Anatomic and visual outcomes of corneal transplantation during infancy

PURPOSE

To determine the effect of age at penetrating keratoplasty (PKP) on graft survival and visual outcome in children with corneal opacities transplanted during infancy.

METHODS

In this two-center retrospective consecutive cohort study, the medical records of infants who underwent unilateral or bilateral PKP during the first year of life between 2004 and 2011 were reviewed retrospectively. PKP was categorized as early (age 0-90 days) or late (age 91-365 days). Main outcome measures were graft survival and vision (classified as poor, fair, or good, considering both testing method and age norms).

RESULTS

A total of 62 eyes of 52 infants were included: 19 eyes underwent early PKP; 43 eyes, late PKP. Of the 62 eyes, 61 had central congenital corneal opacities; 1 was acquired. Median follow-up was 38.1 months (range, 12.2-150.5 months). Kaplan-Meier graft survival estimates were 0.92 at 1 year (95% CI, 0.81-0.96) and 0.61 at 5 years (0.44-0.74). Graft survival (early PKP, 73.7%; late PKP, 65.1% [P = 0.57]) did not differ between groups. Of the 55 eyes with recorded visual acuities, no significant difference existed in proportion with ambulatory or better vision at latest follow-up between early and late PKP (42.1% vs 55.6%; P = 0.61).

CONCLUSIONS

Visual outcomes were better for PKP performed during infancy compared to results of prior reports of late PKP; however, clearing of congenital opacities in the first 3 months of life did not improve visual outcomes compared to later PKP. One-half of grafts survived >5 years. Early PKP did not worsen graft survival, but PKP may be technically easier to perform later in infancy.

Improved adherence and treatment outcomes with an engaging, personalized digital therapeutic in amblyopia

Given the prevalence of poor adherence to therapy and the biases of self-reporting across healthcare, we hypothesized that an engaging, personalized therapy may improve adherence and treatment outcomes in the home. We tested this hypothesis in the initial indication of amblyopia, a neurodevelopmental disorder for which available treatments are limited by low adherence. We designed a novel digital therapeutic that modifies patient-selected cinematic content in real-time into therapeutic visual input, while objectively monitoring adherence. The therapeutic design integrated a custom-designed headset that delivers precise visual input to each eye, computational algorithms that apply real-time therapeutic modifications to source content, a cloud-based content management system that enables treatment in the home, and a broad library of licensed content. In a proof-of-concept human study on the therapeutic, we found that amblyopic eye vision improved significantly after 12 weeks of treatment, with higher adherence than that of available treatments. These initial results support the utility of personalized therapy in amblyopia and may have broader relevance for improving treatment outcomes in additional indications.

Imaging Methods for Differentiating Pediatric Papilledema from Pseudopapilledema: A Report by the American Academy of Ophthalmology

PURPOSE

To review the published literature on the accuracy of ophthalmic imaging methods to differentiate between papilledema and pseudopapilledema in children.

METHODS

Literature searches were conducted in January 2020 in the PubMed database for English-language studies with no date restrictions and in the Cochrane Library database without any restrictions. The combined searches yielded 354 abstracts, of which 17 were reviewed in full text. Six of these were considered appropriate for inclusion in this assessment and were assigned a level of evidence rating by the panel methodologist. All 6 included studies were rated as level III evidence.

RESULTS

Fluorescein angiography, a combination of 2 OCT protocols, and multicolor confocal scanning laser ophthalmoscopy (Spectralis SD-OCT; Heidelberg Engineering, Heidelberg, Germany) demonstrated the highest positive percent agreement (92%-100%; 95% confidence interval [CI], 69%-100%) and negative percent agreement (92%-100%; 95% CI, 70%-100%) with a clinical diagnosis of papilledema in children. However, results must be interpreted with caution owing to methodologic limitations, including a small sample size leading to wide CIs and an overall lack of data (there was only 1 study each for the above methods and protocols). Ultrasonographic measures showed either a high positive percent agreement (up to 95%) with low negative percent agreement (as low as 58%) or vice versa. Autofluorescence and fundus photography showed a lower positive (40%-60%) and negative (57%) percent agreement.

CONCLUSIONS

Although several imaging methods demonstrated high positive and negative percent agreement with clinical diagnosis, no ophthalmic imaging method conclusively differentiated papilledema from pseudopapilledema in children because of the lack of high-quality evidence. Clinicians must continue to conduct thorough history-taking and examination and make judicious use of ancillary testing to determine which children warrant further workup for papilledema.

