Retinopathy of prematurity: Past, present and future

The possible effect of pentoxifylline on development and severity of retinopathy of prematurity

BACKGROUND AND AIM

Retinopathy of prematurity (ROP) is the major ocular problem of preterm infants that occurs with abnormal proliferation of immature retinal vessels. Although pentoxifylline (PTX) was reported to inhibit vasculogenesis and neovascularization in experimental studies, there is no clinical data about the effects of PTX treatment on the development and severity of ROP. This clinical study aimed to investigate the possible effects of PTX on the development of ROP.

MATERIALS AND METHODS

A single-centre retrospective study was conducted including preterm infants who were hospitalised in the neonatal intensive care unit between 2015-2017 years. Infants were divided into two groups in terms of PTX administration for adjuvant therapy, as PTX and non-PTX groups.

RESULTS

A total of 211 infants were included in the study [gestational age 29 (27-31) weeks, birth weight 1140 (960-1340) g]. From these, 97 infants (46%) were given PTX treatment. The two groups were similar in terms of demographic data and baseline clinical characteristics. Any stage of ROP was detected in 47.4% of infants in the PTX group, which was significantly higher than those in the non-PTX group (27.2%) (p = 0.002). The incidence of advanced-stage ROP in the PTX group (10.3%) was also higher than in the non-PTX group (2.6%) (p = 0.021). Repeated usage of PTX was not found to be related to the development of ROP (p = 0.059). The time of PTX administration was similar between the ROP and no-ROP groups (median; one vs one week, p = 0.825). Surfactant therapy, duration of hospital stay, and PTX treatment were found as significant risk factors for ROP in the logistic regression analysis.

CONCLUSIONS

In contrast to the experimental studies and also promising results of PTX treatment in some neonatal morbidities, it may be associated with increased incidence and stage of ROP.

Adults Born Preterm: Long-Term Health Risks of Former Very Low Birth Weight Infants

BACKGROUND

Advances in neonatology now enable increasing numbers of very low birth weight neonates (<1500 g) to survive into early adulthood and beyond. What are the implications for their long-term care?

METHODS

Selective literature search on the outcome of very low birth weight neonates in adulthood ("adults born preterm").

RESULTS

Robust data are available on the pulmonary, metabolic, cardiovascular, renal, neurocognitive, sensory-visual, social-emotional, mental, reproductive, and musculoskeletal long-term risks. On the somatic level, elevated rates have been documented for asthma (odds Ratio [OR] 2.37), diabetes mellitus (OR 1.54), and chronic renal disease (hazard ratio [HR] 3.01), along with the cardiovascular and cerebrovascular sequelae of a tendency toward arterial hypertension. On the psychosocial level, the main findings are deficits in romantic partnerships (OR 0.72) and a lower reproduction rate (relative risk [RR] male/female 0.24/0.33). The affected women also have an elevated risk of preterm delivery.

CONCLUSION

A risk profile with both somatic and psychosocial aspects can be discerned for adults who were born prematurely, even if some of these risks are present in low absolute numbers. As the ability to compensate for latent deficits declines with age, such adults may suffer from "premature aging as the late price of premature birth." A holistic approach to care with personalized prevention strategies-which for most of them was discontinued at discharge from pediatric follow-up-therefore seems appropriate in adulthood as well.

Early Postnatal Oxygen Exposure Predicts Choroidal Thinning in Neonates

Purpose

To evaluate whether choroidal thickness (CT) using arm-mounted optical coherence tomography (OCT) in infants screened for retinopathy of prematurity (ROP) correlates with oxygen exposure in neonates.

Methods

OCT images were obtained in infants screened for ROP in a single level IV neonatal intensive care unit. CT was measured at three different locations: the subfoveal center and 1.5 mm from the fovea center in each direction. Correlation and regression analyses were performed to determine the relationship between clinical factors and CT. Clinical factors included gestational age, birth weight, presence of bronchopulmonary dysplasia (BPD), and fraction of inspired oxygen (FiO₂) at defined time points: 30 weeks postmenstrual age (PMA), 36 weeks PMA, and on day of imaging.

Results

Mean subfoveal, nasal, and temporal choroidal thicknesses CT (SFCT, NCT, and TCT, respectively) were 228.0 ± 51.4 µm, 179.7 ± 50.3 µm, and 186.4 ± 43.8 µm, respectively. SFCT was found to be significantly thicker than NCT and TCT (P < 0.0001 and P = 0.0002, respectively), but no significant difference was found between NCT and TCT (P = 0.547). Compared with infants without BPD, infants with BPD had thinner SFCT and NCT (P = 0.01 and P = 0.0008, respectively). Birth weight was positively correlated with SFCT (r = 0.39, P = 0.01) and NCT (r = 0.33, P = 0.045) but not TCT. Gestational age and ROP stage were not significantly associated with CT. SFCT was found to be significantly thinner with higher average FiO₂ supplementation levels at 30 weeks PMA (r = –0.51, P = 0.01) but not at 36 weeks PMA. Regression analysis revealed that FiO₂ at 30 weeks PMA was an independent predictor of SFCT in infants screened for ROP (P = 0.01).

Conclusions

Early postnatal exposure (<32 weeks PMA) to higher oxygen supplementation in premature neonates statistically predicts choroidal thinning.

Features of Retinal Neurogenesis as a Key Factor of Age-Related Neurodegeneration: Myth or Reality?

Age-related macular degeneration (AMD) is a complex multifactorial neurodegenerative disease that constitutes the most common cause of irreversible blindness in the elderly in the developed countries. Incomplete knowledge about its pathogenesis prevents the search for effective methods of prevention and treatment of AMD, primarily of its "dry" type which is by far the most common (90% of all AMD cases). In the recent years, AMD has become "younger": late stages of the disease are now detected in relatively young people. It is known that AMD pathogenesis-according to the age-related structural and functional changes in the retina-is linked with inflammation, hypoxia, oxidative stress, mitochondrial dysfunction, and an impairment of neurotrophic support, but the mechanisms that trigger the conversion of normal age-related changes to the pathological process as well as the reason for early AMD development remain unclear. In the adult mammalian retina, de novo neurogenesis is very limited. Therefore, the structural and functional features that arise during its maturation and formation can exert long-term effects on further ontogenesis of this tissue. The aim of this review was to discuss possible contributions of the changes/disturbances in retinal neurogenesis to the early development of AMD.

Evaluating Contrast Sensitivity in Asian Indian Pre-Term Infants With and Without Retinopathy of Prematurity

Purpose

The purpose of this study was to evaluate the contrast threshold in Asian Indian preterm infants with and without retinopathy of prematurity (ROP) using Newborn Contrast Cards measured during the first ROP screening and to correlate with final outcome and visual acuity at 3 months of corrected age.

Methods

Preterm infants born ≤ 2000 grams birth weight (BW) and/or ≤ 34 weeks gestational age (GA) undergoing ROP screening were enrolled prospectively. Visual acuity was recorded using Teller Acuity Cards. Contrast threshold was measured with Newborn Contrast Cards at first screening visit and at the end of ROP screening at 40 weeks of postmenstrual age or older.

Results

Of the 173 study infants, 134 (77.5%) did not have any stage of ROP. Of the remaining 39 (22.5%), 34 (87%) had type 2 ROP and 5 (13%) had type 1 ROP requiring treatment. The mean contrast threshold at the first visit of the no ROP type 1 and type 2 groups was 0.36 ± 0.07, 0.65 ± 0.19, and 0.46 ± 0.09, respectively (P < 0.001). Contrast threshold had a significant correlation with BW (R = −0.291, P = < 0.001) and gestational age (R = −0.47, P = < 0.001). The contrast threshold at the first visit correlated with visual acuity measured at 3 months of corrected age in logMAR (R = 0.36, P = 0.01). Other than BW and GA, no other systemic risk factors correlated with contrast threshold measured at the first screening visit.

