Retinopathy of prematurity in middle-income countries

Non-contact smartphone-based fundus imaging compared to conventional fundus imaging: a low-cost alternative for retinopathy of prematurity screening and documentation

Retinopathy of prematurity (ROP) is a frequent cause of treatable childhood blindness. The current dependency of telemedicine-based ROP screening on cost-intensive equipment does not meet the needs in economically disadvantaged regions. Smartphone-based fundus imaging (SBFI) allows for affordable and mobile fundus examination and, therefore, could facilitate cost-effective telemedicine-based ROP screening in low-resources settings. We compared non-contact SBFI and conventional contact fundus imaging (CFI) in terms of feasibility for ROP screening and documentation. Twenty-six eyes were imaged with both SBFI and CFI. Field-of-view was smaller (ratio of diameters, 1:2.5), level of detail was equal, and examination time was longer for SBFI as compared to CFI (109.0 ± 57.8 vs. 75.9 ± 36.3 seconds, p < 0.01). Good agreement with clinical evaluation by indirect funduscopy was achieved for assessment of plus disease and ROP stage for both SBFI (squared Cohen's kappa, 0.88 and 0.81, respectively) and CFI (0.86 and 0.93). Likewise, sensitivity/specificity for detection of plus disease and ROP was high for both SBFI (90%/100% and 88%/93%, respectively) and CFI (80%/100% and 100%/96%). SBFI is a non-contact and low-cost alternative to CFI for ROP screening and documentation that has the potential to considerably improve ROP care in middle- and low-resources settings.

The CD40-ATP-P2X 7 Receptor Pathway: Cell to Cell Cross-Talk to Promote Inflammation and Programmed Cell Death of Endothelial Cells

Extracellular adenosine 5′-triphosphate (ATP) functions not only as a neurotransmitter but is also released by non-excitable cells and mediates cell–cell communication involving glia. In pathological conditions, extracellular ATP released by astrocytes may act as a “danger” signal that activates microglia and promotes neuroinflammation. This review summarizes in vitro and in vivo studies that identified CD40 as a novel trigger of ATP release and purinergic-induced inflammation. The use of transgenic mice with expression of CD40 restricted to retinal Müller glia and a model of diabetic retinopathy (a disease where the CD40 pathway is activated) established that CD40 induces release of ATP in Müller glia and triggers in microglia/macrophages purinergic receptor-dependent inflammatory responses that drive the development of retinopathy. The CD40-ATP-P2X₇ pathway not only amplifies inflammation but also induces death of retinal endothelial cells, an event key to the development of capillary degeneration and retinal ischemia. Taken together, CD40 expressed in non-hematopoietic cells is sufficient to mediate inflammation and tissue pathology as well as cause death of retinal endothelial cells. This process likely contributes to development of degenerate capillaries, a hallmark of diabetic and ischemic retinopathies. Blockade of signaling pathways downstream of CD40 operative in non-hematopoietic cells may offer a novel means of treating diabetic and ischemic retinopathies.

Telemedicine for Retinopathy of Prematurity in 2020

Purpose:

Retinopathy of prematurity (ROP) is the leading cause of visual impairment in premature infants, and middle-income nations are currently experiencing the “third epidemic” of ROP. Screening programs are essential to prevent negative visual outcomes, but screening efforts require a great amount of resources from healthcare systems and are difficult to marshal, particularly in geographically isolated or resource-limited settings. Telemedical screening programs using remote digital fundus imaging (RDFI) systems hold the promise of alleviating many of the burdens that currently make screening for ROP logistically challenging.

Methods:

Literature review of the current evidence for RDFI telescreening for ROP, with editorial discussion and recommendations.

Results:

In this review, we summarize the robust body of literature regarding the efficacy of RDFI, the feasibility of telescreening programs, and experiences from current live telescreening programs. We discuss the strengths and limitations of the current evidence and of the screening programs and consider the best practices in developing de novo telemedical screening programs for ROP. The review concludes with a discussion of promising future areas of research and development.

Conclusions:

RDFI ROP screening programs can be accurate and reliable. They show promise in improving many current challenges in screening infants for ROP, may be able to improve some aspects of care, and have been demonstrated to be cost-effective.

Epidemiology of ROP update - Africa is the new frontier

Several epidemics of blindness due to retinopathy of prematurity (ROP) have been described, with the most recent (the third) occurring in middle income countries in Latin America and Eastern Europe initially, and more recently in the more advanced economies in Asia. In these settings, which are characterized by variation in the quality of neonatal care and inadequate coverage of ROP screening and treatment, larger, more mature infants are affected as well as extremely preterm infants. In 2010 the annual incidence of blindness and visual impairment from ROP globally was estimated to be 32,300, with the lowest incidence in sub-Saharan countries. However, ROP is likely to become an increasingly important cause of blindness in children in sub-Saharan Africa as neonatal care expands unless policies and programmes for control are included at the outset.

Aggressive posterior retinopathy of prematurity in two cohorts of patients in South India: implications for primary, secondary, and tertiary prevention

BACKGROUND

Aggressive posterior retinopathy of prematurity (APROP), which has a poor visual prognosis, is common in low- and middle-income countries (LMICs) as a result of suboptimal oxygen monitoring (primary prevention). The purpose of this study was to compare outcomes in APROP eyes treated with laser to eyes treated with antivascular endothelial growth factor (anti-VEGF) therapy.

METHODS

The medical records of a cohort of APROP eyes treated with anti-VEGF (2010-2018) and another of eyes treated with laser photocoagulation (2002-2010) at the same institution in South India were reviewed retrospectively and compared. The main outcome was the proportion of eyes developing retinal detachment during resolution of acute ROP.

RESULTS

A total of 398 eyes of 199 preterm babies with APROP were included: 168 eyes were treated with photocoagulation; 230, with anti-VEGF. From 2002 to 2010, compared to the more recent cohort, babies diagnosed with APROP tended to be heavier (P < 0.001), older (P < 0.001), and exposed to fewer days of oxygen (P = 0.02). In the laser-treated cohort, 17 of 168 eyes (10%) developed retinal detachment (7, stage 5; 12, stage 4), compared with 3 of 230 (1%) in the anti-VEGF cohort (all stage 4 [P = 0.002]).

CONCLUSIONS

The incidence of retinal detachment was significantly lower in eyes treated with anti-VEGF compared with laser-.treated eyes In the absence of a randomized trial, these data suggest that anti-VEGF may lead to better anatomic outcomes, although questions remain concerning dosage, timing, and risks.

Retinopathy of prematurity prevention, screening and treatment programmes: Progress in South America

Retinopathy of prematurity (ROP) is the main cause of blindness and visual impairment in Latin America and prevention, detection and treatment have been a priority in the Region in the last two decades. There is progress in the number of eligible babies screened and treated in at least half of the countries with strong regulations on ROP, but screening is not yet available in all provinces in most. More effort is needed to increase national protocols and legislation, strengthening of services and human resources to cover all national provinces; telemedicine might be a promising strategy.

Prevalence, risk factors and pattern of severe retinopathy of prematurity in eastern Madhya Pradesh

Purpose

To describe the prevalence, characteristics including risk factors, and pattern of severe ROP from eastern Madhya Pradesh region of India.

