|Year : 2013 | Volume
| Issue : 2 | Page : 98-100
Comparison of conventional adult-single-lid-retraction-by-thumb-method with two-thumb and two-bud methods in eye drop instillation prior to retinopathy of prematurity screening in neonates and infants
Bali Jatinder1, Ashish Jain2, Bali Renu Thakur3
1 Department of Ophthalmology, Hindu Rao Hospital, New Delhi, India
2 Department of Pediatrics, Hindu Rao Hospital, New Delhi, India
3 Department of Medicine, Jag Pravesh Chandra Hospital, New Delhi, India
|Date of Submission||19-Nov-2012|
|Date of Acceptance||11-Feb-2013|
|Date of Web Publication||20-May-2013|
55-D, Third Floor, DDA Flats, Kalidas Road, Gulabibagh, New Delhi - 110 007
Source of Support: None, Conflict of Interest: None
In our retinopathy of prematurity (ROP) screening program we found that babies tended to show poor, erratic and variable response to mydriatic drug instilled prior to ROP screening. We compared the adult Single-lid Retraction by Thumb Method (SRTM) with two-thumb-retraction-method (TTM) and the two-bud-instillation-method (TBM). Thirty instillations each for the three methods were studied using computerized randomization. Neonates with plus disease, Iris neovascularization and threshold ROP were excluded from study. Instillations were carried out by nurses and residents, who rated the ease of administration on a 5 point Likert Scale administered as a visual analog scale (5 = fully satisfied and 1 = fully dissatisfied). The instillation was rated as successful if the drop was instilled in the cul de sac and unsuccessful if delivered outside it in the first attempt. Second attempts and change of technique were considered unsuccessful. The percentage of successful instillations in the first attempt was 36.7% in SRTM, 70.0% in TTM and 83.3% in TBM (χ2 = 14.928, P = 0.001; Chi-square test). The mean ranks for the ease of administration were 43.02, 57.00, and 36.48 for the SRTM, TTM, and TBM methods respectively (H(2) =10.367, P = 0.006; Kruskal-Wallis test). SRTM failed in most cases on first attempt (67.3%). TBM was significantly more difficult than TTM or the SRTM. SRTM should not be recommended for infants and neonates in pediatric ophthalmology practices and ROP screenings in nurseries. However, larger studies are required to validate the findings of present study.
Keywords: Mydriasis, retinopathy of prematurity, screening
|How to cite this article:|
Jatinder B, Jain A, Thakur BR. Comparison of conventional adult-single-lid-retraction-by-thumb-method with two-thumb and two-bud methods in eye drop instillation prior to retinopathy of prematurity screening in neonates and infants. J Clin Ophthalmol Res 2013;1:98-100
|How to cite this URL:|
Jatinder B, Jain A, Thakur BR. Comparison of conventional adult-single-lid-retraction-by-thumb-method with two-thumb and two-bud methods in eye drop instillation prior to retinopathy of prematurity screening in neonates and infants. J Clin Ophthalmol Res [serial online] 2013 [cited 2020 May 30];1:98-100. Available from: http://www.jcor.in/text.asp?2013/1/2/98/112191
Pupillary dilatation is essential for screening for retinopathy of prematurity (ROP). , Different regimens for pupillary mydriasis have been described. ,,
We reviewed the literature and found that no method for eye drop instillation has been recommended for use in infants and neonates. The difficulty and predictability of instillation has been documented by different authors. 
To the best of our knowledge no study has been reported for methods of instillation in infants and neonates.
The standard method used for instillation of eye drops in adults involves the retraction of the lower eyelid with a thumb with the patient looking upwards. The eye drops is instilled in the inferior cul de sac. ,, Since this method fails frequently in children it was found that upper eyelid retraction was practiced by many instillers. In the ophthalmic operation theatres it is a common practice to use sterile buds for eyelid retraction at the time of draping of eyes prior to surgery. We studied the three methods: SRTM; both lid retraction by thumbs or two-thumb-method (TTM); and both lid retraction by ear-buds or two-buds-method (TBM).
| Material and Methods|| |
Thirty eyes (right eye) of 30 patients for each method of instillation were studied. The patients were randomized to each arm using computerized randomization. Neonates with plus disease, Iris neovascularization and threshold ROP were excluded from the study.
Instillations were carried out by nurses and residents, who rated the ease of administration on a 5 point Likert Scale administered as a visual analog scale (5 = fully satisfied, 1 = fully dissatisfied). The operator was trained in the use of the scale by conducting dry runs on hand washing practices.