Conclusions

Newborn Contrast Cards are a viable tool to test contrast threshold in preterm infants. The association between contrast threshold and ROP, and its correlation with visual acuity, suggest that contrast threshold measurement may help predict the clinical vision outcome among prematurely born infants.

Translational Relevance

Contrast threshold measurement may prove to be a useful tool in the estimation of visual potential in preterm infants.

Nigerian neonatologists perception and experience with retinopathy of prematurity

BACKGROUND

Retinopathy of Prematurity (ROP) is an avoidable condition that affects premature infants exposed to oxygen stresses at or soon after birth. In low- and middle-income countries, like Nigeria, neonatal mortality rates are high and very few infants live to develop ROP. With recent better care, ROP is now being diagnosed.

OBJECTIVE

This study aimed to characterize what Nigerian neonatologists understand about ROP.

METHODS

At a joint meeting of Nigerian pediatric ophthalmologists and neonatologists in Kebbi State held 26-29 July 2018, questionnaires collected attendees' perspective and experience with ROP including causes, risk factors and experiences.

RESULTS

Fifty-one neonatologists out of 71 returned a completed questionnaire (response rate: 71.8%). The male:female ratio was 1:1.8, and approximately 40% were aged 41-50 years (n=20, 39.22%). Only 3 (6.39%) had experience managing infants below 500g that survived. A majority managed babies with a mean weight of 913g ± 300.37 and age of 27.87 weeks ±2.37. Most had no access to oxygen monitors (n=39,78%). Most had 10 babies to one monitor and used average settings of 90-95%. One third had seen a case of ROP (n=15,29.41%). Only 5.88% (n=3) were unaware of uncontrolled oxygen use as a risk factor. Only 4 (8.89%) had a functional screening team. None were aware of local screening guidelines.

CONCLUSIONS

Regular educational programs, collaborative clinical presentations and webinars about ROP targeted at the neonatologists and parents, including establishment of screening programs across country will likely help reduce the burden of ROP blindness in Nigeria.

Flying baby optical coherence tomography alters the staging and management of advanced retinopathy of prematurity

PURPOSE

To report the use of flying baby spectral domain optical coherence tomography (SD-OCT) on infants with advanced retinopathy of prematurity (ROP), where clinical findings alone failed to differentiate between retinoschisis and retinal detachment.

METHODS

Prospective, non-interventional case-series study of three premature infants with advanced ROP of clinically uncertain stage, after examination by indirect ophthalmoscopy. To confirm the diagnosis, table-mounted SD-OCT retinal imaging was performed with the infant held in the flying baby position under topical ocular anaesthesia only. Spectral domain optical coherence tomography (SD-OCT) findings were correlated with clinical examination and ultra-widefield scanning laser ophthalmoscopy to determine disease stage and appropriate management.

RESULTS

The flying baby position was well tolerated, and SD-OCT images of central and peripheral retina were successfully obtained in all three cases. Additional information provided by the SD-OCT changed the ROP staging from 3 to 4 in one case, which subsequently required surgical treatment. In two other cases, clinical suspicion of stage 4 ROP was overruled as SD-OCT revealed tractional retinoschisis rather than full-thickness retinal detachment, thereby avoiding the need for immediate surgical intervention.

CONCLUSIONS

In this case-series study, flying baby SD-OCT provided a rapid and widely accessible imaging approach that overruled clinical findings and altered classification and management of infants with advanced ROP. The methodology was suitable for outpatient settings with no risks associated with systemic anaesthesia. The increased use of OCT imaging will make apparent how structural information is useful in management of ROP and may influence future classification of the disease.

Stable incidence but regional differences in retinopathy of prematurity in Norway from 2009 to 2017

PURPOSE

To explore the changes over time and regional differences in the incidence of retinopathy of prematurity (ROP) in a national cohort of infants born <28 weeks' gestational age (GA).

METHODS

A population-based study of infants with GA <28 weeks in Norway from 2009 to 2017. Prospectively collected data on clinical variables and outcomes were obtained from the Norwegian Neonatal Network.

RESULTS

Of 1499 live-born infants transferred to a neonatal intensive care unit, 1156 were discharged alive. Four-hundred and fifty-eight infants (39.6%) had ROP, 152 (13.1%) had severe ROP, and 110 (9.5%) were treated for ROP. Eleven hundred infants (95.2%) had complete data sets. In a model comprising region of primary care, GA [odds ratios (OR): 0.65; 95% CI: 0.55-0.77], growth velocity (OR: 1.10; 95% CI: 1.00-2.00), medically treated patent ductus arteriosus (OR: 1.80; 95% CI: 1.19-2.72), weeks of supplemental oxygen (OR: 1.07; 95% CI: 1.03 to 1.11) and region of primary care (OR: 4.95; 95% CI: 3.05-8.04 for the pair of regions with the highest estimated OR) were significantly associated with severe ROP. Additionally, institutional differences for severe ROP were found, with ORs from 0.41 (95% CI: 0.05-3.23) to 5.36 (95% CI: 3.05-9.43) using the largest institution as reference. Incidences were stable over time after adjusting for GA. A larger proportion was treated with anti-vascular endothelial growth factor after 2011.

CONCLUSIONS

The incidence of severe ROP was stable between 2009 and 2017 in Norway. Regional and institutional differences need to be explored in future studies.

MicroRNA-126 inhibits pathological retinal neovascularization via suppressing vascular endothelial growth factor expression in a rat model of retinopathy of prematurity

Vascular endothelial growth factor (VEGF) is the principal growth factor responsible for the retinal neovascularization in the pathogenesis of retinopathy of prematurity (ROP). Current therapies for ROP include laser ablation and intravitreal anti-VEGF injection. However, these treatments either destroy the peripheral retina or associate with problems of persistent peripheral avascular retina or later recurrence of ROP. In the present study we investigated a new therapeutic approach by exploring the potential role of a specific microRNA, miR-126, in regulating VEGFA expression and retinal neovascularization in a rat oxygen-induced retinopathy (OIR) model. We demonstrated that miR-126 mimic and plasmid effectively suppresses VEGFA mRNA expression in both human and rat retinal pigment epithelium cell lines, quantified with qRT-PCR. Animal experiments on rat OIR model revealed that intravitreal injection of miR-126 plasmid efficiently downregulated VEGFA expression in the intraocular fluid and retinal tissues measured by ELISA, and significantly suppressed retinal neovascularization, which was confirmed by calculating sizes of neovascularization areas on fluorescence microscopic images of flat mounted retina stained with Alexa Fluor 594-conjugated isolectin B4 to visualize blood vessels. Together, these results showed that intravitreal injection of miR-126 plasmid could inhibit retinal neovascularization by down-regulating VEGFA expression, suggesting a potential therapeutic effect for ROP.

Retinal vessel architecture in retinopathy of prematurity and healthy controls using swept-source optical coherence tomography angiography

PURPOSE

To determine microvascular changes in children with a history of retinopathy of prematurity (ROP) and in a control group of full-term children.

METHODS

In a cross-sectional study, 30 eyes of 15 children aged 6-8 years with a history of ROP were evaluated with swept-source optical coherence tomography angiography (SS-OCTA). Twenty-eight eyes of 22 age-matched full-term children served as a healthy control group. The foveal avascular zone (FAZ), vessel density (VD) and choroidal vascular flow area (VFA) were evaluated on OCTA and correlated with central retinal thickness (CRT), visual acuity (VA), birth weight (BW), gestational age (GA) and ROP stages.

