Several attempts to evaluate the eyes of the newborn may be necessary. Eyelid edema related to the birth process, medications, or infection makes this part of the examination difficult.
Inspect the eyes for symmetry. The eyes should be the same size and should be at the same depth in the orbits. Bulging eyes may be a sign of congenital glaucoma. Microcornea may result from congenital rubella.
Assess whether the eyes are normal distance from one another. If there is a concern about the eyes being too close together (hypotelorism) or too far apart (hypertelorism), careful measurements should be taken. These include inner canthal distance (distance between the inner canthi), outer canthal distance (distance between the outer canthi), and interpupil distance (distance between the pupils). Each of these measurements should be plotted on an appropriate growth curve. Such growth curves can be found in reference texts, such as Smith's Recognizable Patterns of Human Malformations (Jones, 2005). Hypotelorism (all measurements less than the fifth percentile) may be associated with midline defects of the brain, such as alobar holopro-sencephaly; hypertelorism can be part of a number of multiple malformation syndromes, such as cleidocranial dysplasia and Aarskog's syndrome.
*As noted earlier, forceps are now rarely used in the United States.
Inspect the eyelids for evidence of trauma. Use a soft cloth gently to remove the vernix caseosa and any conjunctival exudate. Newborns rarely have eyebrows, but long eyelashes are frequently present. Medial epicanthal folds, flaps of skin covering the inner canthus of the eye, are seen frequently in individuals with midface hypoplasia. This condition occurs in a number of disorders, including trisomy 21 and fetal alcohol syndrome, but may be seen in normal individuals as well.
The best method of evaluating the eyes of a newborn is to hold the infant upright at arm's length while slowly rotating him or her in one direction. The infant's eyes usually open spontaneously.
Inspect the sclerae. In newborns, the sclerae may be icteric as a result of physiologic jaundice (described earlier). When icterus is absent, the sclerae of a young infant may appear bluish. During the first 6 months, the connective tissue of the sclera becomes thicker, leading to the normal white color expected in an adult. Persistence of blue color of the sclera after 6 months of age is suggestive of the presence of a connective tissue disorder, such as osteogenesis imperfecta or Ehlers-Danlos syndrome (see Fig. 10-48).
Inspect the cornea. The cornea should be clear. Cloudiness or a corneal diameter that is greater than 0.4 inch (1 cm) may be indicative of congenital glaucoma.
Inspect the iris. The iris of a newborn may be pale because full pigmentation does not occur before 10 to 12 months of life. Is an abnormal ventral cleft present in the iris? This cleft, known as a coloboma, is associated with defects in the iris and retina (see Figs. 10-62 and 10-140). A coloboma is commonly associated with chromosomal abnormalities such as trisomy 13 or 18 and the syndrome of coloboma, heart disease, atresia choanae, retardation of growth or development, genitourinary tract anomalies, and ear anomalies (CHARGE). In rare cases, the irides are absent; this condition is associated with the susceptibility to development of Wilms' tumor. Is there a ring of whitish dots at the periphery of the iris? These dots are best seen in a slit-lamp examination by an ophthalmologist, but the ring is sometimes visible to the naked eye. These dots, called Brushfield's spots, may be associated with trisomy 21 or may be normal.
Inspect the conjunctivae. Small subconjunctival hemorrhages are common, a result of the forces involved in the birth process. They heal without any effect on the child's vision. As a result of the erythromycin drops* instilled at birth, there may be some inflammation of the conjunctivae, as well as edema of the eyelids.
The pupils of neonates are usually constricted until about the third week after birth. Pupillary reflexes are present but hard to interpret in this age group.
Rotate the infant slowly to one side. The eyes should turn in the direction to which he or she is being turned. At the end of the motion, the eyes should quickly look back in the opposite direction after a few quick, nonsustained nystagmoid movements. This is termed the rotational response, and its presence establishes that the motor control of the eyes is intact.
To test for visual acuity in the newborn, the examiner must rely on indirect methods such as the response to a bright light, known as the optical blink reflex. This reflex is normally observed when a bright light is shined on each eye: the newborn blinks and dorsiflexes the head. The visual acuity of newborns has been estimated to be approximately 20/100 to 20/150, according to their ability to fixate on and imitate the adult face.
In all newborns, the presence of the red reflex bilaterally suggests grossly normal eyes and the absence of glaucoma, cataract, or intraocular disorders. Determine the presence of the red reflex by holding the ophthalmoscope 10 to 12 inches (25 to 30.5 cm) away from the infant's eyes. The presence of the red reflex indicates that there is no serious obstruction to light between the cornea and the retina. If a red reflex is absent, funduscopic examination is required at this time. A funduscopic examination by an ophthalmologist is also indicated if you suspect any of the intrauterine infections associated with chorioretinitis, such as toxoplas-mosis, congenital rubella, or cytomegalovirus infection.
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