The instillation was rated as successful if the drop was instilled in the cul de sac and unsuccessful if delivered outside it in the first attempt using standard vial containing desired dilution of the drug shaken before use. Three instillations of 0.5% tropicamide were followed by single drop of 2.5% phenylephrine at 15 min intervals as per the nursery policy. Second attempts and change of technique were considered unsuccessful. After the first attempt the instiller was free to use the technique of his choice for the remaining drop instillations. A total of four instillations took place per eye. The instillers rated all four attempts on the analog scale. Only the first instillation data was considered for the study. The instillers were blinded regarding which attempts were being observed for consideration in the study and they rated some blank patients also.
| Results|| |
The percentage of successful instillations in the first attempt was 36.7% (n = 11) in SRTM, 70.0% (n = 21) in TTM and 83.3% (n = 25)in TBM. It is depicted in [Table 1] and [Figure 1]. The difference was statistically significant (χ2 = 14.928, P = 0.001; Chi-square test). The single lid retraction by thumb method was found to fail in 63.3% cases.
|Figure 1: Ease of instillation by success of different methods: Satisfi cing|
Click here to view
The distribution of ease of administration is shown in [Table 2]. The 5 point Likert Scale was used and the distribution of responses is depicted. One indicated difficult instillation while five indicated that the administration of drops was extremely comfortable for the instiller.
The ranks for the ease of administration were significantly different for SRTM, TTM, and TBM methods with mean ranks of 43.02, 57.00 and 36.48 respectively (H(2) =10.367, P = 0.006; Kruskal-Wallis test). The higher the rank in the Kruskal-Wallis test, the easier was the administration as the higher end of the scale represented easier administration.
| Discussion|| |
It is not uncommon to find a variable, erratic, and unpredictable response to eye drops used for pupillary dilatation. The difficulty encountered in making the children submit to eye drops is a difficult one. Smith et al. described a method of instillation of eye drops at the medial canthus followed by opening of the eyelids. They reported the rate of drug penetration into the eye of 66% (confidence intervals 28-104%) of that obtained by conventional instillation, into the conjunctival sac.  Various authors have recommended lower doses of mydriatic drugs than used in adults and a number of innovations have been described in literature. Phamonvaechavan et al. compared the effectiveness and safety of two instillation methods of combined 0.75% tropicamide and 2.5% phenylephrine at 0, 5 min (min) with the same combined regimen at 0, 30 min in 42 preterm infants in a cross-over, randomized controlled trial and found both to be efficacious. However, the latter regimen gave slight longer mydriatic effect thus, giving more time for evaluation of peripheral fundus to the ophthalmologists.  Vicente et al. compared the mydriatic efficacy of cyclopentolate 0.2% and phenylephrine 1% ophthalmic solution in dose of either: 0, 1, or 2 drops for retinal examination of 64 premature infant eye examinations. They reported that effective mydriasis achieved with 1 or 2 drops was sustained up to 120 min. Retinal examinations could be completed by 90 min in most infants with the use of 1 drop.  However, Punyawattanaporn et al. in their study comparing the pupillary response to a single drop and 3 drops of a combination of eye drops (0.2% cyclopentolate and 1.0% phenylephrine) in 70 pre-term infants reported that pupil size of preterm infants was significantly larger after 3 drops of the eye drop mixture (0.2% cyclopentolate and 1.0% phenylephrine) than after a single drop. 
The nursery policy at our center was to instill 0.5% tropicamide 3 times at 15 min intervals followed by 2.5% phenylephrine once. The total dose of the drug delivered equals the dose delivered by Phamonvaechavan et al.  The standard method used for instillation of eye drops in adults involves the retraction of the lower eyelid with a thumb with the patient looking upwards. The eye drops is instilled in the inferior cul de sac. ,,,7] In children, this method fails frequently and it was found that upper eyelid retraction was practiced by many instillers. No evidence based recommendation was available for the preferred method of instillation in organized literature.
Sterile ear-buds are commonly used in the ophthalmic operation theatres retraction of eyelids at the time of draping prior to surgery. Such sterile ear-buds are used for tamponading in intravitreal injections and cleaning in post-operative period also.
Thanathanee et al. have described a method of lower conjunctival fornix packing using one small piece of the cotton wool soaked with one drop of 2.5% phenylephrine and 1 drop of 1% tropicamide in the lower conjunctival fornix for 15 min. They compared the mydriatic effect of lower conjunctival fornix packing to conventional instillation of eye drops containing 2.5% phenylephrine and 1% alternately instilled every 5 min for two doses each. Dilated pupil diameter after receiving the lower conjunctival fornix packing was larger (5.76 ± 1.01 mm) than conventional instillation (4.50 ± 1.08 mm) (P < 0.05). 