RESULTS

Twenty-two eyes of 14 children with a history of ROP (stage 1-3) and 25 eyes of 19 full-term children were available for evaluation. In the ROP group, the gestational age was 27 ± 2 weeks and birth weight was 781 ± 164 g. In the ROP group, CRT was higher in the central ETDRS segment (mean difference [95% CI]: 32.8 µm [18.7; 47.0], p = 0.0002) compared to the controls. Smaller mean FAZ area (-0.12 [-0.19; -0.04], p = 0.004) and perimeter (-662 [-1228; -96], p = 0.03) was found in comparison to the control group. An oval shape of the FAZ was observed among patients with a history of ROP. The mean central VD of the superficial plexus was 28 ± 8/23 ± 8% and of the deep plexus 7 ± 7/3 ± 5% (ROP group/control group; p > 0.05). No statistically significant difference was found regarding the choroidal VFA. Only weak correlation of FAZ and VD with function was observed.

CONCLUSIONS

Swept-source optical coherence tomography angiography imaging revealed significant microvascular anomalies in children with a history of ROP indicating disturbance of early morphological development of the central retina.

Quantitatively comparing weekly changes in retinal vascular characteristics of eyes eventually treated versus not treated for retinopathy of prematurity

PURPOSE

To quantitatively compare retinal vascular characteristics over time in eyes eventually treated versus not treated for retinopathy of prematurity (ROP), using ROPtool analysis of narrow-field retinal images.

METHODS

This longitudinal study used prospectively collected narrow-field retinal images of infants screened for ROP, prior to treatment, if needed. Images were analyzed using a methodology that combines quadrant-level measures from several images of the same eye. For the longitudinal analysis, one examination per postmenstrual age (PMA) was included per eye. We compared the following ROPtool indices and their change per week between eyes eventually treated versus not treated for ROP: tortuosity index (TI), dilation index (DI), sum of adjusted indices (SAI), and tortuosity-weighted plus (TWP). Analysis was performed on three levels: eye (mean value/eye), quadrant (highest quadrant value/eye), and blood vessel (highest blood vessel value/eye).

RESULTS

Of 832 examinations (99 infants), 745 images (89.5%) had 3-4 quadrants analyzable by ROPtool. On the eye level, ROPtool indices differed between eyes eventually treated versus not treated at PMA of 33-35 and 37 weeks for TI, SAI, and TWP, and at PMA of 33-34 and 37 weeks for DI (P ≤ 0.0014), and change per week differed between eyes eventually treated versus not treated only for SAI at PMA of 32 weeks (P < 0.001).

CONCLUSIONS

Quantitative analysis of retinal vascular characteristics using ROPtool can help predict eventual need for treatment for ROP as early as 32 weeks PMA. ROPtool index values were more useful than change in these indices to predict eyes that would eventually need treatment for ROP.

Three-dimensional Imaging Coupled with Topological Quantification Uncovers Retinal Vascular Plexuses Undergoing Obliteration

Introduction: Murine models provide microvascular insights into the 3-D network disarray seen in retinopathy and cardiovascular diseases. Light-sheet fluorescence microscopy (LSFM) has emerged to capture retinal vasculature in 3-D, allowing for assessment of the progression of retinopathy and the potential to screen new therapeutic targets in mice. We hereby coupled LSFM, also known as selective plane illumination microscopy, with topological quantification, to characterize the retinal vascular plexuses undergoing preferential obliteration. Method and Result: In postnatal mice, we revealed the 3-D retinal microvascular network in which the vertical sprouts bridge the primary (inner) and secondary (outer) plexuses, whereas, in an oxygen-induced retinopathy (OIR) mouse model, we demonstrated preferential obliteration of the secondary plexus and bridging vessels with a relatively unscathed primary plexus. Using clustering coefficients and Euler numbers, we computed the local versus global vascular connectivity. While local connectivity was preserved (p > 0.05, n = 5 vs. normoxia), the global vascular connectivity in hyperoxia-exposed retinas was significantly reduced (p < 0.05, n = 5 vs. normoxia). Applying principal component analysis (PCA) for auto-segmentation of the vertical sprouts, we corroborated the obliteration of the vertical sprouts bridging the secondary plexuses, as evidenced by impaired vascular branching and connectivity, and reduction in vessel volumes and lengths (p < 0.05, n = 5 vs. normoxia). Conclusion: Coupling 3-D LSFM with topological quantification uncovered the retinal vasculature undergoing hyperoxia-induced obliteration from the secondary (outer) plexus to the vertical sprouts. The use of clustering coefficients, Euler's number, and PCA provided new network insights into OIR-associated vascular obliteration, with translational significance for investigating therapeutic interventions to prevent visual impairment.

Rate and Treatment of Retinopathy of Prematurity in Extremely Low Birth Weight Infants with Gestational Age ≤28 Weeks in Eastern China

Purpose

To investigate the incidence and clinical characteristics of ROP in extremely preterm (EP) and extremely low birth weight (ELBW) infants in eastern China.

Patients and Methods

This retrospective study included 104 infants with a birth weight (BW) ≤ 1000 g and gestational age (GA) ≤ 28 weeks, who were admitted to the Eye and ENT Hospital of Fudan University over 10 years. The infants were examined for ROP with RetCam. Infants with type 1 ROP and aggressive posterior ROP (AP-ROP) were treated. The risk factors evaluated were GA and BW.

Results

Mean GA was 26.63 ± 0.88 weeks and mean BW was 892.39 ± 108.06 g. Of the 104 infants, 83 (79.8%) developed ROP, three (2.9%) had AP-ROP, 14 (13.5%) had type 1 ROP, and 10 (9.6%) had type 2 ROP. The proportions of infants with BW ≤750 g and 751-1000 g were 8.7% and 91.3%, respectively, and the incidences of severe ROP in these infants were 22.2% and 15.8%, respectively. The infants with severe ROP had a mean GA of 26.56 ± 0.68 weeks and mean BW of 860.00 ± 163.48 g, and 47.1% of severe ROP occurred in infants with a GA of 26 weeks. However, multivariate logistic regression showed that the severity of ROP was not directly inversely related to GA or BW in this study population.

Conclusion

In EP and ELBW Chinese infants, who were admitted to the Eye and ENT Hospital of Fudan University, the development of ROP was more frequent and the incidence of severe ROP that progressed to the stage that required treatment was high.

Risk factors for myopia at 1-year corrected age following laser photocoagulation for retinopathy of prematurity

BACKGROUND/OBJECTIVES

The prevalence of myopia is higher in preterm infants who underwent laser photocoagulation (LPC) for retinopathy of prematurity (ROP). The aim of this study was to investigate factors associated with myopia in preterm infants who undergo LPC for ROP.

SUBJECTS/METHODS

We retrospectively analysed the medical records of preterm infants born at Kyushu University Hospital (October 2008-March 2018) at ≤32 weeks of gestational age or with birth weight ≤1500 g. We evaluated the associations between nine clinical factors and the spherical equivalent at 1-year corrected age by performing multivariable linear regression in LPC-treated ROP patients.

RESULTS

Among the 485 infants enroled, 76 developed ROP requiring treatment. Of these, 71 underwent LPC, which was provided to 63 infants as the primary treatment (LPC alone or the combination therapy of LPC and intravitreal injection of bevacizumab [IVB]) and to eight infants as additional LPC after IVB monotherapy. The results of a refractive examination at 1-year corrected age were available for 110 eyes of 56 infants (78.9%). The mean ± standard deviation of the SE value was -0.5 ± 3.0 dioptres (D). Multivariable linear regression analysis revealed a significant association between laser spot count and SE value (ß = -0.081 ± 0.040 D per 100 spots [mean ± standard error], p = 0.045).

