How to Perform an Infant Contact Lens Fitting Exam Under Anesthesia (EUA) N h S if OD D Noha Seif, OD; Derek Louie, MSc, OD, FAAO; Winston Chamberlain, MD, PhD; Beth Edmunds, MD, PhD k L i MS OD FAAO Wi t Ch b l i MD PhD B th Ed d MD PhD Casey Eye Institute, Oregon Health & Science University, Portland, Oregon, USA P URPOSE C ONCLUSIONS To demonstrate the process and considerations needed to fit contact lenses before, during, and after an exam under anesthesia (EUA) on an infant. I NTRODUCTION When eye examinations for infants prove impossible to perform in the clinic, but with a need to determine refractive and ocular health status, an EUA is warranted to provide accurate data for clinical decision making, diagnosis, and prognosis. This procedure allows multiple physicians to examine the infant and proceed with a clearer plan of action. It is recommended that putting an infant under general anesthesia should only be done when absolutely necessary, considering the risk of anesthesia related deaths are higher in infants than adults (1 in 250,000) due to obstructed breathing. Thus, when and EUA is performed, collecting all necessary data to design and order an initial contact lens for the patient is crucial.  Before performing a contact lens fit while an infant is under anesthesia, collaboration with multiple doctors is required to make the exam most effective.  The goal during this exam is to collect all necessary data to order an initial lens for the patient. Being prepared before scheduling the exam allows for the most useful information to be obtained during the time in the OR and decrease the time the infant is under general anesthesia. Discussions with parents immediately after the EUA with the new data and new treatment course makes this exam a very dynamic process that requires careful consideration and collaboration.   The infant contact lens wearer requires more dedication, training, The infant contact lens wearer requires more dedication, training, and higher level of service, but is a very rewarding, ongoing experience. Sample contact lens diagnostic fitting set M ETHODS AND M ATERIALS    P RE ‐EUA   Collaboration with the cataract surgeon, cornea surgeon, pediatric ophthalmologist, anesthesiologist, and the glaucoma surgeon , or other providers in the operating room (OR) so that each can perform their portion of the exam at the appropriate stage of the perform their portion of the exam at the appropriate stage of the procedure. It is crucial to prepare an as inclusive as possible diagnostic kit as many of these tools are not standard in operating rooms: Contact lens fitting sets Retinoscope and loose lenses Fluorescein strips and Wratton filter Keratometer (optional) DMV plunger(s) DMV plunger(s) Burton lamp or magnifier with light Contact lens solution, cases, and cleaners  Instructions to the parents should be given regarding what to expect. This includes what foods/drinks are appropriate or if the child should fast and how long they should expect to spend in the hospital (see photo above).    Fitting philosophy of contact lenses remains the same as adults! An initial diagnostic lens often times is based on the expected age value. value The average corneal curvature at birth is between 48.50D and 47.00D. The average corneal diameter is approximately 10 mm at birth. Keep in mind there will be rapid growth during the first 1.5 years of life, so expect to have decreasing hyperopia and multiple lens changes in the near future. Fit the lens slightly on the steeper side. If you have K readings, 1‐ 2D steeper than the flat K is a good start. Also, fit the lens 2‐3mm l larger than the HVID for both soft or GP lenses. th th HVID f b th ft GP l The working distance for retinoscopy should be nearly half the average working distance (around 33cm). General anesthesia reduces intraocular pressure, so corneal curvature and refraction may be different than when they are awake. Gas Permeable (GP) vs. Soft Lenses    GP lenses are easier to insert, remove, come in unlimited parameters, provide better quality of vision at higher powers, and p p q y g p have much higher oxygen permeability. Menicon Z material is approved for 30 days of extended wear in adults. Soft lenses for aphakia are immediately comfortable, easy to prescribe, and parents may be more familiar with soft modalities. Silsoft is approved for 30 days extended wear for aphakia. However, careful monitoring for corneal hypoxia and neovascularization is essential. P OST ‐EUA      Once a plan has been determined between you and the other team of physicians, assure the parents what the next course of action is. The infant will be taken to a recovery room to monitor vital signs and be offered fluids. There should be no pain, but disorientation, fatigue, and nausea from the anesthesia is possible. No activities are generally restricted, but since the infant may be tired, adult supervision is highly recommended for the rest of the day day. Arrange for an in office visit to teach the parents how to apply, remove, and care for the lens(es) you have prescribed. Instruction sheets and videos are priceless! R EFERENCES 1. Saltarelli DP. Hyper oxygen‐permeable rigid contact lenses as an alternative for the treatment of pediatric aphakia. Eye Contact Lens. 2008 Mar;34(2):84‐93. 2. Lindsay RG, Chi JT. Contact lens management of infantile aphakia. Clinical and Experimental Optometry. 2010; 93: 3‐14. 3. Morray JP, Geiduschek JM, Caplan RA, Posner KL, Gild WM, Cheney FW. A comparison of pediatric and adult anesthesia closed malpractice claims. Anesthesiology 1993; 78: 461–467. 4. "Health 4. Health Topics. Topics " Eye Exam Under Anesthesia. Cincinnati Children Eye Exam Under Anesthesia Cincinnati Children'ss Hospital. Oct. 2012. Web. 5 Dec. 2013 5. Mountford J. Prescribing for Pediatric Aphakia. Basuch & Lomb Boston Update. 2010; 23: 4‐5. A CKNOWLEDGEMENTS The authors have no financial interest in any of the products or companies cited in this study. Thanks to the CEI photography service for help preparing the images used in this poster. Casey Eye Institute is for help preparing the images used in this poster. Casey Eye Institute is supported by an unrestricted grant from Research to Prevent Blindness. Eyelid speculums placed during an EUA on a two month old infant with Peter’s anomaly