Refractive change in children with accommodative esotropia

OBJECTIVE

To determine whether there is a measurable change in hyperopia in children with accommodative esotropia over time.

METHODS AND ANALYSIS

A retrospective cohort of children with fully or partially accommodative esotropia diagnosed by age 7 years, followed to age 10 or older, and with at least two cycloplegic refractions, one before age 7 years and one after age 10 years. The annual change was calculated from linear mixed-effect models, overall and during two age periods with subgroup analysis by baseline refractive error (<4D, ≥4D) and type (partial, full) of accommodative esotropia.

RESULTS

405 subjects were studied. Mean age at first and last visit was 3.2 and 12.1 years, respectively, with mean 7.6 cycloplegic refractions. The annual change (95% CI) in refractive error was -0.071 (-0.087 to -0.055) D/yr. Between ages 3 and 7, hyperopia among children with baseline hyperopia <4D increased by 0.12 (0.08 to 0.16) D/yr, while hyperopia among those with baseline 4D or greater was stable (0.0D/yr, -0.03 to 0.04) (p<0.001). Hyperopia decreased from age 7 to 15 years in both subgroups: <4D subgroup -0.17 (-0.20 to -0.14) D/yr, ≥4D subgroup -0.18 (-0.21 to -0.15) D/yr (p=0.58). There was no significant difference in refractive change between fully (n=274) and partially (n=131) accommodative esotropia (p≥0.10).

CONCLUSION

Hyperopia in children with accommodative esotropia is stable or increases up to age 7 years, depending on baseline hyperopia, but decreases gradually between ages 7 and 15 years regardless of baseline refractive error.

Treatment of non-type 1 retinopathy of prematurity in the Postnatal Growth and Retinopathy of Prematurity (G-ROP) study

PURPOSE

To determine the prevalence and characteristics of eyes treated for retinopathy of prematurity (ROP) not meeting currently recommended early treatment (type 1) criteria.

METHODS

This was a secondary analysis of data from the Postnatal Growth and ROP (G-ROP) study, a retrospective cohort study of 7,483 infants undergoing ROP examinations and treatment at 29 North American hospitals between January 2006 and June 2012. Medical records were reviewed to determine the prevalence and characteristics of eyes treated for ROP less severe than type 1 ROP.

RESULTS

Of 1,004 eyes that received ROP treatment, 126 eyes of 91 infants (0.8% of all eyes; 12.5% of treated eyes) underwent treatment for ROP less severe than type 1. Mean age at treatment was 38 weeks' post-menstrual age (range, 32-49 weeks). Reasons for treatment included type 1 ROP in the fellow eye (43%), stage 3 ROP with pre-plus in the treated eye (30%), concerning structural changes in the retina (7%), persistent stage 3 ROP for ≥6 weeks without regression (6%), stage 3 ROP with no plus disease in the treated eye (5%), stage 3, zone III ROP with plus disease (3%), logistical considerations (3%), or stage 2 disease in the treated eye (2%).

CONCLUSIONS

Of all eyes treated for ROP, 1/8 were treated for disease less severe than currently recommended type 1 criteria. Clinician judgment of risk for permanent vision impairment superseded recommended treatment criteria and was usually related to type 1 disease in the fellow eye or pre-plus vascular changes in one or both eyes.

Association of Weight Gain Acceleration With Risk of Retinopathy of Prematurity

Importance

Early slow postnatal weight gain, a surrogate for low insulinlike growth factor 1 (IGF-1) levels, is predictive of retinopathy of prematurity (ROP). While low IGF-1 levels inhibit retinal vessel growth, a later rise theoretically activates vascular endothelial growth factor, causing neovascularization. Rate of rise of IGF-1 level is represented by weight gain acceleration (WGA) and may be used to evaluate risk of ROP.

Objective

To evaluate whether faster WGA during a later postnatal period is associated with a higher, rather than lower, risk of severe ROP.

Design, Setting, and Participants

This secondary analysis of data from the Postnatal Growth and Retinopathy of Prematurity (G-ROP) study included 6835 infants undergoing ROP examinations from 29 hospitals in North America from January 2006 to June 2012. Data were analyzed from September to December 2016.

Main Outcomes and Measures

Early weight gain rate (WGR) during 29 to 33 weeks' postmenstrual age and late WGA during 34 to 38 weeks' postmenstrual age were determined using linear regression of daily weight measurements and changes in daily weight measurements, respectively. The primary outcome was the association of late WGA with severe ROP.