CONCLUSIONS

Our results suggest that an increased laser spot count observed during ROP treatment associates with myopia.

An inhibitor of endothelial ETS transcription factors promotes physiologic and therapeutic vessel regression

During the progression of ocular diseases such as retinopathy of prematurity and diabetic retinopathy, overgrowth of retinal blood vessels results in the formation of pathological neovascular tufts that impair vision. Current therapeutic options for treating these diseases include antiangiogenic strategies that can lead to the undesirable inhibition of normal vascular development. Therefore, strategies that eliminate pathological neovascular tufts while sparing normal blood vessels are needed. In this study we exploited the hyaloid vascular network in murine eyes, which naturally undergoes regression after birth, to gain mechanistic insights that could be therapeutically adapted for driving neovessel regression in ocular diseases. We found that endothelial cells of regressing hyaloid vessels underwent down-regulation of two structurally related E-26 transformation-specific (ETS) transcription factors, ETS-related gene (ERG) and Friend leukemia integration 1 (FLI1), prior to apoptosis. Moreover, the small molecule YK-4-279, which inhibits the transcriptional and biological activity of ETS factors, enhanced hyaloid regression in vivo and drove Human Umbilical Vein Endothelial Cells (HUVEC) tube regression and apoptosis in vitro. Importantly, exposure of HUVECs to sheer stress inhibited YK-4-279-induced apoptosis, indicating that low-flow vessels may be uniquely susceptible to YK-4-279-mediated regression. We tested this hypothesis by administering YK-4-279 to mice in an oxygen-induced retinopathy model that generates disorganized and poorly perfused neovascular tufts that mimic human ocular diseases. YK-4-279 treatment significantly reduced neovascular tufts while sparing healthy retinal vessels, thereby demonstrating the therapeutic potential of this inhibitor.

Does the number of laser applications for ROP treatment influence the degree of myopia?

PURPOSE

To evaluate the relationship between the number of laser shots applied during laser photocoagulation treatment and the degree of myopia at 3 years in children with laser-treated retinopathy of prematurity (ROP).

METHOD

A total of 68 eyes of 34 infants who had developed prethreshold ROP and were treated by diode laser therapy were included in the current study. Cycloplegic retinoscopic refraction testing was performed in the children at the age of 3 years, and the spherical equivalent (SE) was calculated for all the examined eyes. The number of laser shots that had been applied was compared between the eyes with and without high myopia (SE < - 5 diopters (D)). In addition, the relationship between the difference in the SE values between the two eyes in each infant and the difference in the number of laser shots applied between the two eyes was also analyzed.

RESULTS

The number of laser shots applied was significantly higher for the eyes with high myopia than for those without high myopia (p = 0.0088), and the number of laser shots applied was significantly positively correlated with the degree of myopia (p < 0.001). A significant correlation was also observed between the differences in the SE values between the two eyes and the differences in the number of laser shots applied between the two eyes (p = 0.0013).

CONCLUSION

The number of laser shots applied in photocoagulation treatment for ROP is significantly associated with the degree of myopia seen subsequently in the children.

Deep Learning Models for Automated Diagnosis of Retinopathy of Prematurity in Preterm Infants

Retinopathy of prematurity (ROP) is a disease that can cause blindness in premature infants. It is characterized by immature vascular growth of the retinal blood vessels. However, early detection and treatment of ROP can significantly improve the visual acuity of high-risk patients. Thus, early diagnosis of ROP is crucial in preventing visual impairment. However, several patients refrain from treatment owing to the lack of medical expertise in diagnosing the disease; this is especially problematic considering that the number of ROP cases is on the rise. To this end, we applied transfer learning to five deep neural network architectures for identifying ROP in preterm infants. Our results showed that the VGG19 model outperformed the other models in determining whether a preterm infant has ROP, with 96% accuracy, 96.6% sensitivity, and 95.2% specificity. We also classified the severity of the disease; the VGG19 model showed 98.82% accuracy in predicting the severity of the disease with a sensitivity and specificity of 100% and 98.41%, respectively. We performed 5-fold cross-validation on the datasets to validate the reliability of the VGG19 model and found that the VGG19 model exhibited high accuracy in predicting ROP. These findings could help promote the development of computer-aided diagnosis.

Automated detection of early-stage ROP using a deep convolutional neural network

BACKGROUND/AIM

To automatically detect and classify the early stages of retinopathy of prematurity (ROP) using a deep convolutional neural network (CNN).

METHODS

This retrospective cross-sectional study was conducted in a referral medical centre in Taiwan. Only premature infants with no ROP, stage 1 ROP or stage 2 ROP were enrolled. Overall, 11 372 retinal fundus images were compiled and split into 10 235 images (90%) for training, 1137 (10%) for validation and 244 for testing. A deep CNN was implemented to classify images according to the ROP stage. Data were collected from December 17, 2013 to May 24, 2019 and analysed from December 2018 to January 2020. The metrics of sensitivity, specificity and area under the receiver operating characteristic curve were adopted to evaluate the performance of the algorithm relative to the reference standard diagnosis.

RESULTS

The model was trained using fivefold cross-validation, yielding an average accuracy of 99.93%±0.03 during training and 92.23%±1.39 during testing. The sensitivity and specificity scores of the model were 96.14%±0.87 and 95.95%±0.48, 91.82%±2.03 and 94.50%±0.71, and 89.81%±1.82 and 98.99%±0.40 when predicting no ROP versus ROP, stage 1 ROP versus no ROP and stage 2 ROP, and stage 2 ROP versus no ROP and stage 1 ROP, respectively.

CONCLUSIONS

The proposed system can accurately differentiate among ROP early stages and has the potential to help ophthalmologists classify ROP at an early stage.

Gene expression profile analysis of the rabbit retinal vein occlusion model

The rabbit retinal vein occlusion (RVO) model is an experimental system that mimics retinal ischemic diseases in humans. The rabbit RVO model is widely used to assess the therapeutic efficacy of various experimental surgical procedures. In the present study, we measured temporal retinal expression of Vegfa, which is known as an ischemic response gene, in rabbit RVO. This analysis revealed that the retinal Vegfa transcriptional response began 7 days after generation of RVO, rather than immediately after induction of ischemia. Next, in order to analyze ischemia-induced changes in gene expression profiles, we performed microarray analysis of day 7 RVO retina versus control retina. The angiogenic regulators Dcn and Mmp1 and pro-inflammatory factors Mmp12 and Cxcl13 were significantly upregulated in RVO retinas. Further, we suggest that epigenetic regulation via the REST/cofactor-complex could contribute to RVO pathology. Among human homologous genes in rabbits, genes associated with hypoxia, angiogenesis, and inflammation were significantly upregulated in RVO retinas. Components of the Tumor necrosis factor-alpha (TNFα) and Nuclear factor-kappa B (NF-κB) pathways, which play regulatory roles in angiogenesis and inflammation, were significantly upregulated in RVO, and the expression levels of downstream factors, such as the transcription factor AP-1 and chemokines, were increased. Further, connectivity map analyses suggested that inhibitors of the NF-κB pathway are potential therapeutic agents for retinal ischemic disease. The present study revealed new insights into the pathology of retinal ischemia using the rabbit RVO model, which accurately recapitulates human disease.

