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CLINICAL
SCIENCE
Comparison of the effectiveness
of a nondilated versus dilated fundus
examination in the pediatric population
Maria L. Parisi, O.D.a
Mitchell Scheiman, O.D.a
Rachel S. Coulter, O.D.a
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B
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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 fundu s 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.
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 colleagues 5 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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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.
SCIENCE
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
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
required action
Posterior pole anonlalies detected
were asymptomatic.
total
nu.nber
Silverman 16 described two cases of
asymptomatic patients age 18 and 55
years who received
routine pupillary
dilation and were
found to have a
situs inversus
small rhegmatogechoroidal and scleral crescents
nous detachment
prepapillary vessel loop
and a choroidal
macular drusen
melanoma, respecmacular pigment dot
tively. Likewise,
....... ........... ... ............. .. ...
isol~ted posterior pole drusen
selective dilation of
only symptomatic
optic nerve glial remnants
pediatric patients
· t9rtuou~ . blood vessElI~ assOCiated
with prematurity
has been the subject of legal opinbear track
ion, most notably in
the case of Keir v
United States. 1,17
This case suggests
that optometrists *multiple occurrences of an anomaly in the same patient were counted once
will be judged
according to a medical standard of care and that optometrists
number of peripheral anomalies found with
the dilated examination that were missed with
should routinely screen for peripheral disease
regardless of previous normal fundus examia nondilated examination.
nations, family history, associated systemic or
ocular disease, or presenting signs and symptoms. I7
of
Table 1
Methods
Sllbjects
To investigate these issues in a pediatric population, a study was undertaken to determine
the effectiveness of a nondilated retinal examJOURNAL
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The population consisted of 90 pediatric
patients aged 5 to 16 years (mean age 9.2
years). Subjects were selected randomly from
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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
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
SCIENCE
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 examina269
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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 administration of the eye
drops, and experienced the symptoms
immediately following
instillation. An emo6
tional component may
2
have been causal or
15
contributory to the
4
symptoms. No other
ocular or systemic
4
adverse reactions were
3
reported.
Peripheral anomalies detected
...~~~~.~~. ~~~.~.~~~ ............ ... ,.. ..d..I,d..~.. '.Ii&RI~;
...~~.~~.~~,I.~~.I.. r.~~.i .~~~.. ~!~~~~~ ~~~_~~~!~.I.. ~~~~~~....... ..
isolated white without pressure
..
retinal pigment epithelial dropout
asymptomatic vitreous floaters.
isolated peripheral drusen
...~~~~~..~~.Y~.~~~~~~~.. ~~~~!~.................,."..~ ......,.............. ..
operculated asymptomatic holes
2
2
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
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.
atrophic hole within lattice degeneration
Time constraints may
be a clinical considervenous sheathing
ation, especially in a
.. I?c:lrspl .allitisvv/PLJffballsCillcls.Il()\I\I~ank.ill~ ..
pediatric population,
because of poor coop*Multiple occurrences of an anomaly in the same patient were counted
eration. The pediatric
dilated fundus examination may at times
require alteration of drug instillation proceSome clinicians argue that the adverse side
dures. In uncooperative pediatric patients it
effects of mydriatic or cycloplegic drug use may
may be helpful to use a spray technique. 25 It
outweigh the advantages of administrating these
can be very time-consuming to perform
agents to children on a routine basis. In this
binocular indirect ophthalmoscopy when the
study, however, only one patient reported a tranchild is resistant to looking in the directions
sient adverse reaction. A healthy 7- year-old
white female experienced transient nausea folof gaze required to view the retinal periphery.
w(p~?i.~ional risk .f actors for rd
.. .... .. .......
Table 2
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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 difficulty 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.
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.
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 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 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
SCIENCE
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
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2. Whitmer L To see or not to see routine pupillary dilation. J Am Optom
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3. Cole RM III. Make dilation part of your routine. Rev Optom 1992;
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19. Harley RD. Pediatric ophthalmology, 2nd ed. Philadelphia WB. Saunders Co ,1983 527-833
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Philadelphia WB . Sa unders CO,1991 306-8.
23. Tasman W Retinal diseases in children . New York Harper &
Row,1971: 30,110-2,116,121·5,213-4
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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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