Results

Of the 6835 included infants, the mean (SD) birth weight was 1086 (357) g, and the mean (SD) gestational age was 27.9 (2.5) weeks. Risk of severe ROP increased with increasing late WGA up to about the 80th percentile of WGA. After adjusting for birth weight and gestational age, among infants in the lowest early WGR tertile, there was no association of late WGA with severe ROP, and among infants in the moderate and highest early WGR tertiles, the moderate WGA tertiles had the highest risk of ROP (moderate early WGR tertile: adjusted odds ratio, 1.38; 95% CI, 0.98-1.94; highest early WGR tertile: adjusted odds ratio, 1.63; 95% CI, 1.02-2.60).

Conclusions and Relevance

Although much attention has been paid to the association of slow weight gain with ROP, the association may be more complex than appreciated. These findings suggest that low early WGR is associated with severe ROP regardless of subsequent WGA, but if early WGR is moderate or high, subsequent rapid rises in WGR are associated with increasing risk of severe ROP. If validated in additional cohorts, this finding may affect potential therapies, such as the timing of IGF-1 supplementation.

Incidence and Early Course of Retinopathy of Prematurity: Secondary Analysis of the Postnatal Growth and Retinopathy of Prematurity (G-ROP) Study

Importance

The current guidelines for retinopathy of prematurity (ROP) detection programs in the United States include a range of birth weights (BWs) and gestational ages and likely require examinations of many premature infants who are at low risk for developing serious retinopathy.

Objective

To determine the incidence, onset, and early course of ROP in what to our knowledge is the largest cohort to date that is representative of infants who are undergoing ROP screening.

Design, Setting, and Participants

This secondary analysis of data from the Postnatal Growth and Retinopathy of Prematurity (G-ROP) retrospective cohort study was conducted in 29 hospitals in the United States and Canada between January 2006 and December 2011 and included 7483 infants who underwent serial ROP examinations.

Main Outcomes and Measures

Most severe ROP in either eye, classified as no ROP, mild ROP, type 2 ROP, or type 1 ROP (per Early Treatment for ROP Study criteria). Onset at postmenstrual age for zone I disease and stage of ROP, plus disease, and treatment.

Results

This study included 7483 infants with a mean (SD) BW of 1099 (259) g and a mean (SD) gestational age of 28 (3) weeks who underwent ROP examinations. Of these, 3224 infants (43.1%) developed ROP, 459 (6.1%) developed type 1 and 472 (6.3%) type 2 ROP, 514 (6.9%) underwent treatment in 1 or both eyes, and 147 (2%) had zone I disease. Additionally, 98.1% of type 1 or 2 ROP cases occurred in infants with a BW of less than 1251 g. Only about half of the eyes (49.4%) were vascularized into zone III by 37 weeks postmenstrual age.

Conclusions and Relevance

These findings add to our knowledge of ROP screening as they include all eligible infants, not just high-risk infants as in previous studies. More than 40% of at-risk premature infants develop some stage of ROP, and most retinopathy regresses without treatment. However, approximately 12.5% develop severe ROP, which occurs almost exclusively among infants with a BW of less than 1251 g.

Binocular Treatment of Amblyopia: A Report by the American Academy of Ophthalmology

PURPOSE

To review the published literature assessing the efficacy of binocular therapy for the treatment of amblyopia compared with standard treatments.

METHODS

Literature searches with no date restrictions and limited to the English language were conducted in January 2018 and updated in April 2019 in the PubMed database and the Cochrane Library database with no restrictions. The search yielded 286 citations, and the full text of 50 articles was reviewed. Twenty articles met the inclusion criteria for this assessment and were assigned a level of evidence rating by the panel methodologist. Six studies were rated level I, 1 study was rated level II, and 13 studies were rated level III because of the impact on the development and popularization of this technology.

RESULTS

Two of the level I and II studies reviewed described a significant improvement in visual acuity in the binocular group versus standard patching standard treatment (the total number of patients in these 2 studies was 147). However, the 5 studies that failed to show a visual improvement from binocular therapy compared with standard treatments were larger and more rigorously designed (the total number of patients in these 5 studies was 813). Level I and II studies also failed to show a significant improvement over baseline in sensory status, including depth of suppression and stereopsis of those treated with binocular therapy. Several smaller level III case series (total number of patients in these 13 studies was 163) revealed more promising results than the binocular treatments studied in the level I and II studies, especially using treatments that are more engaging and are associated with better compliance.

CONCLUSIONS

There is no level I evidence to support the use of binocular treatment as a substitute for current therapies for amblyopia (including patching and optical treatment). Furthermore, 2 large randomized controlled trials showed inferior performance compared with standard patching treatment. On the basis of this review of the published literature, binocular therapy cannot be recommended as a replacement for standard amblyopia therapy. However, more research is needed to determine the potential benefits of proposed binocular treatments in the future.