Methods

In this 5-year retrospective study, Baseline characteristics, systemic risk factors, and findings of ROP screening were noted. Factors associated with severe ROP including aggressive posterior ROP (APROP), stage IV and V ROP were analyzed. Statistical analysis was done using SPSS version 20.

Results

Of 763 babies screened, 30% were diagnosed to have ROP. Prevalence of severe ROP was 14.2% (109) of which 60 (55.5%) were classic and 30 (27.7%) were APROP. Eighteen (16.6%) were diagnosed as advanced ROP (stage IV and V). Mean gestational age (GA) and birth weight (BW) for severe ROP were 31.05 weeks and 1.34 kg, respectively which were inversely associated with severe ROP. But a significant 10% of severe ROP were seen in late preterm babies, >34 weeks. Low GA and respiratory distress syndrome (RDS) were significant risk factors for APROP. Most important factor for stage IV and V ROP was late presentation for screening.

Conclusion

The study found a high prevalence of severe ROP including APROP. Almost 7% severe ROP cases were outside screening guidelines of NNF. Late presentation for screening is the most important factor associated with ROP related blindness.

Safety and efficacy of 532 nm frequency-doubled Nd-YAG green laser photocoagulation for treatment of retinopathy of prematurity

Purpose

To evaluate the safety and efficacy of 532 nm frequency-doubled Nd-YAG green laser for treatment of retinopathy of prematurity (ROP).

Methods

This retrospective interventional case series included infants undergoing treatment for ROP with 532 nm green laser between January 2012 and March 2017 at a single tertiary-care referral center. Review of clinical records was done to identify baseline ROP characteristics, procedural difficulties, complications related to the laser procedure and outcome of treatment at ≥ 1 year of follow-up.

Results

There are about 347 eyes of 182 infants were included in this present study. ROP presented in zone I in 76 eyes (21.9%) and zone II in 271 eyes (78.1%). Tunica vasculosa lentis (TVL) was present in 43.8% and pre-existing vitreous hemorrhage in 4.6% of the eyes. 532 nm green laser could be performed as a primary procedure in all eyes, including those with TVL. 322 eyes completed a minimum follow up of 1 year with a mean follow up of 22.8 months (range, 12-54 months). At the last follow-up visit, 298 (92.5%) of the 322 eyes had a favorable outcome. On logistic regression analysis, pre-existing fibrovascular proliferation (p = 0.04) and new-onset fibrovascular proliferation after treatment (p = 0.001) were the most significant independent predictors of poor outcome. Complications encountered were new-onset hemorrhage in 36 eyes (11.2%), anterior segment ischemia in two eyes (0.006%) and cataract in one eye (0.003%).

Conclusion

532 nm frequency-doubled Nd-YAG green laser appears to be safe and effective in the treatment of ROP.

Retinopathy of prematurity in Rwanda: a prospective multi-centre study following introduction of screening and treatment services

Objectives

To investigate risk factors for retinopathy of prematurity (ROP) in a newly established ROP screening and management programme in Rwanda, Africa.

Methods

In this multi-centre prospective study 795/2222 (36%) babies fulfilled the inclusion criteria (gestational age (GA) < 35 weeks or birth weight (BW) < 1800 g or unstable clinical course), 424 (53%) of whom were screened for ROP. 270 died before the first screening. ROP and treatment-warranted ROP were classified using the revised International Classification of ROP (2005). Data on maternal and perinatal risk factors were collected from daily neonatal notes.

Results

31 babies (7.3%, CI 5.0–10.2) developed any ROP, 13 of whom (41.9%, CI 24.5–60.9) required treatment. ROP was seen in six neonates with GA > 30 weeks and BW > 1500 g, one of whom required treatment. In univariate analysis the following were associated with any ROP: increasing number of days on supplemental oxygen (OR 2.1, CI 1.5–3.0, P < 0.001), low GA (OR 3.4, CI 1.8–6.4, P < 0.001), low BW (OR 2.3, CI 1.5–3.4, P < 0.001), at least one episode of hyperglycaemia ≥ 150 mg/dl (OR 6.6, CI 2.0–21.5, P < 0.001), blood transfusion (OR 3.5, CI 1.6–7.4, P < 0.001) or sepsis (OR 3.2, CI 1.2–8.6, P = 0.01). In multivariate analysis longer exposure to supplemental oxygen (OR 2.1, CI 1.2–3.6, P = 0.01) and hyperglycaemia (OR 3.5, CI 1.0–12.4, P = 0.05) remained significant.

Conclusions

ROP has become an emerging health problem in Rwanda, requiring programmes for screening and treatment. ROP screening is indicated beyond the 2013 American Academy guidelines. Improved quality of neonatal care, particularly oxygen delivery and monitoring is needed.

Refractive Outcomes of 4-Year-old Children after Intravitreal Anti-vascular Endothelial Growth Factor versus Laser Photocoagulation for Retinopathy of Prematurity

Purpose

To compare long-term refractive outcomes associated with intravitreal anti-vascular endothelial growth factor (VEGF) versus laser photocoagulation treatment for retinopathy of prematurity (ROP).

Methods

A total of 52 eyes from 27 ROP patients treated at two tertiary referral-based hospitals from August 2006 to December 2013 were reviewed. The primary outcome was refractive error measured at the age of 4 years, accounting for within-patient inter-eye correlation. Secondary outcomes included the recurrence rate and treatment complications.

Results

The mean age at refraction was 4.7 ± 0.3 years in the laser group (n = 30) and 4.4 ± 0.3 years in the anti-VEGF group (n = 22). No significant differences were noted in gestational age, birthweight, post-menstrual age at treatment, or ROP stage/zone distribution between groups. Mean spherical equivalent was also not significantly different (−1.0 diopters in the laser group and −0.3 diopters in the injection group, p = 0.603). Clustered regression analysis revealed that only gestational age was significantly correlated with mean spherical equivalent (p < 0.001; 95% confidence interval, −0.007 to −0.002). Recurrence was noted in four eyes (13.3%) in the laser group, but this difference was not significant (p = 0.128). There were no major systemic complications reported in either group.

Conclusions

Treatment type, whether laser or anti-VEGF injection, does not appear to influence long-term refractive outcomes in ROP. Concern regarding refractive outcomes should not be the most important factor when selecting ROP treatment modality.

THE EVOLUTION OF ISOLATED NEOVASCULAR TUFTS ("POPCORN") IN RETINOPATHY OF PREMATURITY

PURPOSE

To explore the natural evolution of isolated neovascular tufts ("popcorn") in retinopathy of prematurity (ROP) and its significance in the progression of acute ROP.

METHODS

In this retrospective case series, 89 infants (89 eyes) in total having acute ROP were analyzed during serial retinal examinations with a RetCam III wide-angle fundus imaging system, among which 53 eyes were observed to have popcorn and 36 eyes did not. The clinical outcomes of the popcorn (+) group and the popcorn (-) group were compared.