Resilience, anxiety and depression, coping style, social support and their correlation in parents of premature infants undergoing outpatient fundus examination for retinopathy of prematurity

Retinopathy of prematurity (ROP) has become the main cause of blindness in children. To study resilience, anxiety and depression, coping style and social support and their correlation in parents of premature infants undergoing outpatient fundus examination for ROP, and thereby provide evidence for clinical intervention. Questionnaire surveys were conducted by using General Information Questionnaire, Connor-Davidson Resilience Scale, Self-rating Anxiety Scale, Self-rating Depression Scale, Social Support Scale, and the Simplified Coping Style Questionnaire. The resilience in the parents scored (63.24 ± 12.97) points, which was lower than that of Chinese norm (t = 2.309, P < 0.05). The scores of anxiety and depression were higher than those of Chinese norm (t = 12.592, t = 2.362, both P < 0.05). The score of social support was lower than that of Chinese norm (t = 3.793, p < 0.01). Resilience was negatively correlated with anxiety and depression (r = -0.287, -0.358, both P < 0.01), and positively correlated with coping tendency and social support (r = 0.299, 0.139, both P < 0.05). These findings suggested that the parents have low resilience, high levels of anxiety and depression, and low level of social support. Medical staff should assess and improve their psychological status.

Risk factors associated with avascular fibrous membrane in patients with retinopathy of prematurity

PURPOSE

We sought to assess the risk factors associated with avascular fibrous membrane development in patients with retinopathy of prematurity (ROP).

METHODS

This retrospective, cross-sectional study included premature infants diagnosed with ROP. Gestational age, birth weight, stage and zone of the ROP, the presence of plus disease, and laser photocoagulation (LP) application were noted for each patient. Location, extension, development time, vanishing time of the avascular fibrous membrane, and associated complications were also noted. Patients who developed avascular fibrous membrane formed the membrane group (n = 38) and those who did not develop avascular fibrous membrane formed the control group (n = 208).

RESULTS

Mean gestational age and birth weight did not differ between the groups (p = 0.897 and p = 0.343). ROP developed significantly earlier in the control group than in the membrane group (p < 0.001). The patients in the control group underwent LP treatment significantly earlier than did patients in the membrane group (p < 0.001). Regression analysis showed that higher postmenstrual age at the time of ROP diagnosis increased the risk of avascular fibrous membrane development by up to 1.6-fold (p = 0.002; 95% CI 1.2-2.3) and later LP treatment was associated with a 3.3-fold increased risk of avascular fibrous membrane development (p = 0.003; 95% CI 1.5-7.3).

CONCLUSIONS

Late-onset ROP and later LP treatment were found to be associated with an increased risk of avascular fibrous membrane development in patients with ROP.

Update on Anti-Vascular Endothelial Growth Factor Safety for Retinopathy of Prematurity

Retinopathy of prematurity (ROP) is a neovascular retinal disorder that occurs in infants born prematurely. Nowadays, ROP constitutes a leading cause of childhood blindness worldwide and for decades the standard of care has involved peripheral retinal ablation. However, this type of treatment requires the use of specialized equipment by well-trained physicians, has been associated with poor structural and visual outcomes in some preterm infants, and despite its adequate application, some cases of ROP may continue to progress. Therefore, the need for simpler and more efficient strategies made anti-vascular endothelial growth factor (anti-VEGF) medications an appealing option for treatment. Recently, the use of anti-VEGF agents for ROP has increased worldwide; nevertheless, this practice remains off-label, and there is a lack of information regarding its safety profile and the possibility of unfavorable long-term outcomes causes the utmost concern. This review updates the recent evidence regarding the systemic and ocular safety of anti-VEGF treatment for ROP.

Ursodeoxycholic Acid Halts Pathological Neovascularization in a Mouse Model of Oxygen-Induced Retinopathy

Retinopathy of prematurity (ROP) is the leading cause of blindness in infants. We have investigated the efficacy of the secondary bile acid ursodeoxycholic acid (UDCA) and its taurine and glycine conjugated derivatives tauroursodeoxycholic acid (TUDCA) and glycoursodeoxycholic acid (GUDCA) in preventing retinal neovascularization (RNV) in an experimental model of ROP. Seven-day-old mice pups (P7) were subjected to oxygen-induced retinopathy (OIR) and were treated with bile acids for various durations. Analysis of retinal vascular growth and distribution revealed that UDCA treatment (50 mg/kg, P7-P17) of OIR mice decreased the extension of neovascular and avascular areas, whereas treatments with TUDCA and GUDCA showed no changes. UDCA also prevented reactive gliosis, preserved ganglion cell survival, and ameliorated OIR-induced blood retinal barrier dysfunction. These effects were associated with decreased levels of oxidative stress markers, inflammatory cytokines, and normalization of the VEGF-STAT3 signaling axis. Furthermore, in vitro tube formation and permeability assays confirmed UDCA inhibitory activity toward VEGF-induced pro-angiogenic and pro-permeability effects on human retinal microvascular endothelial cells. Collectively, our results suggest that UDCA could represent a new effective therapy for ROP.

Late-Onset Retinal Findings and Complications in Untreated Retinopathy of Prematurity

PURPOSE

To investigate late retinal findings and complications of eyes with a history of retinopathy of prematurity (ROP) that did not meet treatment criteria and did not receive treatment during infancy.

DESIGN

Retrospective, nonconsecutive, noncomparative, multicenter case series.

PARTICIPANTS

Three hundred sixty-three eyes of 186 patients.

METHODS

Data were requested from multiple providers on premature patients with a history of ROP and no treatment during infancy who demonstrated late retinal findings or complications and included age, gender, gestational age and weight, zone and stage at infancy, visual acuity, current retina vascularization status, vitreous character, presence of peripheral retinal findings such as lattice retinal tears and detachments (RDs), retinoschisis, and fluorescein findings.

MAIN OUTCOME MEASURES

Rate of RDs and factors conferring a higher risk of RDs.

RESULTS

The average age was 34.5 years (range, 7-76 years), average gestational age was 26.6 weeks (range, 23-34 weeks), and average birth weight was 875 g (range, 425-1590 g). Findings included lattice in 196 eyes (54.0%), atrophic holes in 126 eyes (34.7%), retinal tears in 111 eyes (30.6%), RDs in 140 eyes (38.6 %), tractional retinoschisis in 44 eyes (11.9%), and visible vitreous condensation ridge-like interface in 112 eyes (30.5%). Fluorescein angiography (FA) was performed in 113 eyes, of which 59 eyes (52.2%) showed leakage and 16 eyes (14.2%) showed neovascularization. Incomplete vascularization posterior to zone 3 was common (71.6% of eyes). Retinal detachments were more likely in patients with a gestational age of 29 weeks or less (P < 0.05) and in eyes with furthest vascularization to posterior zone 2 eyes compared with zone 3 eyes (P = 0.009).

CONCLUSIONS

Eyes with ROP not meeting the treatment threshold during infancy showed various late retinal findings and complications, of which RDs were the most concerning. Complications were seen in all age groups, including patients born after the Early Treatment for Retinopathy of Prematurity Study. Contributing factors to RDs included atrophic holes within peripheral avascular retina, visible vitreous condensation ridge-like interface with residual traction, and premature vitreous syneresis. We recommend regular examinations and consideration of ultra-widefield FA examinations. Prospective studies are needed to explore the frequency of complications and benefit of prophylactic treatment and if eyes treated with anti-vascular endothelial growth factor therapy are at risk of similar findings and complications.

Association of small for gestational age with retinopathy of prematurity: a systematic review and meta-analysis

CONTEXT

The association between small for gestational age (SGA) and retinopathy of prematurity (ROP) is unclear.

OBJECTIVE

A systematic review and meta-analysis was conducted to evaluate the association between ROP and SGA in preterm infants <37 weeks' gestational age (GA) admitted to neonatal intensive care unit.

METHODS

Medline, PubMed, Web of Science and Cochrane Central databases were searched from inception through 15 January 2019. Studies reporting outcomes based on SGA as the primary exposure variable were included. Data were extracted independently by two coauthors. Modified Newcastle-Ottawa scale was used for risk of bias assessment.