Development of Modified Screening Criteria for Retinopathy of Prematurity: Primary Results From the Postnatal Growth and Retinopathy of Prematurity Study

Importance

Current retinopathy of prematurity (ROP) guidelines, which are based on studies of high-risk infants and expert opinion, have low specificity for disease requiring treatment. Postnatal weight gain-based models improve specificity but have been limited by complexity and small development cohorts, which results in model overfitting and resultant decreased sensitivity in validation studies.

Objective

To develop a birth weight (BW), gestational age (GA), and weight gain (WG) prediction model using data from a broad-risk cohort of premature infants.

Design, Setting, and Participants

The Postnatal Growth and ROP Study was a retrospective multicenter cohort study conducted in 29 hospitals in the United States and Canada from 2006 to 2012 that included 7483 premature infants at risk for ROP with a known ROP outcome. A hybrid modeling approach was used that combined BW/GA criteria, weight comparison with expected growth from infants without ROP, multiple growth-interval assessments, consideration of nonphysiological WG, and user-friendly screening criteria. Numerous BW/GA levels, postnatal age periods, time intervals, and WG percentile thresholds were evaluated to identify the most robust parameters.

Main Outcome and Measures

Sensitivity for Early Treatment of ROP Study type 1 ROP and potential reduction in infants who require examinations.

Results

Of 7483 infants, the median (SD) BW was 1099 (359) g, the median GA was 28 weeks (range, 22-35), 3575 (47.8%) were female, 3615 (48.4%) were white, 2310 (30.9%) were black, 233 (3.1%) were Asian, 93 (1.2%) were Pacific Islander, and 40 (0.5%) were American Indian/Alaskan Native. Infants who met any of 6 criteria would undergo examinations: (1) a GA of younger than 28 weeks; (2) a BW of less than 1051 g; a WG of less than 120 g, 180 g, or 170 g during ages 10 to 19, 20 to 29, or 30 to 39 days, respectively; or hydrocephalus. These criteria predicted 459 of 459 (100%) type 1 (sensitivity, 100%; 95% CI, 99.2%-100%), 524 of 524 (100%) treated, and 466 of 472 (98.7%) type 2 cases while reducing the number of infants who required examinations by 2269 (30.3%).

Conclusions and Relevance

This cohort study, broadly representative of infants who are undergoing ROP examinations, provides evidence-based screening criteria. With validation, the Postnatal Growth and ROP Study criteria could be incorporated into ROP screening guidelines to reduce the number of infants who require examinations in North America.

Postnatal weight gain and retinopathy of prematurity

Infants meeting retinopathy of prematurity (ROP) screening guidelines based on birth weight and gestational age undergo serial examinations by ophthalmologists for detection and treatment. However, less than 10% require treatment, and less than half develop ROP. Slow postnatal weight gain is highly predictive of ROP, and investigators have incorporated weight gain measures to develop more specific criteria for ROP screening. Such clinical prediction model use involves a large development study, validation studies specific to the target populations, and ongoing impact surveillance, with adjustment as necessary. Of the many weight gain inclusive prediction models intended to improve the precision of ROP screening, the Postnatal Growth and ROP (G-ROP) modified screening criteria were developed using the largest dataset and may provide the most robust model for clinical use. A recently completed G-ROP validation study will evaluate the generalizability of these modified criteria prior to clinical use.

Perinatal Risk Factors for the Retinopathy of Prematurity in Postnatal Growth and Rop Study

Objective: To evaluate perinatal risk factors for retinopathy of prematurity (ROP), in a large, broad-risk cohort of premature infants. Study design: Secondary analysis of data from the Postnatal Growth and ROP (G-ROP) Study, a retrospective cohort study of infants undergoing ROP examinations at 29 North American hospitals in 2006-2012. Results: Among 7483 infants, 3224 (43.1%) had any ROP and 931 (12.4%) had severe ROP (Type 1 or 2 ROP). In multivariable logistic regression analysis, significant risk factors for any ROP were lower birth weight (BW, odds ratio (OR) = 5.2, <501 g vs. >1250 g), younger gestational age (GA, OR = 32, <25 vs. >29 weeks), 1-min Apgar score <4 (OR = 1.2), race (OR = 1.6, White vs. Black), outborn (OR = 1.5), and delivery room intubation (OR = 1.3); and for severe ROP were lower BW (OR = 20, <501 g vs. >1250 g), younger GA (OR = 30, <25 vs. >29 weeks), male (OR = 1.5), Hispanic ethnicity (OR = 1.8), race (OR = 1.6, White vs. Black), outborn (OR = 1.6), and delivery room intubation (OR = 1.6). Together, these factors predicted well for any ROP (area under ROC curve (AUC) = 0.87) and severe ROP (AUC = 0.89), but BW and GA were the dominant factors for ROP (AUC = 0.86) and severe ROP (AUC = 0.88). Conclusions: Based on the largest report to date with detailed ROP data from infants meeting current screening guidelines, ROP risk is predominantly determined by the degree of prematurity at birth, with other perinatal factors contributing minimally.