RESULTS

Popcorn was located only in Zone II, Stage 2 ROP, primarily in the temporal field (65%). It appeared at a mean postmenstrual age of (37.6 ± 1.3) weeks, disappeared at (41.0 ± 2.2) weeks, and lasted for (2.8 ± 1.1) weeks. The popcorn (+) group had a significantly higher natural regression incidence than the popcorn (-) group (P < 0.05). The laser-treated eyes in the popcorn (+) group had earlier presentations (36.4 ± 0.7 vs. 38.2 ± 1.3 weeks) and shorter existences (1.5 ± 0.5 vs. 3.2 ± 0.9 weeks) of popcorn than the regressed eyes (P < 0.01, respectively).

CONCLUSION

Popcorn is generally a "benign" indicator of the regression of ROP. The early presentation (<postmenstrual age 37 weeks) and short duration of popcorn require further observation.

Model Registry of Early Childhood Visual Impairment: First-Year Results

This study obtained information on 406 children from birth to age 3 with visual impairments at the point of entry into specialized early intervention programs in nine states. It found that the majority of the children were legally blind and had disabilities in addition to visual impairment. Cortical visual impairment, retinopathy of prematurity, and optic nerve hypoplasia were the three most prevalent eye conditions in the sample. Furthermore, about a six-month mean lag was found between the diagnosis of children's visual impairment and referral for services.

India to gear up to the challenge of "third epidemic" of retinopathy of prematurity in the world

Many of the causes of childhood blindness are avoidable, being either preventable or treatable. Retinopathy of prematurity (ROP) remains one of the most preventable causes of childhood blindness worldwide. Currently, India is facing the third epidemic of ROP. In India, the health system involving the mother and child health services needs to be strengthened with a policy to cover the existing inadequacies in neonatal care and implementation of program covering newborn, especially premature. The access, availability, and affordability of services related to the care of premature babies need strengthening in India. ROP-trained ophthalmologists and neonatal care pediatricians and a professional togetherness is a big issue. Inadequacies in awareness of ROP among the parents, health care workers, counsellors add up to the problem. Community-based health workers such as Accredited Social Health Activist are a good dependable force in India and are needed to be trained in awareness and establishing a proper identification for prompt referral. ROP prevention needs a multidisciplinary team approach. ROP management stands as a good example of all the strategies for prevention, which includes primary prevention (improving obstetric and neonatal care), secondary prevention (screening and treatment programs), and tertiary prevention (treating complications and rehabilitation to reduce disability). Given its demographic and cultural diversity, India faces numerous challenges, with significant rural-urban, poor-rich, gender, socioeconomic, and regional differences. So, we need to gear up to face the present challenge of the third epidemic of ROP and prevent ROP-related childhood blindness as it is the need of the hour.

Retinopathy of Prematurity among Syrian Refugees: Incidence and Severity

PURPOSE:

The aim of this study is to compare the incidence and severity of retinopathy of prematurity (ROP) in premature newborns of Syrian refugees and those of Turkish origin.

METHODS:

This retrospective, the single-center study included 1545 premature infants assigned to two groups based on maternal origin. Group 1 comprised 1366 premature infants of Turkish origin, and Group II comprised 179 premature infants born to Syrian refugees. All the premature infants were screened for ROP by the same ophthalmologist who is experienced in the screening and treatment of ROP. All data including gestational age (GA), birth weight (BW), the presence of ROP, and severe ROP collected from 2014 to 2017 were recorded for each group. The outcomes were compared between the two groups.

RESULTS:

The mean GA at birth was 30.6 ± 2 weeks and was significantly lower in Group II (P = 0.03). The overall incidence of ROP was similar in both groups. The incidence of severe ROP in Group II was nearly seven times higher than in Group I (1.5% and 10%, respectively). The incidence of severe ROP seen in Group II evaluated according to different ranges of GA and BW was higher than in Group I.

CONCLUSION:

The higher incidence of severe ROP in the premature newborns of Syrian refugees could play an important role in identifying ongoing health problems of refugees.

Automated Detection and Classification of Telemedical Retinopathy of Prematurity Images

Background: Retinopathy of prematurity (ROP) is a retinal disorder of low birth weight infants and it is the leading cause of childhood blindness. The capability of wide field digital imaging systems to capture the clinical features of ROP has greatly helped the physicians to assess the severity of ROP and prevent childhood blindness due to ROP. Currently there is a lack of automated systems to assess the severity of ROP to assist the ROP specialist to make treatment decision. Objective: To present an automated detection and classification approach to assess the severity of ROP using wide field telemedical images. Materials and Methods: A total of 160 telemedical ROP (tele-ROP) images were collected out, of which 36 images were Normal, 79 images were Stage 2, and 45 images were Stage 3. Hessian analysis and support vector machine (SVM) classifier have been used to detect and classify the severity of ROP from tele-ROP images. Results: Classified the Normal, Stage 2, and Stage 3 images using SVM. Achieved accuracy of 91.8%, sensitivity of 90.37%, specificity of 94.65%, false positive rate of 5.35%, and false negative rate of 9.63%. Conclusions: The automated approach of detecting and classifying ROP would support pediatric ophthalmologists for early treatment decisions with optimal care.

The current state of retinopathy of prematurity in India, Kenya, Mexico, Nigeria, Philippines, Romania, Thailand, and Venezuela

Retinopathy of prematurity (ROP) is one of the leading causes of preventable blindness in children worldwide. Middle-income nations are currently experiencing epidemic levels of ROP, because greater access to neonatal intensive care units has improved survival rates of premature infants, but without sophisticated oxygen regulation. The epidemiology, screening infrastructure, treatment options, and challenges that these countries face are often tied to unique local socioeconomic, cultural, geopolitical, and medical factors. We present an overview and narratives of the current state of ROP in eight countries that are or soon will be experiencing ROP epidemics-India, Kenya, Mexico, Nigeria, Phillipines, Romania, Thailand, and Venezuela-with a view to fostering both an understanding of the differences in the ROP landscape in various settings and an interest in the further development of ROP screening and treatment services tailored to local requirements.

A Novel, Low-Cost, Wide-Field, Infant Retinal Camera, "Neo": Technical and Safety Report for the Use on Premature Infants

Purpose

To report the technical aspects, systemic, and ocular safety of a novel, low-cost, wide-field, infant retinal camera for use on premature infants.

Methods

The device, the “3nethra Neo” (Neo) is a 120° portable, contact, wide-field, unibody camera, with a CMOS sensor (2040 × 2040 resolution) and a warm light-emitting diode (LED) illumination source. The Neo was used to image 140 awake, preterm infants between postmenstrual age (PMA) of 28 to 37 weeks, undergoing retinopathy of prematurity (ROP) screening. Baseline, ‘during procedure', at 5 minutes, and for 60 minutes postprocedure, readings of oxygen saturation and heart rate were recorded. The device design, optics, illumination, and software specifications were compared with the RetCam 3.