No study is available that evaluates the various methods used in clinical practice by the instillers. This is the first study that describes the efficacy of the different methods available to us. The SRTM failed more frequently (63.3% [n = 19]) than it succeeded; it was successful in only 36.7% (n = 11) in the first attempt. TTM successfully delivered the drop in 70.0% (n = 21) and TBM in 83.3% (n = 25) of the cases in the first attempt. The difference was statistically significant (χ2 = 14.928, P = 0.001; Chi-square test). It has been observed that in neonates some amount of the drop spills out of the cul de sac and wets the eyelid skin making it difficult to retract them for the subsequent instillations. It is better to completely dry the skin or use a cotton/gauze to retract the eyelids. The skin is fragile and needs to be patted dry. Without wiping hard no amount of patting makes the lid dry enough for retraction without absorbing cotton pad. This could partly explain better efficacy of the TBM.
In case of failure, the technique was changed if required by the instiller as the adequacy of the examination for ROP would have been compromised if a single method would have been stuck to. On ethical grounds the study did not persist with a single technique or measure the pupil dilatation from one technique alone. After the failure of instillation, any one combination of techniques was permitted to be used to ensure that the examination was not compromised. The SRT method was rated to be the second most difficult (Rank = 43.02) by the instillers behind the TBM (Rank = 36.48). TTM (Rank = 57.00) was ranked as the easiest by the operators. This difference was statistically significant (H(2) =10.367, P = 0.006; Kruskal-Wallis test).
In view of the extremely low success rate of the SRTM, it is recommended that the method should not be adopted for use in the infants and neonates. The two handed and two budded methods gave better results and should logically be preferred over the former. The two budded method requires dexterity and skill which can be acquired by repeated use and training only. It was rated as the most difficult method to follow.
The study suffers from the inherent defect of a small sample size. Studies with larger sample sizes would be required to validate the findings of the present study.
Another source of bias would be the training and motivation levels of the personnel involved. This study was carried out in the neonatal intensive care unit operators. Similar levels of training and motivation may not be replicated in other settings. This may limit the generalizability of the findings.
| Conclusions|| |
The study proved that the conventional SRTM cannot be reliably used in infants and neonates. The ease of administration was maximum with TTM followed by SRTM and TBM. However, this could change with prolonged training.
The study is limited by the small sample size. Larger studies with multi-centric design would be required to ensure the validity and repeatability of the findings of the present study.
A strong case for use of two handed methods exists. The single thumb technique must not be advocated for use in infants and neonates.
| References|| |
|1.||Punyawattanaporn A, Tengtrisorn S, Sangsupawanich P. Pupil dilatation after single and triple doses of mydriatic agent in preterm infants. J Med Assoc Thai 2009;92:1458-62. |
|2.||Phamonvaechavan P, Chutasmit K, Damrongrak P, Koukiatkul S, Wongkiatkajorn T, Ngerncham S. Comparison of the effectiveness of mydriasis by two instillation methods of combined 0.75% tropicamide and 2.5% phenylephrine eye drop in preterm infants. J Med Assoc Thai 2012;95:S1-7. |
|3.||Vicente GV, Bahri M, Palafoutas JJ, Wang H, Mehta N. A randomized controlled trial to determine the lowest effective dose for adequate mydriasis in premature infants. J AAPOS 2012;16:365-9. |
|4.||Smith SE. Eyedrop instillation for reluctant children. Br J Ophthalmol 1991;75:480-1. |
|5.||Wirral.nhs.uk [Internet]. London: Primary Care Management Board; 2007. Nursing Policy File No. 16. Available from: http://www.wirral.nhs.uk/document_uploads/Policies_Nursing/NP16ProcedureInstillationEyeDropsOintAug07_d1c75.pdf [Updated 2007 Jul; Last cited on 2012 Oct 29 Oct]. |
|6.||Marsden J, Shaw M. Correct administration of topical eye treatment. Nurs Stand 2003;17:42-4. |
|7.||Fraunfelder FT. Extraocular fluid dynamics: how best to apply topical ocular medication. Trans Am Ophthalmol Socnone 1976;74:457-87. |
|8.||Thanathanee O, Ratanapakorn T, Morley MG, Yospaiboon Y. Lower conjunctival fornix packing for mydriasis in premature infants: A randomized trial. Clin Ophthalmol 2012;6:253-6. |
[Table 1], [Table 2]