Retinal Findings in Young Children With Increased Intracranial Pressure From Nontraumatic Causes

OBJECTIVES

Increased intracranial pressure (ICP) has been suggested in legal settings as an alternative cause of retinal hemorrhages (RHs) in young children who may have sustained abusive head trauma. We assessed the prevalence and characteristics of RHs in children with increased ICP.

METHODS

We conducted a prospective, multicenter study of children <4 years old with newly diagnosed increased ICP as determined by using direct measurement and/or clinical criteria. Infants who were premature, neonates, and suspected survivors of abusive head trauma were excluded on the basis of nonocular findings. Fundus examinations were performed; extent, number, and type of RH in each of 4 distinct retinal zones were recorded.

RESULTS

Fifty-six children (27 boys) were studied (mean age 15.4 months; range 1-43 months). All of the children had elevated ICP that required intervention. One child had papilledema. No child (0%; 95% confidence interval: 0%-6.4%) or eye (0%; 95% confidence interval: 0%-3.3%) was found to have an RH. Causes of increased ICP included hydrocephalus, intraventricular hemorrhage, congenital malformations, malfunctioning shunts, and the presence of intracranial space-occupying lesions.

CONCLUSIONS

Although acute increased ICP can present in children with a pattern of peripapillary superficial RHs in the presence of papilledema, our study supports the conclusion that RHs rarely occur in the absence of optic disc swelling and do not present beyond the peripapillary area in the entities we have studied.

Outbreak of Adenovirus in a Neonatal Intensive Care Unit: Critical Importance of Equipment Cleaning During Inpatient Ophthalmologic Examinations

PURPOSE

Outbreaks of adenovirus in neonatal intensive care units (NICUs) can lead to widespread transmission and serious adverse outcomes. We describe the investigation, response, and successful containment of an adenovirus outbreak in a NICU associated with contaminated handheld ophthalmologic equipment used during retinopathy of prematurity (ROP) screening.

DESIGN

Epidemiologic outbreak investigation.

PARTICIPANTS

A total of 23 hospitalized neonates, as well as NICU staff and parents of affected infants.

MAIN OUTCOME MEASURES

Routine surveillance identified an adenovirus outbreak in a level IV NICU in August 2016. Epidemiologic investigation followed, including chart review, staff interviews, and observations. Cases were defined as hospital-acquired adenovirus identified from any clinical specimen (NICU patient or employee) or compatible illness in a family member. Real-time polymerase chain reaction (PCR) and partial- and whole-genome sequencing assays were used for testing of clinical and environmental specimens.

RESULTS

We identified 23 primary neonatal cases and 9 secondary cases (6 employees and 3 parents). All neonatal case-patients had respiratory symptoms. Of these, 5 developed pneumonia and 12 required increased respiratory support. Less than half (48%) had ocular symptoms. All neonatal case-patients (100%) had undergone a recent ophthalmologic examination, and 54% of neonates undergoing examinations developed adenovirus infection. All affected employees and parents had direct contact with infected neonates. Observations revealed inconsistent disinfection of bedside ophthalmologic equipment and limited glove use. Sampling of 2 handheld lenses and 2 indirect ophthalmoscopes revealed adenovirus serotype 3 DNA on each device. Sequence analysis of 16 neonatal cases, 2 employees, and 2 lenses showed that cases and equipment shared 100% identity across the entire adenovirus genome. Infection control interventions included strict hand hygiene, including glove use; isolation precautions; enhanced cleaning of lenses and ophthalmoscopes between all examinations; and staff furlough. We identified no cases of secondary transmission among neonates.

CONCLUSIONS

Adenovirus outbreaks can result from use of contaminated ophthalmologic equipment. Even equipment that does not directly contact patients can facilitate indirect transmission. Patient-to-patient transmission can be prevented with strict infection control measures and equipment cleaning. Ophthalmologists performing inpatient examinations should take measures to avoid adenoviral spread from contaminated handheld equipment.

