procedure; ask the ophthalmologist to cease the examination if the infant is unstable
    • Settle infant appropriately after the examination

    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. 

    Special considerations

    Following eye examinations, send used retractors and vectis to CSSD for cleaning and sterilising.


    Evidence table

    Please remember to read the disclaimer.

    The development of this nursing guideline was coordinated by Chris Lim, RN, Butterfly Ward, and approved by the Nursing Clinical Effectiveness Committee. Updated June 2017.