RESULTS

Database search yielded 536 records (Medline=152, PubMed=171, Web of Science=144 and Cochrane Central=69). Twenty-one studies evaluating 190 946 infants were included. SGA was associated with significantly higher odds of any stage of ROP on unadjusted analysis (unadjusted OR (uOR) 1.55; 95% CI 1.22 to 1.98; 10 studies) but not on adjusted analysis (adjusted OR (aOR) 2.16; 95% CI 0.66 to 7.11; 3 studies). SGA was associated with significantly higher odds of severe ROP (aOR 1.92; 95% CI 1.57 to 2.34; nine studies). SGA was also significantly associated with higher odds of treated ROP (aOR 1.39; 95% CI 1.18 to 1.65; three studies). In subgroup analysis of infants <29 weeks' GA, SGA was significantly associated with increased odds of ROP (uOR 1.64; 95% CI 1.19 to 2.26; two studies), severe ROP (aOR 1.61; 95% CI 1.23 to 2.10; four studies) and treated ROP (aOR 1.37; 95% CI 1.16 to 1.62; two studies).

CONCLUSION

SGA was associated with increased odds of any stage of ROP, severe ROP and treated ROP in preterm infants. Neonatologists should incorporate SGA into the risk assessment during ROP evaluation and while providing counselling to the families of preterm SGA infants. ROP screening guidelines should look into the frequency of follow-up examination in SGA infants in aim to offer early detection and treatment.

Treatment of retinopathy of prematurity (ROP) outside International Classification of ROP (ICROP) guidelines

AIM

To evaluate the incidence and clinical indications for which eyes were treated for retinopathy of prematurity (ROP) outside the guidelines set by International Classification of ROP (ICROP).

METHODS

Medical records of the patients treated at a single tertiary care ophthalmology hospital for ROP from January 2016 to December 2019 were retrospectively analysed to evaluate the indications for which they were treated.

RESULTS

Out of 241 eyes, 33 eyes (13.7%) were treated outside the guidelines. The reasons for the treatment outside the guidelines were structural changes (n = 24, 72.7%), persistent stage 3 ROP that did not show any sign of regression for 6 weeks (n = 7, 21.2%) and active ROP with fellow eye being treated (n = 2, 6.1%). The recorded specific structural changes were tangential traction with temporal vessel straightening concerning for macular distortion and ectopia (n = 5, 15.2%), and stage 3 neovascularisation or ridge with anteroposterior traction with risk of progression to stage 4 disease (n = 19, 57.6%). Pre-plus disease was present in 11 eyes (33.3%).After the treatment, ROP stages regressed and retinal vessels grew either until the ora or at least into zone III in all the treated eyes. None of the eyes showed worsening of structural changes after treatment. The mean follow-up of the patients was 12.4 ± 11.7 months.

CONCLUSION

Experts occasionally recommend treatment in eyes with disease milder than type 1 ROP. This study may help paediatric retinal practitioners in decision-making in borderline cases.

Neonatal oxygen therapy in low- and middle-income countries: a pragmatic review

Background

We assessed and summarized the peer-reviewed literature on the state of neonatal oxygen therapy in low and lower-middle income countries.

Methods

A literature search was performed in 3 online databases (Pub Med, EMBASE, CAB Global Health) and amongst USAID’s Service Provision Assessment (SPA) reports for publications pertaining to neonatal oxygen therapy in low and lower-middle income countries over the past 10 years (2007-2017).

Results

Our search yielded 474 records, of which 26 were relevant and included in the review. Maintenance and indirect costs associated with the procurement of oxygen may constitute barriers to oxygen supply. The quality of therapy provided to neonates was affected by factors including a lack of necessary equipment at neonatal healthcare facilities and high indirect costs associated with the procurement of oxygen. Pulse oximeters used for monitoring of oxygen therapy were available in healthcare facilities, but there is scant data on the frequency of that monitoring. There are some hospitals that deliver neonatal oxygen therapy without any necessary monitoring equipment. Prevalence of retinopathy of prematurity among neonates with risk factors ranged from 11.9-47.2%, which is notably higher than published rates in neonates of similar gestational age being treated in high-income countries.

Conclusion

There is a lack of data that provides direct estimates of availability of neonatal oxygen equipment and related clinical applications of oxygen therapy across health systems, particularly around the usage and availability of necessary monitoring equipment. Attention to the maintenance of oxygen and ancillary equipment for neonates and quality improvement initiatives to promote adherence to those guidelines can reduce the morbidity and mortality burden among neonates in low and lower-middle income countries.

Screening premature infants for retinopathy of prematurity in a tertiary hospital in Saudi Arabia

BACKGROUND

Early detection of retinopathy of prematurity (ROP) in preterm infants is critical, especially with advancements in neonatal care and improved survival rates. However, a balance should be found between not missing any ROP requiring treatment and minimizing workload, saving resources, and reducing unnecessary examinations to fragile neonates.

OBJECTIVE

Ascertain whether our current inclusion criteria in screening ROP could be modified to ≤1250 g (while keeping the gestational age at ≤30 6/7 weeks) to reduce the number of screened babies without missing any type I ROP requiring treatment.

DESIGN

Retrospective, record-based study.

SETTING

Referral center.

MAIN OUTCOME MEASURES

ROP outcome and risk factors.

PATIENTS AND METHODS

Neonates screened for ROP in the neonatal intensive care unit of our institution between January 2016 and November 2018 were included. Data collected for each neonate included demographics, ROP details and risk factors. We used a revised version of ROP screening guidelines by the American Academy of Pediatrics.

SAMPLE SIZE AND CHARACTERISTICS

155 neonates (median birth weight, 1035 g; range, 527-1982 g; and gestational age range, 23-39 weeks).

RESULTS

Of 1393 live births, 155 babies met the inclusion criteria. ROP occurred in 60/155 (38.7%) screened babies while sixteen developed threshold ROP. All 16 babies who required treatment had both a birthweight ≤1000 g and a gestational age of ≤30 weeks. Using the screening recommendations of the Canadian Policy, more infants would have been screened without diagnosing a case of ROP of any stage, and no case of ROP requiring treatment would have been missed compared to the AAP recommendations.

CONCLUSION

ROP requiring treatment is a rare occurrence in premature infants with a gestational age >30 weeks and body weight >1000 g at our institute. Nonetheless, this is not an attempt to alter national screening guidelines. A multicenter prospective study with an adequate sample size is needed to assess whether guidelines for ROP screening should be altered in this category of neonates.

LIMITATIONS

Retrospective design.

CONFLICT OF INTEREST

None.

Trans-pars-planar illumination enables a 200° ultra-wide field pediatric fundus camera for easy examination of the retina

This study is to test the feasibility of using trans-pars-planar illumination for ultra-wide field pediatric fundus photography. Fundus examination of the peripheral retina is essential for clinical management of pediatric eye diseases. However, current pediatric fundus cameras with traditional trans-pupillary illumination provide a limited field of view (FOV), making it difficult to access the peripheral retina adequately for a comprehensive assessment of eye conditions. Here, we report the first demonstration of trans-pars-planar illumination in ultra-wide field pediatric fundus photography. For proof-of-concept validation, all off-the-shelf optical components were selected to construct a lab prototype pediatric camera (PedCam). By freeing the entire pupil for imaging purpose only, the trans-pars-planar illumination enables a 200° FOV PedCam, allowing easy visualization of both the central and peripheral retina up to the ora serrata. A low-cost, easy-to-use ultra-wide field PedCam provides a unique opportunity to foster affordable telemedicine in rural and underserved areas.