Ocular complications following treatment in the Postnatal Growth and Retinopathy of Prematurity (G-ROP) Study

PURPOSE

To determine the prevalence of treatment-related ocular complications and disease progression following treatment for retinopathy of prematurity (ROP).

METHODS

This was a retrospective cohort study of eyes treated for ROP at 29 North American neonatal intensive care units in the Postnatal Growth and ROP (G-ROP) Study. Data from the time of treatment through 15 months were abstracted from medical records by certified data collectors. Treatment-related complication (cataract, hyphema, glaucoma, corneal abrasion/opacity), and disease-progression (retinal fold, dragging, or stage 4 or 5 detachment) were calculated by treatment modality. Vitreous hemorrhage was classified separately, because it can relate to treatment or disease progression.

RESULTS

Of 7,483 infants included in the study, 1,004 eyes (512 infants) underwent ROP treatment: 970 eyes received laser as initial therapy; 34 eyes received intravitreal bevacizumab (IVB). Median follow-up after treatment was 18 weeks. Overall, one or more complications occurred in 2.6% (95% CI, 1.8%-3.8%) laser treated eyes and no (0%; 95% CI, 0.0%-10.1%) IVB eyes. Disease-progression occurred in 9.2% (95% CI, 7.6%-11.2%) laser treated eyes, no (0%; 95% CI, 0.0-12.9%) IVB-only eyes. Vitreous hemorrhage occurred in 5.4% (95% CI: 4.1% - 7.0%) laser treated eyes, no IVB-only eyes.

CONCLUSIONS

Rates of complications are very low following ROP treatment with either laser or IVB. Of laser-treated eyes, 9% experienced disease progression despite treatment.

Validation of the Colorado Retinopathy of Prematurity Screening Model

Importance

The Colorado Retinopathy of Prematurity (CO-ROP) model uses birth weight, gestational age, and weight gain at the first month of life (WG-28) to predict risk of severe retinopathy of prematurity (ROP). In previous validation studies, the model performed very well, predicting virtually all cases of severe ROP and potentially reducing the number of infants who need ROP examinations, warranting validation in a larger, more diverse population.

Objective

To validate the performance of the CO-ROP model in a large multicenter cohort.

Design, Setting, Participants

This study is a secondary analysis of data from the Postnatal Growth and Retinopathy of Prematurity (G-ROP) Study, a retrospective multicenter cohort study conducted in 29 hospitals in the United States and Canada between January 2006 and June 2012 of 6351 premature infants who received ROP examinations.

Main Outcomes and Measures

Sensitivity and specificity for severe (early treatment of ROP [ETROP] type 1 or 2) ROP, and reduction in infants receiving examinations. The CO-ROP model was applied to the infants in the G-ROP data set with all 3 data points (infants would have received examinations if they met all 3 criteria: birth weight, <1501 g; gestational age, <30 weeks; and WG-28, <650 g). Infants missing WG-28 information were included in a secondary analysis in which WG-28 was considered fewer than 650 g.

Results

Of 7438 infants in the G-ROP study, 3575 (48.1%) were girls, and maternal race/ethnicity was 2310 (31.1%) African American, 3615 (48.6%) white, 233 (3.1%) Asian, 40 (0.52%) American Indian/Alaskan Native, and 93 (1.3%) Pacific Islander. In the study cohort, 747 infants (11.8%) had type 1 or 2 ROP, 2068 (32.6%) had lower-grade ROP, and 3536 (55.6%) had no ROP. The CO-ROP model had a sensitivity of 96.9% (95% CI, 95.4%-97.9%) and a specificity of 40.9% (95% CI, 39.3%-42.5%). It missed 23 (3.1%) infants who developed severe ROP. The CO-ROP model would have reduced the number of infants who received examinations by 26.1% (95% CI, 25.0%-27.2%).

Conclusions and Relevance

The CO-ROP model demonstrated high but not 100% sensitivity for severe ROP and missed infants who might require treatment in this large validation cohort. The model requires all 3 criteria to be met to signal a need for examinations, but some infants with a birth weight or gestational age above the thresholds developed severe ROP. Most of these infants who were not detected by the CO-ROP model had obvious deviation in expected weight trajectories or nonphysiologic weight gain. These findings suggest that the CO-ROP model needs to be revised before considering implementation into clinical practice.