Results

Study defined bradycardia (9 infants, 6.4%), tachycardia (3 infants, 2.1%), and hypoxia (2 infants, 1.4%) were observed but there were no clinically significant systemic changes that required intervention during or following any of the study time intervals. There was a transient increase in heart rate by 9.68 (7.53–11.83; P < 0.0001) and marginal decrease in oxygen saturation (−1.94 [−1.60 to −2.28], P < 0.0001), which started to return to baseline 5 minutes after the procedure. Transient redness was seen in two eyes (0.7%) of two infants. No other ocular adverse effects were observed.

Conclusions

The Neo is easy to use in preterm infants and being compact was readily portable. There were no significant ocular or systemic adverse effects, potentially allowing it to be a viable low-cost device for ROP screening in low resource settings.

Translational Relevance

The camera provides a safe and affordable alternative to image the retina of infants by using novel illumination and lens mechanics and has the potential of worldwide acceptance.

The Accuracy of Digital Imaging in Diagnosis of Retinopathy of Prematurity in Iran: A Pilot Study

Purpose:

To evaluate sensitivity and specificity of digital retinal image reading in the diagnosis of referral-warranted retinopathy of prematurity (ROP).

Methods:

Infants referred to the ROP clinic underwent fundus examination through indirect ophthalmoscopy. Fundus photographs were acquired using RetCam (shuttle 2; Clarity medical systems, Pleasanton, CA, USA). Four retinal specialists who were blind to patients’ information reviewed the RetCam fundus photographs. By comparing the results of photographs’ readings with that of indirect ophthalmoscopy as the gold standard, the sensitivity and specificity of telescreening was determined.

Results:

A total of 147 treatment-naïve patients met the inclusion criteria and were enrolled in the study. Mean gestational age (GA) was 28.6 ± 2.0 weeks. Digital retinal imaging had sensitivity of 85% and specificity of 35% in detecting referral-warranted ROP in our study. Positive predictive value of digital photography was 80%, and negative predictive value was 43%.

Conclusion:

Digital photography for diagnosis of ROP may show good potential as a screening modality in developing countries. It can facilitate early diagnosis, prevent unnecessary referrals, and be implemented for investigational purpose. However, the overall study result did not provide evidence to propose digital photography as a substitute for indirect ophthalmoscopy in the diagnosis of ROP.

Heated and Humidified High Flow Nasal Canal Oxygen Supplementation as an Effective Treatment for High-Risk Prethreshold Retinopathy of Prematurity

PURPOSE

We evaluated the effect of heated and humidified high flow nasal cannula (HFNC) oxygen supplementation to promote regression of high-risk prethreshold retinopathy of prematurity (Hrp-ROP) in premature infants.

METHODS

A prospective study was designed for Hrp-ROP premature infants undergoing HFNC oxygen supplementation to evaluate its capacity for promoting ROP regression. Statistical analysis with independent samples t-tests and Fisher's exact tests was performed, and forest plots were created to illuminate the odds ratio of factors associated with ROP regression as well as HFNC complication.

RESULTS

With HFNC, 16 of 20 infants with Hrp-ROP experienced regression, which is higher than the natural regression rate, comparing to the data in other clinical trials (52% in the STOP-ROP study). Among four progressed ROP infants, three were treated with laser photocoagulation and one received anti-vascular endothelial growth factor (VEGF) therapy. The anti-VEGF treated patient encountered ROP recurrence one month after injection and was treated successfully by additional HFNC. No significant differences between regression and progression cases were found for gestational age, birth weight, plus disease, age for HFNC, and SO2 level. The blood saturation of oxygen was significantly increased after HFNC (92 ± 1.3% vs. 96.6 ± 0.8%, P < 0.001), while the heartbeat rate (HR) and respiratory rate (RR) had no significant differences (139.4 ± 5.4 vs. 140.6 ± 4.5, P = 0.409; 37.7 ± 2.3 vs. 37 ± 1.9, P = 0.330, respectively). The main complication of HNFC was nasal erosion associated with airflow and HFNC duration (RR = 1.8, P = 0.026; RR = 1.8, P = 0.026, respectively).

CONCLUSIONS

The progression of Hrp-ROP was significantly decreased after HFNC oxygen supplementation with slightly tolerable complication.

TRANSLATIONAL RELEVANCE

Our study suggests that HNFC can be an alternative treatment for Hrp-ROP, potentially avoiding the problems caused by other invasive treatment.

Retinopathy of prematurity in Africa: a systematic review

Purpose: Retinopathy of prematurity (ROP) is widely regarded worldwide as a major cause of childhood blindness, however until recently the disease has not been recognized in most of the African continent. As a result of changing economic conditions, there is growing evidence that the population at risk for ROP in Africa is increasing. This report aims to summarize the published literature on ROP from Africa. Methods: We performed a systematic literature review of the English and French online literature databases by applying a general search strategy initially on May 1, 2017 with repeat inquiry on May 20, 2018. Search phrases included multiple variants of terms including "ROP", "retinopathy of prematurity", in conjunction with each of the individual 54 recognized sovereign African states. Findings: A total of 25 individual studies from six African nations were identified: South Africa (10), Egypt (7), Nigeria (4), with the nations of Sudan, Rwanda, and Kenya each having one respective study. Two countries (South Africa and Kenya) have developed national ROP policies for primary and secondary prevention. Summary: Review of the published literature suggests that ROP is emerging in Africa, however, there are published data from 6/54 (11%) African nations. Blindness from ROP is often preventable with appropriate primary and secondary prevention. This report provides compelling evidence that these efforts should be undertaken to implement and evaluate regionally appropriate ROP prevention programs in a growing number of African countries.

Artificial intelligence and deep learning in ophthalmology

Artificial intelligence (AI) based on deep learning (DL) has sparked tremendous global interest in recent years. DL has been widely adopted in image recognition, speech recognition and natural language processing, but is only beginning to impact on healthcare. In ophthalmology, DL has been applied to fundus photographs, optical coherence tomography and visual fields, achieving robust classification performance in the detection of diabetic retinopathy and retinopathy of prematurity, the glaucoma-like disc, macular oedema and age-related macular degeneration. DL in ocular imaging may be used in conjunction with telemedicine as a possible solution to screen, diagnose and monitor major eye diseases for patients in primary care and community settings. Nonetheless, there are also potential challenges with DL application in ophthalmology, including clinical and technical challenges, explainability of the algorithm results, medicolegal issues, and physician and patient acceptance of the AI 'black-box' algorithms. DL could potentially revolutionise how ophthalmology is practised in the future. This review provides a summary of the state-of-the-art DL systems described for ophthalmic applications, potential challenges in clinical deployment and the path forward.

Demographic profile and ocular characteristics of stage 5 retinopathy of prematurity at a referral center in Northwest China: implications for implementation

Background

Severe retinopathy of prematurity (ROP) with extremely unfavorable prognosis among infants can do great damage to individuals and bring tremendous social-economic burden. The purpose of this study is to describe the demographic and ocular characteristics of infants who presented with stage 5 ROP in order to identify reasons why they have become blind, and to identify contributing factors in order to focus great attention on the current ROP program and to inspire more effort in ROP screening in middle income countries.

Methods

A retrospective review of consecutive infants with stage 5 ROP from December 2010 to December 2016 in Department of Ophthalmology, Xijing Hospital. Various parameters retrieved included birthweight, gestational age, age at initial examination, postmenstrual age, screening details, check-up details and reasons for consultation. Ocular findings were recorded and also detected by ultrasonography.