Effects of Congenital Ocular Toxoplasmosis on Peripheral Retinal Vascular Development in Premature Infants at Low Risk for Retinopathy of Prematurity

Congenital toxoplasmosis and retinopathy of prematurity (ROP) are two devastating clinical entities of the newborn. There is little information in the literature about the interaction between congenital infections and retinal vascular development at the fetal stage, and none regarding the relationship between ROP and congenital toxoplasmosis. In this report, we present two premature newborns diagnosed with congenital toxoplasmosis with ocular involvement, accompanied by ROP with interrupted retinal vascularization, peripheral avascular regions, and retinal detachment. The aim of this paper is to emphasize the possibility of ROP and congenital toxoplasmosis coexistence wherein one condition may mask the other and make it difficult to distinguish the cause of retinal detachment. Timely management with medical and surgical treatment of congenital toxoplasmosis and ROP could save eyes and vision in those cases.

Can IL-33 and Endocan be New Markers for Retinopathy of Prematurity?

BACKGROUND

Retinopathy of Prematurity (ROP) is a pathophysiologic condition of the retina due to abnormal proliferation of retinal vessels.

OBJECTIVE

The study aimed too ascertain the importance of vascular endothelial growth factor (VEGF), insulin-like growth factor-1 (IGF-1), interleukin-33 (IL-33) and endocan in the diagnosis and follow-up of ROP.

METHODS

This prospective cohort study was conducted in the neonatal intensive care unit (NICU) of Health Science University, Zekai Tahir Burak Maternity Teaching Hospital, Ankara, Turkey, between February 2017 and August 2018. Preterm infants (gestational age (GA) of ≤32 weeks and birth weight of ≤1500 gr), diagnosed ROP were included in the study. VEGF, IGF-1, IL-33 and endocan levels were evaluated in the cord blood and in the serum before and after treatment of infants in the ROP and control groups.

RESULTS

A final number of 146 infants were included in the study. During the study period, 73 infants were identified as the ROP group, and 73 infants were allocated as the control group. In the ROP group, the cord blood VEGF value was higher than the control group (p <0.05). However, IGF-1 levels in the cord blood were lower in the ROP group than control (P<0.05). IL-33 and endocan values in the cord blood were similar in both control and ROP groups (p>0.05). Although serum levels of IL-33, VEGF and endocan were higher before laser treatment, these biomarkers decreased significantly after laser treatment (p <0.05).

CONCLUSION

We determined that serum IL-33 and endocan levels might be suggested as sensitive novel markers for the prediction of severe ROP.

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.

Autonomous early detection of eye disease in childhood photographs

The "red reflex test" is used to screen children for leukocoria ("white eye") in a standard pediatric examination, but is ineffective at detecting many eye disorders. Leukocoria also presents in casual photographs. The clinical utility of screening photographs for leukocoria is unreported. Here, a free smartphone application (CRADLE: ComputeR-Assisted Detector of LEukocoria) was engineered to detect photographic leukocoria and is available for download under the name "White Eye Detector." This study determined the sensitivity, specificity, and accuracy of CRADLE by retrospectively analyzing 52,982 longitudinal photographs of children, collected by parents before enrollment in this study. The cohort included 20 children with retinoblastoma, Coats' disease, cataract, amblyopia, or hyperopia and 20 control children. For 80% of children with eye disorders, the application detected leukocoria in photographs taken before diagnosis by 1.3 years (95% confidence interval, 0.4 to 2.3 years). The CRADLE application allows parents to augment clinical leukocoria screening with photography.

Rapidly Developing Large Bilateral Cataracts in a 58-Year-Old Woman After Only 46 Hyperbaric Oxygen Treatments

We are reporting a 52-year-old female that developed documented vision impairing, large, bilateral nuclear and cortical cataracts during therapy after 46 treatments of a planned 60 treatment course of HBO2 for a non-healing post-radiation leg wound. A review of the available literature makes this one of the earliest cases of cataract formation.

Changing patterns of early childhood blinding conditions presenting to a tertiary eye center: The epidemic of retinopathy of prematurity in India

Purpose:

Retinopathy of prematurity (ROP) is now emerging as one of the major causes of preventable childhood blindness. The proportion of preterm babies has increased dramatically over the past decade. Our study aims to emphasize the need for ROP screening and management services in these preterm infants.

Methods:

ICD-coded medical records of children less than 10 years of age presenting to a subspecialty eye hospital from 2000 to 2017 were reviewed. ROP, congenital cataract, congenital glaucoma, and vitamin A deficiency were the most common diagnoses. We evaluated the trend of these diseases from 2000 to 2017.

Results:

Our data suggested a 20-fold increase in the attendance of children with a diagnosis of ROP who now make over 2% of outpatient children. Vitamin A deficiency has declined over time whereas cataract and glaucoma have remained stable.

Conclusion:

Our data indicate a need to scale up ROP screening integrated with neonatal care, as well as to build capacity for the treatment of acute and late-stage ROP in India.

The process of retinal vascularization in retinopathy of prematurity after ranibizumab treatment in China

AIM

To explore the process of retinal vascularization and risk factors for retinopathy of prematurity (ROP) treated with intravitreal ranibizumab (IVR) as monotherapy.

METHODS

Infants with type 1 ROP who received IVR as primary treatment from August 2014 to October 2016 at Peking University People's Hospital's Ophthalmology Department were included in the study. All eyes received 0.25 mg ranibizumab at initial treatment. Retinal vascularization was evaluated clinically. Potential risk factors were also recorded and examined.

RESULTS

Retinal vascularization was completed in 126 eyes (62.7%), and retinal vascularization terminated in zone II and zone III with 16 eyes (7.9%) and 44 eyes (21.9%), respectively, after more than 1-year follow-up. In multivariate regression analysis, lower birth weight (BW), severity of ROP and repeated injections were found to be risk factors for peripheral avascular area (P<0.05).

CONCLUSION

In our retrospective study, 29.8% of the ROP eyes treated with ranibizumab have peripheral avascular area at the last follow-up. Lighter BW and the severity of ROP are risk factors. Furthermore, repeated injections also increase the risk of retinal peripheral avascular area remaining in ROP patients.

IL-1 Family Members Mediate Cell Death, Inflammation and Angiogenesis in Retinal Degenerative Diseases

Inflammation underpins and contributes to the pathogenesis of many retinal degenerative diseases. The recruitment and activation of both resident microglia and recruited macrophages, as well as the production of cytokines, are key contributing factors for progressive cell death in these diseases. In particular, the interleukin 1 (IL-1) family consisting of both pro- and anti-inflammatory cytokines has been shown to be pivotal in the mediation of innate immunity and contribute directly to a number of retinal degenerations, including Age-Related Macular Degeneration (AMD), diabetic retinopathy, retinitis pigmentosa, glaucoma, and retinopathy of prematurity (ROP). In this review, we will discuss the role of IL-1 family members and inflammasome signaling in retinal degenerative diseases, piecing together their contribution to retinal disease pathology, and identifying areas of research expansion required to further elucidate their function in the retina.

The safety and effectiveness of 0.16 mg bevacizumab plus or minus additional laser photocoagulation in the treatment of retinopathy of prematurity

Purpose

Retinopathy of prematurity (ROP) is the leading cause of preventable blindness in premature infants. Antivascular endothelial growth factor (anti-VEGF) therapy has been used increasingly in treatment as a pharmacological alternative to laser therapy. In this study, we evaluate the results of low-dose anti-VEGF treatments.

Methods

Design: Retrospective--observational study. Infants who had been evaluated for ROP disease between February 2016 and February 2017 were assessed. We retrospectively reviewed the ROP stages, treatment results, and complications. Laser photocoagulation (LPC) and intravitreal bevacizumab (0.16 mg IVB) were used for treatment and fundus fluorescein angiography (FFA) was also performed in some of the cases.