Longitudinal study of the association between thrombocytopenia and retinopathy of prematurity

BACKGROUND

An association between thrombocytopenia and retinopathy of prematurity (ROP) has been suggested but not been studied longitudinally. We sought to identify the time period in postnatal development during which thrombocytopenia and the subsequent development of severe ROP are associated.

METHODS

This was a retrospective case-control study of 100 subjects who received laser photocoagulation for type 1 ROP between 2005 and 2009 and 100 controls with no ROP or only stage 1 ROP. The proportions of infants with thrombocytopenia, defined as a serum platelet level of <150,000/μL, among cases versus controls were compared on a weekly basis from birth through the time of laser during early (postmenstrual age [PMA] weeks 24-28), middle (PMA weeks 29-34), and late (PMA weeks 35-38) time periods. Main outcome measures were odds ratios for the association between thrombocytopenia and type 1 ROP from multivariate logistic regression models adjusted for gestational age, birth weight, culture-proven sepsis, and necrotizing enterocolitis.

RESULTS

Thrombocytopenia was significantly associated with severe ROP during PMA weeks 24-28 (adjusted OR, 4.7; 95% CI, 2.0-1.1; P = 0.001) and 29-34 (adjusted OR, 2.8; 95% CI, 1.4-5.6; P = 0.006), but not during weeks 35-38 (adjusted OR, 2.0; 95% CI, 0.9-4.3; P = 0.10).

CONCLUSIONS

Thrombocytopenia from birth through 34 weeks' PMA was associated with subsequent severe ROP. This time period corresponds to a period of poor retinal vascular growth, suggesting a possible proangiogenic effect of platelets in normal retinal vascular development in infants at risk for ROP.

Validation of the Children's Hospital of Philadelphia Retinopathy of Prematurity (CHOP ROP) Model

Importance

The Children's Hospital of Philadelphia Retinopathy of Prematurity (CHOP ROP) model uses birth weight (BW), gestational age at birth (GA), and weight gain rate to predict the risk of severe retinopathy of prematurity (ROP). In a model development study, it predicted all infants requiring treatment, while greatly reducing the number of examinations compared with current screening guidelines.

Objective

To validate the CHOP ROP model in a multicenter cohort that is large enough to obtain a precise estimate of the model's sensitivity for treatment-requiring ROP.

Design, Setting, and Participants

This investigation was a secondary analysis of data from the Postnatal Growth and Retinopathy of Prematurity (G-ROP) Study. The setting was 30 hospitals in the United States and Canada between January 1, 2006, and June 30, 2012. The dates of analysis were September 28 to October 5, 2015. Participants were premature infants at risk for ROP with a known ROP outcome.

Main Outcomes and Measures

Sensitivity for Early Treatment of Retinopathy of Prematurity type 1 ROP and potential reduction in the number of infants requiring examinations. In the primary analysis, the CHOP ROP model was applied weekly to predict the risk of ROP. If the risk was above a cut-point level (high risk), examinations were indicated, while low-risk infants received no examinations. In a secondary analysis, low-risk infants received fewer examinations rather than no examinations.

Results

Participants included 7483 premature infants at risk for ROP with a known ROP outcome. Their median BW was 1070 g (range, 310-3000 g), and their median GA was 28 weeks (range, 22-35 weeks). Among them, 3575 (47.8%) were female, and their race/ethnicity was 3615 white (48.3%), 2310 black (30.9%), 233 Asian (3.1%), 93 Pacific Islander (1.2%), and 40 American Indian/Alaskan native (0.5%). The original CHOP ROP model correctly predicted 452 of 459 infants who developed type 1 ROP (sensitivity, 98.5%; 95% CI, 96.9%-99.3%), reducing the number of infants requiring examinations by 34.3% if only high-risk infants received examinations. Lowering the cut point to capture all type 1 ROP cases (sensitivity, 100%; 95% CI, 99.2%-100%) resulted in only 6.8% of infants not requiring examinations. However, if low-risk infants were examined at 37 weeks' postmenstrual age and followed up only if ROP was present at that examination, all type 1 ROP cases would be captured, and the number of examinations performed among infants with GA exceeding 27 weeks would be reduced by 28.4%.

Conclusion and Relevance

The CHOP ROP model demonstrated high but not 100% sensitivity and may be better used to reduce examination frequency. The model might be used reliably to guide a modified ROP screening schedule and decrease the number of examinations performed.

A Randomized Controlled Study of Art Observation Training to Improve Medical Student Ophthalmology Skills

PURPOSE

Observation and description are critical to the practice of medicine, and to ophthalmology in particular. However, medical education does not provide explicit training in these areas, and medical students are often criticized for deficiencies in these skills. We sought to evaluate the effects of formal observation training in the visual arts on the general and ophthalmologic observational skills of medical students.