Results

A retrospective review of 20 consecutive infants with stage 5 ROP are included. Mean birthweight was1712.3 ± 512.97 g and mean gestational age at birth was 32.1 ± 2.21 weeks. Median age at first consultancy was 9.7 month. Median postmenstrual age first consultancy was 52 weeks. All infants were never screened for ROP before they came to the referral center. Of twenty stage 5 ROP infants, 13 cases presented with bilateral stage 5 features. Of the 40 eyes of 20 infants, 33 eyes were diagnosed as stage 5. Leukocoric pupil, closed funnel configuration of retinal detachment (RD), posterior synechia, extraretinal fibrovascular proliferation and retinal folds were the most significant indicators of bad prognosis. Ten eyes appeared no fixation to light, while 30 eyes exhibited following to light or following to toys.

Conclusions

Our study shows that in relatively less-developed regions of China, more needs to be done to spread awareness about the disease among pediatricians, neonatologists and ophthalmologists as well as parents of premature infants. Thus, a comprehensive control system which is a whole network of propaganda, screening, treatment and follow-up are encouraged especially in less developed areas in China as well as worldwide.

The treatment and risk factors of retinopathy of prematurity in neonatal intensive care units

Background

Retinopathy of prematurity (ROP) is a vascular proliferative disorder of the developing retina and a significant cause of childhood blindness around the world. The incidence of ROP is affected by many factors, and the incidence rate varies from country to country. The purpose of this study is to report the incidence and risk factors of ROP in neonatal intensive care unit (NICU) of Guangzhou First People’s Hospital in China.

Methods

A retrospective review was performed on 436 premature infants who were consecutive ROP screened in the NICU of Guangzhou First People’s Hospital from March 2013 to October 2017. The single-factor analysis and the logistic multivariate regression analysis were used to detect risk factors of ROP.

Results

Total 436 premature infants were consecutive ROP screened, 138 (31.65%) were found ROP, and 61(13.99%) were treated. The single-factor analysis revealed that the incidence of ROP was associated with multiple births, gestational age, birth weight, mechanical ventilation, intravascular hemolysis, the number of operations and blood culture results. The logistic multivariate regression analysis revealed that gestational age; birth weight, mechanical ventilation, minimum SaO2 and daily weight gain were independent risk factors for ROP onset. Forty-nine patients underwent retinal laser photocoagulation with recurrence 20 patients. Twelve patients underwent anti-VEGF drug (Ranibizumab) via intraocular injection with 5 patients of recurrence.

Conclusions

The incidence of ROP in NICU of Guangzhou China will match those in middle-income countries, but higher than high-income countries. Anti-VEGF drugs could be preferred as a good treatment method for zone 1 ROP and aggressive posterior ROP.

Reducing Blindness from Retinopathy of Prematurity (ROP) in Argentina Through Collaboration, Advocacy and Policy Implementation

Retinopathy of prematurity (ROP) is a largely avoidable cause of blindness in children worldwide, requiring high-quality neonatal care, early detection and treatment. In middle-income countries throughout Latin America, Eastern Europe and South Asia, there has been a rise in ROP blindness due to a combination of increased survival of preterm infants, resource-scarce medical environments and lack of policies, training and human resources. However, Argentina is an example of country where rates of ROP blindness have declined and ROP programmes have been successfully and effectively embedded within the health and legal system. The purpose of this study is to describe the activities and stakeholders, including Ministry of Health (MoH) and UNICEF, involved in the process, from recognition of an epidemic of ROP blindness to the development of national guidelines, policies and legislation for control. Using a retrospective mixed methods case study design, data on rates of severe ROP was collected from 13 neonatal intensive care units from 1999 to 2012, and on the proportion of children blind from ROP in nine blind schools in seven provinces. Legislative document review, focus group discussions and key informant interviews were conducted with neonatologists, ophthalmologists, neonatal nurses, parents, MoH officials, clinical societies, legislators and UNICEF officials in seven provinces. Results are presented combining the stages heuristic policy framework and Shiffman including: agenda setting, policy formulation, implementation and evaluation. By 2012, ROP had declined as a cause of blindness in children in schools for the blind as had rates of severe ROP needing treatment in the NICUs visited. Multiple factors played a role in reducing blindness from ROP in Argentina and successfully coordinating its control including national advocacy, leadership, legislation and international collaboration. Lessons learned in Argentina can potentially be scaled to other LMICs in Latin America and beyond with further context-specific research.

Public health system integration of avoidable blindness screening and management, India

In India, 73 million people have diabetes and 3.5 million infants are born preterm. Without timely screening, there is a risk of visual loss due to diabetic retinopathy and retinopathy of prematurity in these two groups, respectively. Both conditions are emerging causes of visual impairment in India but there is no public health programme for screening or management. Pilot projects were initiated in 2014 to integrate the screening and management of these conditions into existing public health systems, particularly in rural communities and their referral networks. The World Health Organization's health systems framework was used to develop the projects and strategies were developed with all stakeholders, including the government. Both projects involved hub-and-spoke models of care units around medical schools. For diabetic retinopathy, screening was established at primary health-care facilities and treatment was provided at district hospitals. For retinopathy of prematurity, screening was integrated into sick newborn care units at the district level and treatment facilities were improved at the closest publically funded medical schools. In the first two years, there were substantial improvements in awareness, screening, treatment and partnership between stakeholders, and changes in public health policy. By March 2018, diabetic retinopathy screening was established at 50 facilities in 10 states and treatment had been improved at 10 hospitals, whereas retinopathy of prematurity screening was established at 16 sick newborn care units in district hospital in four states and treatment had been improved at six medical schools. Advocacy within state governments was critical to the success of the initiative.

Real-World Simulation of an Alternative Retinopathy of Prematurity Screening System in Thailand: A Pilot Study

PURPOSE

To evaluate an alternative retinopathy of prematurity (ROP) screening system that identifies infants meriting examination by an ophthalmologist in a middle-income country.

METHODS

The authors hypothesized that grading posterior pole images for the presence of pre-plus or plus disease has high sensitivity to identify infants with type 1 ROP that requires treatment. Part 1 of the study evaluated the feasibility of having a non-ophthalmologist health care worker obtain retinal images of prematurely born infants using a non-contact retinal camera (Pictor; Volk Optical, Inc., Mentor, OH) that were of sufficient quality to grade for pre-plus or plus disease. Part 2 investigated the accuracy of grading these images to identify infants with type 1 ROP. The authors prospectively recruited infants at Chulalongkorn University Hospital (Bangkok, Thailand). On days infants underwent routine ROP screening, a trained health care worker imaged their retinas with Pictor. Two ROP experts graded these serial images from a remote location for image gradability and posterior pole disease.

RESULTS

Fifty-six infants were included. Overall, 69.4% of infant imaging sessions were gradable. Among gradable images, the sensitivity of both graders for identifying an infant with type 1 ROP by grading for the presence of pre-plus or plus disease was 1.0 (95% confidence interval [CI]: 0.31 to 1.0) for grader 1 and 1.0 (95% CI: 0.40 to 1.0) for grader 2. The specificity was 0.93 (95% CI: 0.76 to 0.99) for grader 1 and 0.74 (95% CI: 0.53 to 0.88) for grader 2.

