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Original Investigation
April 1, 2021

Preterm Infant Stress During Handheld Optical Coherence Tomography vs Binocular Indirect Ophthalmoscopy Examination for Retinopathy of Prematurity

Author Affiliations
  • 1Department of Ophthalmology, Duke University School of Medicine, Durham, North Carolina
  • 2Department of Ophthalmology, University of Pennsylvania, Philadelphia
  • 3Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
  • 4Department of Biomedical Engineering, Pratt School of Engineering, Duke University, Durham, North Carolina
JAMA Ophthalmol. Published online April 1, 2021. doi:10.1001/jamaophthalmol.2021.0377
Key Points

Question  Is infant stress from optical coherence tomography (OCT) imaging different from that of clinical binocular indirect ophthalmoscopy (BIO) examinations for retinopathy of prematurity?

Findings  In this cross-sectional study of 71 eye examinations of 16 infants, several indicators of behavioral stress (crying and facial expression) and physiologic stress (heart rate) were less during OCT imaging than BIO, even though the time for OCT imaging was longer.

Meaning  While the clinical relevance of adding or substituting OCT imaging of retinopathy of prematurity is yet to be determined, OCT imaging may be less stressful to the infant compared with BIO by a trained ophthalmologist.


Importance  Binocular indirect ophthalmoscopy (BIO) examination for retinopathy of prematurity (ROP) is a well-known cause of repeated preterm infant stress.

Objective  To compare stress during investigational optical coherence tomography (OCT) imaging to that during BIO for ROP.

Design, Setting, and Participants  This cross-sectional study examined infants at the bedside in the intensive care nursery. Consecutive preterm infants enrolled in Study of Eye Imaging in Preterm Infants (BabySTEPS) who had any research OCT imaging as part of the study. Patients were recruited from June to November 2019, and analysis began April 2020.

Main Outcomes and Measures  Infant stress was measured using modified components of a neonatal pain assessment tool before (baseline) and during OCT imaging and BIO examination of each eye.

Results  For 71 eye examinations of 16 infants (mean [SD] gestational age, 27 [3] weeks; birth weight, 869 [277] g), change from baseline to each eye examination was lower during OCT imaging than during BIO and the difference between OCT imaging and BIO at each eye examination was significant for the following: infant cry score (first eye examination: mean [SD], 0.03 [0.3] vs 1.68 [1.2]; −1.65 [95% CI, −1.91 to −1.39]; second eye examination: mean [SD], 0.1 [0.3] vs 1.97 [1.2]; −1.87 [95% CI, −2.19 to −1.54]), facial expression (first eye: 3 [4%] vs 59 [83%]; −79% [95% CI, −87% to −72%]; second eye: 4 [6%] vs 61 [88%]; −83% [95% CI, −89% to −76%]), and heart rate (first eye: mean [SD], −7 [16] vs 13 [18]; −20 [95% CI, −26 to −14]); second eye: mean [SD], −3 [18] vs 20 [20] beats per minute; −23 [95% CI, −29 to −18]) (P < .001 for all). Change in respiratory rate and oxygen saturation did not differ between OCT imaging and BIO.

Conclusions and Relevance  While the role of OCT alone or in combination with BIO is currently unknown for ROP, these findings suggest that investigational OCT imaging of ROP is less stressful than BIO examination by a trained ophthalmologist.

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