DESIGN

Randomized, single-masked, controlled trial.

PARTICIPANTS

Thirty-six first-year medical students, randomized 1:1 into art-training and control groups.

METHODS

Students in the art-training group were taught by professional art educators at the Philadelphia Museum of Art, during 6 custom-designed, 1.5-hour art observation sessions over a 3-month period. All subjects completed pre- and posttesting, in which they described works of art, retinal pathology images, and external photographs of eye diseases.

MAIN OUTCOME MEASURES

Grading of written descriptions for observational and descriptive abilities by reviewers using an a priori rubric and masked to group assignment and pretesting/posttesting status.

RESULTS

Observational skills, as measured by description testing, improved significantly in the training group (mean change +19.1 points) compared with the control group (mean change -13.5 points), P = 0.001. There were significant improvements in the training vs. control group for each of the test subscores. In a poststudy questionnaire, students reported applying the skills they learned in the museum in clinically meaningful ways at medical school.

CONCLUSIONS

Art observation training for first-year medical students can improve clinical ophthalmology observational skills. Principles from the field of visual arts, which is reputed to excel in teaching observation and descriptive abilities, can be successfully applied to medical training. Further studies can examine the impact of such training on clinical care.

A Tiered Approach to Retinopathy of Prematurity Screening (TARP) Using a Weight Gain Predictive Model and a Telemedicine System

Importance

The Telemedicine Approaches to Evaluating Acute-Phase Retinopathy of Prematurity (e-ROP) Study telemedicine system of remote fundus image grading and The Children's Hospital of Philadelphia Retinopathy of Prematurity (CHOP-ROP) postnatal weight gain predictive model are 2 approaches for improving ROP screening efficiency. Current screening has low specificity for severe ROP.

Objective

To describe a tiered approach to ROP screening (TARP) for identifying children who develop severe ROP using telemedicine and a predictive model synergistically.

Design, Setting, and Participants

This investigation was a post hoc analysis of a cohort in the e-ROP Study (a multicenter prospective telemedicine study) and the Postnatal Growth and Retinopathy of Prematurity (G-ROP) Study (a multicenter retrospective cohort study). The setting was neonatal intensive care units at The Children's Hospital of Philadelphia and the Hospital of the University of Pennsylvania. Participants in the e-ROP Study were premature infants with a birth weight less than 1251 g and a known ROP outcome enrolled between May 25, 2011, and October 31, 2013. The G-ROP Study enrolled all infants undergoing ROP examinations with a known ROP outcome who were born between January 1, 2006, and December 31, 2011.

Main Outcomes and Measures

The mean outcomes were the sensitivity for type 1 ROP, reductions in infants requiring imaging or examinations, numbers of imaging sessions and examinations, and total clinical encounters (imaging sessions and examinations combined). The following 4 screening approaches were evaluated: ROUTINE (only diagnostic examinations by an ophthalmologist), CHOP-ROP (birth weight and gestational age, with weekly weight gain initiating examinations when the risk cut point is surpassed), e-ROP IMAGING (trained reader grading of type 1 or 2 ROP initiates diagnostic examinations), and TARP (CHOP-ROP alarm initiates imaging, and imaging finding of severe ROP initiates diagnostic examinations).

Results

A total of 242 infants were included in the study, with a median birth weight of 858 g (range, 690-1035 g). The median gestational age was 27 weeks (range, 25-29 weeks). Fifty-one percent (124 of 242) were female, and 49% (118 of 242) were male. The race/ethnicity was 27.3% (66 of 242) white, 56.2% (136 of 242) black, 2.1% (5 of 242) Native American, 1.7% (4 of 242) Asian, and 12.8% (31 of 242) other. The sensitivity for detecting type 1 ROP (32 infants) was 100% (95% CI, 89.3%-100%) with each approach. With ROUTINE, 242 infants had 877 examinations; with CHOP-ROP, 184 infants had 730 examinations; with e-ROP IMAGING, 242 infants had 532 imaging sessions, and 94 infants had 345 examinations (877 patient encounters); and with TARP, 182 infants had 412 imaging sessions, and 87 infants had 322 examinations (734 patient encounters).

Conclusions and Relevance

The tiered approach to ROP screening was associated with a reduced number of examinations and imaging sessions compared with the other approaches. Applying a postnatal growth model and telemedicine system in a tiered approach may reduce the number of clinical ROP interventions more than either approach alone.