CONCLUSIONS

It was feasible for a trained non-ophthalmologist health care worker to obtain retinal images of infants using the Pictor that were of sufficient quality to identify infants with type 1 ROP. [J Pediatr Ophthalmol Strabismus. 2018;55(4):245-253.].

Automated Diagnosis of Plus Disease in Retinopathy of Prematurity Using Deep Convolutional Neural Networks

Importance

Retinopathy of prematurity (ROP) is a leading cause of childhood blindness worldwide. The decision to treat is primarily based on the presence of plus disease, defined as dilation and tortuosity of retinal vessels. However, clinical diagnosis of plus disease is highly subjective and variable.

Objective

To implement and validate an algorithm based on deep learning to automatically diagnose plus disease from retinal photographs.

Design, Setting, and Participants

A deep convolutional neural network was trained using a data set of 5511 retinal photographs. Each image was previously assigned a reference standard diagnosis (RSD) based on consensus of image grading by 3 experts and clinical diagnosis by 1 expert (ie, normal, pre-plus disease, or plus disease). The algorithm was evaluated by 5-fold cross-validation and tested on an independent set of 100 images. Images were collected from 8 academic institutions participating in the Imaging and Informatics in ROP (i-ROP) cohort study. The deep learning algorithm was tested against 8 ROP experts, each of whom had more than 10 years of clinical experience and more than 5 peer-reviewed publications about ROP. Data were collected from July 2011 to December 2016. Data were analyzed from December 2016 to September 2017.

Exposures

A deep learning algorithm trained on retinal photographs.

Main Outcomes and Measures

Receiver operating characteristic analysis was performed to evaluate performance of the algorithm against the RSD. Quadratic-weighted κ coefficients were calculated for ternary classification (ie, normal, pre-plus disease, and plus disease) to measure agreement with the RSD and 8 independent experts.

Results

Of the 5511 included retinal photographs, 4535 (82.3%) were graded as normal, 805 (14.6%) as pre-plus disease, and 172 (3.1%) as plus disease, based on the RSD. Mean (SD) area under the receiver operating characteristic curve statistics were 0.94 (0.01) for the diagnosis of normal (vs pre-plus disease or plus disease) and 0.98 (0.01) for the diagnosis of plus disease (vs normal or pre-plus disease). For diagnosis of plus disease in an independent test set of 100 retinal images, the algorithm achieved a sensitivity of 93% with 94% specificity. For detection of pre-plus disease or worse, the sensitivity and specificity were 100% and 94%, respectively. On the same test set, the algorithm achieved a quadratic-weighted κ coefficient of 0.92 compared with the RSD, outperforming 6 of 8 ROP experts.

Conclusions and Relevance

This fully automated algorithm diagnosed plus disease in ROP with comparable or better accuracy than human experts. This has potential applications in disease detection, monitoring, and prognosis in infants at risk of ROP.

Mini-peptide RPL41 attenuated retinal neovascularization by inducing degradation of ATF4 in oxygen-induced retinopathy mice

Endoplasmic reticulum (ER) stress signaling is activated in retinal degeneration disease. Activating transcription factor 4 (ATF4), an important mediator of the unfolded protein response (UPR), is a key element that maintains cell survival and proliferation in hypoxic conditions. Our previous studies showed that a small ribosomal protein L41 (RPL41) inhibits ATF4 by inducing its phosphorylation and degradation. In the present study, the effects of mini-peptide RPL41 on retinal neovascularization (RNV) in oxygen-induced retinopathy (OIR) mice was investigated. We induced OIR in C57BL/6 mice and obtained retinas from normoxia, OIR, OIR control (treated with PBS), and OIR treated (treated with RPL41) mice. Our results showed that ER stress signaling was activated and ATF4 was overexpressed in the retinas of OIR mice. After intravitreal injection of RPL41, the size of RNV and vaso-obliteration, and the number of preretinal neovascular cell nuclei in the retinas of OIR mice were significantly decreased. Western blot analysis and quantitative real-time polymerase chain reaction (qPCR) showed ATF4 and VEGF expression decreased after intravitreal injection of RPL41. Furthermore, the expression levels of inflammatory genes including TNF-α, IL-1β, and IL-6 were significantly decreased compared with the OIR control mice. In conclusion, RPL41 prevented pathologic neovascularization and exerted anti-inflammatory effects by degrading the important ER stress factor ATF4, thus, RPL41 could be a promising therapeutic agent for the treatment of neovascular eye diseases, especially retinopathy of prematurity (ROP).

Retinopathy of prematurity in Kenya: prevalence and risk factors in a hospital with advanced neonatal care

Introduction

Increased survival of preterm babies in sub-saharan Africa has held to an increasing prevalence of Retinopathy of prematurity (ROP). This study was done to determine the ROP prevalence in a hospital with advanced neonatal care in urban Kenya.

Methods

A hospital-based retrospective review of the records of premature infants screened for ROP between January 2010 and December 2015. Records of all premature infants screened for ROP in the neonatal unit and outpatient eye clinic were extracted. Information on Birth weights, Gestational age, Maternal risk factors (mode of delivery, pre-eclampsia/eclampsia) and Neonatal risk factors (neonatal sepsis, days on oxygen, blood transfusion) was recorded in a questionnaire then analysed.

Results

103 infants were included in the study. Mean gestational age was 29.9 ± 2.2 weeks and the mean birth weight was 1280.1 ± 333.0 grams. Forty-three infants were diagnosed with ROP, a prevalence of 41.7%. Majority of these had Stage 1 or 2 ROP in Zone II, which spontaneously regressed with follow up. Nine infants were diagnosed with vision-threatening ROP (any Zone I disease or Stage 2/3 disease in Zone II with plus disease), a prevalence of 20.9%. All of these underwent laser treatment in the neonatal unit. The most significant risk factor was low gestational age. Other risk factors identified were: low birth weight and blood transfusions.

Conclusion

ROP prevalence in sub-saharan Africa will match those in middle-income and high income countries in neonatal units with advanced care and low mortality.

Retinopathy of Prematurity: Screening Guidelines Need to be Reevaluated for Developing Countries

Purpose.

Timely screening of premature babies is an important initial step in the management of retinopathy of prematurity (ROP) as earlier treatment results in improved visual prognosis. Screening criteria for ROP currently recommended by the American Academy of Pediatrics may not be applicable in developing countries. The aim of the present study is to find out the incidence of ROP in infants with a gestational age (GA) of ≥32 weeks in Eskisehir, Turkey, to provide information to assist in determining screening criteria.

Methods.

A total of 96 infants with a GA of 32–35 weeks who were referred for ROP between January 1, 2004, and December 31, 2008, were studied. ROP screening, follow-up, and appropriate therapies were applied.

Results.

During ROP screening, there were 42 of 96 (43.8%) infants with no ROP. A total of 54/96 (56.2%) infants were noted to have ROP. Among all infants, 7 (7.3%) had threshold ROP. Two infants with threshold disease were born at the 32nd, 2 at the 33rd, and 3 at the 34th week of gestation. The mean birthweight was 1857.9 (range 1060–3200) grams.

Conclusions.

In our study, it was found that more mature infants may also develop threshold ROP and require early treatment. After more information is gained and widespread screening, screening protocols covering more mature infants can be designed especially for developing countries.

Etiology of Childhood Blindness in Izmir, Turkey

PURPOSE

To identify the anatomic sites and the etiology of childhood blindness and to discern treatable and preventable causes.

METHODS

The records of 998 patients seen in the authors' pediatric ophthalmology unit between June 1998 and May 2002 were examined retrospectively. A total of 148 patients who had visual impairment and blindness according to World Health Organization criteria were included in the study. They are classified according to the etiology based on time of insult and the anatomic site of visual loss.

RESULTS

The most common anatomic site of visual loss was retina, with a rate of 25.0%. The etiology according to the time of insult was unknown in 45.2% of the patients, of whom 20.2% had cataract. Genetic disorders were responsible in 25.0% of the patients. In 69.6% of the patients, the causes of visual impairment were considered either preventable or treatable, including cataract, retinopathy of prematurity, genetic disorders, and refractive errors.

CONCLUSIONS

A high percentage of our patients had avoidable causes of childhood blindness. Genetic counseling services, as well as national screening programs for amblyopia, red fundus reflex, and retinopathy of prematurity, should be established.

Ischemic Retinopathies: Oxidative Stress and Inflammation

Ischemic retinopathies (IRs), such as retinopathy of prematurity (ROP), diabetic retinopathy (DR), and (in many cases) age-related macular degeneration (AMD), are ocular disorders characterized by an initial phase of microvascular changes that results in ischemia, followed by a second phase of abnormal neovascularization that may culminate into retinal detachment and blindness. IRs are complex retinal conditions in which several factors play a key role during the development of the different pathological stages of the disease. Increasing evidence reveals that oxidative stress and inflammatory processes are important contributors to the pathogenesis of IRs. Despite the beneficial effects of the photocoagulation and anti-VEGF therapy during neovascularization phase, the need to identify novel targets to prevent initial phases of these ocular pathologies is still needed. In this review, we provide an update on the involvement of oxidative stress and inflammation in the progression of IRs and address some therapeutic interventions by using antioxidants and anti-inflammatory agents.

Up-regulated basigin-2 in microglia induced by hypoxia promotes retinal angiogenesis

Retinal microglia cells contribute to vascular angiogenesis and vasculopathy induced by relative hypoxia. However, its concrete molecular mechanisms in shaping retinal angiogenesis have not been elucidated. Basigin, being involved in tumour neovasculogenesis, is explored to exert positive effects on retinal angiogenesis induced by microglia. Therefore, we set out to investigate the expression of basigin using a well-characterized mouse model of oxygen-induced retinopathy, which recapitulated hypoxia-induced aberrant neovessel growth. Our results elucidate that basigin is overexpressed in microglia, which accumulating in retinal angiogenic sprouts. In vitro, conditioned media from microglia BV2 under hypoxia treatment increase migration and tube formation of retinal capillary endothelia cells, compared with media from normoxic condition. The angiogenic capacity of BV2 is inhibited after basigin knockdown by small interfering RNAs. A new molecular mechanism for high angiogenic capacity, whereby microglia cells release basigin via up-regulation of PI3K-AKT and IGF-1 pathway to induce angiogenesis is unveiled. Collectively, our results demonstrate that basigin from hypoxic microglia plays a pivotal pro-angiogenic role, providing new insights into microglia-promoting retinal angiogenesis.

FGF21 Administration Suppresses Retinal and Choroidal Neovascularization in Mice

Pathological neovascularization, a leading cause of blindness, is seen in retinopathy of prematurity, diabetic retinopathy, and age-related macular degeneration. Using a mouse model of hypoxia-driven retinal neovascularization, we find that fibroblast growth factor 21 (FGF21) administration suppresses, and FGF21 deficiency worsens, retinal neovessel growth. The protective effect of FGF21 against neovessel growth was abolished in adiponectin (APN)-deficient mice. FGF21 administration also decreased neovascular lesions in two models of neovascular age-related macular degeneration: very-low-density lipoprotein-receptor-deficient mice with retinal angiomatous proliferation and laser-induced choroidal neovascularization. FGF21 inhibited tumor necrosis α (TNF-α) expression but did not alter Vegfa expression in neovascular eyes. These data suggest that FGF21 may be a therapeutic target for pathologic vessel growth in patients with neovascular eye diseases, including retinopathy of prematurity, diabetic retinopathy, and age-related macular degeneration.

Refractive state and optical compositions of preterm children with and without retinopathy of prematurity in the first 6 years of life

This study aimed to investigate the refractive state and optical compositions of preterm children with and without mild retinopathy of prematurity (ROP) and explore the influence of prematurity and mild ROP on the development of refractive state and optical compositions.Preterm children who received fundus screening were recruited, and divided into ROP group and non-ROP group. Term children matched in age were also recruited as controls. Several correspondence indicators were measured before and after ciliary muscle paralysis with 1% cyclopentanone.A total of 250 eyes from 126 patients were included for analysis. The incidence of myopia was the highest in ROP group. The incidence of hyperopia was the highest in control group. The incidence of astigmatism was the highest in ROP group. The corneal astigmatism and mean astigmatism in ROP group and non-ROP group were significantly higher than in control group. Corneal refraction in ROP was markedly higher than in non-ROP group and control group; corneal curvature in ROP group increased significantly as compared with non-ROP group and control group (P < .05). The axial eye length in ROP group and non-ROP group reduced significantly as compared with control group (P < .05). Gestational age had negative relationships with corneal astigmatism (P = .019) and astigmatism (P = .001) and positive relationship with axial eye length (P = .005). Birth weight had negative relationships with corneal astigmatism (P = .001), astigmatism (P < .001), corneal refraction (P = .001), and corneal curvature (P = .001) and positive relationships with axial eye length (P = .001) and spherical equivalent refraction (P = .039). The incidence of myopia increased and that of hyperopia reduced in children over age. In children aged 3 to 4 years, the anterior chamber depth, lens thickness, vitreous thickness, and axial eye length significantly increased as compared with those aged 5 years (P < .05); the vitreous thickness and axial eye length in children aged 5 years increased significantly as compared with those aged 6 years (P < .05).This study shows that preterm children with and without mild ROP are more likely to develop myopia and astigmatism, and low birth weight, prematurity, and ROP may simultaneously affect the development of optical compositions, leading to myopia and astigmatism.

Retinopathy of prematurity in Indonesia: Incidence and risk factors

BACKGROUND

Retinopathy of prematurity (ROP) is a vaso-proliferative disease of the eye, which mainly affects preterm newborn infants with an incompletely vascularized retina. The incidence of ROP has increased in industrialized countries due to the increased survival of extremely low birth weight (ELBW) infants. ROP is also increasing in developing countries like Indonesia, where it is most likely due to the improved survival of ELBW infants.

OBJECTIVE

To ascertain the incidence of ROP and possible risk factors associated with the development of ROP in preterm infants in Indonesia.

METHODS

We reviewed the literature on the incidence and potential risk factors for the development of ROP in Indonesia, obtained data from three referral eye clinics and added data from our institution.

RESULTS

The reported incidence of all stages of ROP in infants with a gestational age of <32 weeks ranged from 18-30%. One study showed that ROP also occurred at older gestational ages. Blindness due to ROP was seen in infants up to 35 weeks and with a birth weight of 2000 g.

CONCLUSION

Retinopathy of prematurity is an important cause of ocular morbidity and blindness in Indonesia. The overall incidence of ROP in infants born below 32 weeks in Indonesia is higher than in developed countries, and it is seen in infants with older gestational ages. This might be due to a less strict monitoring during the use of oxygen in Indonesia compared to industrialized countries.

Trends in Visual Health Inequalities in Childhood Through Associations of Visual Function With Sex and Social Position Across 3 UK Birth Cohorts

Importance

Despite the existing country-specific strategies tackling social inequalities in visual health in adults, little is known about trends in visual function in childhood and its association with social position.

Objective

To investigate the distribution of childhood visual function in the United Kingdom and associations with early-life social position between 1961 and 1986, a period of significant social change.

Design, Setting, and Participants

Longitudinal cohort study using harmonized data sets from the British 1946, 1958, and 1970 national birth cohorts. In total, 14 283 cohort members with complete data on visual acuity at age 15 or 16 years, measured in 1961, 1974, and 1986, respectively, for each cohort, and social position were assessed.

Main Outcomes and Measures

Using habitual distance visual acuity (with correction if prescribed), participants were assigned to a visual function category ranging from bilateral normal to visual impairment/severe visual impairment/blindness (International Statistical Classification of Diseases, Tenth Revision, Clinical Modification). Distribution of visual function over time and associations with social position (risk ratios [RRs] and 95% confidence intervals) were analyzed.

Results

Complete data were available for 3152 participants (aged 15 years; 53% boys [n = 1660]) in the 1946 Medical Research Council National Survey of Health and Development, 6683 participants (aged 16 years; 51% boys [n = 3420]) in the 1958 National Child Development Study, and 4448 participants (aged 16 years; 48% boys [n = 2156]) in the 1970 British Birth Cohort Study. The proportion of children with bilateral normal vision decreased by 1.3% (95% CI, -5.1% to 2.7%) in 1974 and 1.7% (95% CI, -5.9% to 2.7%) in 1986. The risk of overall impaired vision increased by 1.20 times (95% CI, 1.01-1.43) and the risk of visual impairment/severe visual impairment/blindness by 1.75 times (95% CI, 1.03-2.98) during this period. Girls were consistently at increased risk of all vision impairment categories. Higher social position at birth and in childhood was associated with reduced risk of visual impairment/severe visual impairment/blindness (RR, 0.58; 95% CI, 0.20-1.68) and unilateral impairment (RR, 0.89; 95% CI, 0.72-1.11), respectively.

Conclusions and Relevance

Our study provides evidence of temporal decline in childhood visual function between 1961 and 1986. Despite the limited power of the analysis owing to the small sample size of those with impaired vision, we found an emergence of a contribution of sociodemographic status to the cohort effect that may be the antecedent of the current picture of childhood blindness. Equally, early-life social position may also have contributed to the current social patterning in visual function in older adults in the United Kingdom. These findings highlight the potential value of targeting children in national ophthalmic public policies tackling inequalities.

Impact of expansion of telemedicine screening for retinopathy of prematurity in India

PURPOSE

The purpose of this study is to estimate the unknown burden of retinopathy of prematurity (ROP) blindness from nine states of India using demographic, incidence and treatment data from an ongoing statewide ROP program in Karnataka called the Karnataka Internet Assisted Diagnosis of ROP (KIDROP) and to calculate the fiscal quantum of preventable blindness in these states.

MATERIALS AND METHODS

The KIDROP model is an ongoing tele-ROP service providing screening and treatment for ROP in Karnataka since 2008. Using this index strategy, an impact assessment in nine other states was constructed, the number of potential blind babies enumerated, the fiscal quantum of blindness prevented in blind person-years (BPYs), and the increase in burden with improving survival and institutional deliveries calculated.

RESULTS

The total population in the ten study states is 681.5 million. The eligible babies for ROP screening annually are 467,664. The number of babies admitted to neonatal units is 188,561 of which 160,277 are likely to survive and require screening. Based on KIDROP data, ROP would develop in 35,886 of these infants, and 1281 babies would require treatment annually. The fiscal quantum of BPY saved in these ten states is USD 108.4 million annually, with a further increase of USD 106.8 million with improving infant survival and higher admission rates for delivery.

CONCLUSION

A KIDROP like model can provide ROP screening in low-resource settings, remote centers, and regions with few ROP specialists. Expanding the model to other states with similar demographics can prevent over USD 100 million of blindness burden annually.

Homoisoflavonoids as potential antiangiogenic agents for retinal neovascularization

A number of people worldwide have been suffering from ocular neovascularization that may be treated by a variety of drugs but these may possess adverse effects. Therefore, small antiangiogenic molecules with higher potency and lower toxic effects are intended. However, homoisoflavonoids of natural origin show the potential antiangiogenic effect in ocular neovascularization. These homoisoflavonoids are judged quantitatively in terms of statistical validation through multi-chemometric modeling approaches for the betterment and refinement of their structures required for higher antiangiogenic activity targeted to ocular neovascularization. These approaches may be utilized to design better antiangiogenic homoisoflavonoids.

Results of Screening in Schools for Visually Impaired Children

Objectives:

The aim of this study was to identify the causes of visual impairment in children attending schools for students with visual impairment and to identify children suitable for treatment and rehabilitation.

Materials and Methods:

All students were examined in our department by a pediatric ophthalmologist and an ophthalmologist experienced in low vision and visual rehabilitation. The children’s medical histories were recorded. All children underwent ophthalmological examination including visual acuity measurement, anterior segment and dilated fundus evaluation, retinoscopy with cycloplegia, and intraocular pressure measurement. The causes of visual impairment were grouped as avoidable and unavoidable. Children with residual visual acuity better than 20/1250 were included in the low vision rehabilitation programme.

Results:

A total of 120 patients were evaluated and 79.2% were legally blind (visual acuity less than 0.05), 18.4% had low vision (visual acuity between 0.05 and 0.3), and 0.8% had normal vision (>0.3). The main causes of visual impairment were retinal dystrophies (24.2%) and retinopathy of prematurity (17.5%). Of all diseases related to visual impairment, 27.6% were avoidable. Improvement in visual acuity was achieved with low vision aids in 57.5% of all patients.

Conclusion:

The incidence of visual impairment due to avoidable causes can be decreased by ophthalmic screening. Treatment of these children in the early stages of visual development can improve visual acuity. Even in cases with delayed diagnosis, low vision aids are important for visual and neurobehavioral development, and these programmes may improve quality of life and education in these children.