Results

IVB was applied to 43 infants. A macular hole was seen in one infant's eye after IVB. LPC was applied to avascular areas in 21 infants. In three patients, persistence of the disease was observed after administration of a low dose of IVB. Additional LFK was performed in these patients. None of the infants who received LPC had any complications.

Conclusion

IVB is increasingly becoming the first-line treatment for ROP. For severe ROP, 0.16 mg IVB is effective. Using LPC to treat avascular areas after 70 weeks' gestational age (GA) may decrease the risk of late recurrence and appears to be a safe treatment to use.

Neurodevelopmental Outcomes after Intravitreal Bevacizumab Therapy for Retinopathy of Prematurity: A Prospective Case-Control Study

PURPOSE

To evaluate the neurodevelopmental and ocular developmental outcomes in premature children who have undergone intravitreal bevacizumab injection (IVB) for treatment of type 1 retinopathy of prematurity (ROP).

DESIGN

Prospective case-control study.

PARTICIPANTS

We enrolled 3 groups of premature patients: premature children who had no history of ROP (group 0), premature children with history of ROP without treatment (group 1), and premature children with ROP who had received a single IVB (0.625 mg; group 2).

METHODS

Ocular developmental assessment, including cycloplegic refractometry, axial length, Cardiff acuity, and neurodevelopmental assessment via the Bayley Scales of Infant and Toddler Development, Third Edition (Bayley III), were performed at 1 to 3 years of age and were compared between groups.

MAIN OUTCOME MEASURES

Ocular developmental outcomes and Bayley III scores.

RESULTS

A total of 148 patients (85 boys and 63 girls) were included. The mean age at assessment was 1.49±0.59 years. Group 0 patients demonstrated significantly higher gestational age (GA), birth weight, and Apgar scores compared with group 1 and 2 patients. There were no significant differences between groups 1 and 2 in demographics or systemic risk factors except for lower GA in group 2. The cylindrical power was significantly larger in groups 1 and 2 compared with group 0. The spherical equivalent was significantly more myopic and the Cardiff acuity was significantly poorer in group 2 than in group 0. There were no significant differences between groups 1 and 2 in refractive status, axial length, or Cardiff acuity. Neurodevelopmental assessment using Bayley III showed no significant difference among the 3 groups in any aspect after adjusting for GA and other systemic risk factors. The risks for poor neurodevelopmental outcomes also were not significantly different.

CONCLUSIONS

At the mean age of 1.5 years, children with prior history of IVB (group 2) showed similar refractive and visual outcomes and similar neurodevelopmental outcomes compared with premature patients with ROP without requirement of treatment (group 1), although there is a possibility that a small but clinically significant difference may not have been detected in the current study.

The Thiol-Disulfide Homeostasis and Coenzyme Q10 in Conjunction with Vitamin E Effect on Retinopathy Prematurity

Purpose:

This study was performed to determine whether one drop of topical administration of Coqun® (Coenzyme Q10 and Vitamin E)-a potent antioxidant-twice a day has any effect on the thiol-disulphide homeostasis-a novel oxidative stress marker in the Retinopathy Of Prematurity (ROP) disease course.

Methods:

This was a prospective observational study comprising 28 infants with ROP at stage 2 and higher who followed up at the paediatric intensive care unit. Ferric reducing power of plasma (FRAP), albumin, ischemia-modified albumin (IMA) and thiol disulphide homeostasis levels were studied in the infants before and two weeks after Coqun® treatment.

Results:

The mean gestational age was 27 (24–32) weeks, the mean birth weight was 1,012±326 g and the mean duration of care in an incubator was 64±23 days. FRAP levels were 0.91±0.17 μmol/L, IMAs were 0.85±0.29, native thiols were 248±38.9 μmol/L and total thiols were 284±39.2 μmol/L, respectively, at the beginning of therapy.

FRAP levels 0.79±0.21(p= 0.006) μmol/L, IMAs 0.73±0.36(p = 0.096), native thiols 262±42.6(p = 0.164) μmol/L and total thiols 291±43.6(p = 0.344) μmol/L showed no difference after two weeks of therapy.

Conclusion:

Thiol disulphide homeostasis levels do not change with Coqun® therapy during ROP course.

Ocular outcomes and comorbidities in preterm infants enrolled for retinopathy of prematurity screening: A cohort study from western India

BACKGROUND

Retinopathy of prematurity (ROP) is emerging as an important cause of childhood blindness in middle-income countries such as India. Although blindness can be prevented in most cases with timely screening and treatment, certain ocular comorbidities can lead to visual impairment. We evaluated and compared 1-year visual, refractive, and structural outcomes and comorbidities in three subsets of preterm infants enrolled for screening of ROP.

SUBJECTS AND METHODS

Preterm children enrolled in the hospital's ROP screening program and with diagnosis of no ROP, mild ROP, or severe ROP were followed at 1 year of age to evaluate and compare visual, refractive, and structural outcomes as well as the presence of ocular comorbidities. Risk of poor outcome was calculated in children with mild and severe ROP reference population being children without ROP.

RESULTS

Eyes with severe ROP were at highest risk of poor visual (risk ratio [RR]: 3.5, P < 0.001), refractive (RR: 45, P < 0.001), and structural (RR: 11, P = 0.006) outcome as well as ocular comorbidities (RR 11, P < 0.001). Eyes with mild ROP were at higher risk of myopia (RR: 11, P = 0.06) and ocular comorbidities (RR: 4, P = 0.04). Sixteen (16%) of the eyes without ROP developed poor visual outcome.

CONCLUSION

Eyes with severe ROP are at highest risk of poor ocular outcomes and comorbidities and need a long-term follow-up. Eyes which do not develop ROP can have poor visual outcome and need to be assessed within the 1^st year of life.

Development of a mucoinert progesterone nanosuspension for safer and more effective prevention of preterm birth

Preterm birth (PTB) is a significant global problem, but few therapeutic options exist. Vaginal progesterone supplementation has been demonstrated to reduce PTB rates in women with a sonographic short cervix, yet there has been little investigation into the most effective dose or delivery form. Further, vaginal products like progesterone gel often contain excipients that cause local toxicity, irritation, and leakage. Here, we describe the development and characterization of a mucoinert vaginal progesterone nanosuspension formulation for improved drug delivery to the female reproductive tract. We compare the pharmacokinetics and pharmacodynamics to the clinical comparator progesterone gel in pregnant mice and demonstrate increased vaginal absorption and biodistribution via the uterine first-pass effect. Importantly, the unique plasma progesterone double peak observed in humans, reflecting recirculation from the uterus, was also observed in pregnant mice with vaginal dosing. We adapted a mouse model of progesterone withdrawal that was previously believed to be incompatible with testing the efficacy of exogenous progestins, and are first to demonstrate efficacy in preventing preterm birth with vaginal progesterone in this model. Further, improved vaginal progesterone delivery by the nanosuspension led to increased efficacy in PTB prevention. Additionally, we identified histological and transcriptional evidence of cervical and uterine toxicity with a single vaginal administration of the clinical gel that are absent after dosing with the mucoinert nanosuspension formulation. We demonstrate that a progesterone formulation that is designed for improved vaginal progesterone absorption and vaginal biocompatibility could be more effective for PTB prevention.

Intravitreal Ranibizumab Injection for the Treatment of Retinopathy of Prematurity

OBJECTIVES

To evaluate the efficacy of a single injection of 0.3 mg intravitreal ranibizumab for the treatment of retinopathy of prematurity (ROP).

METHODS

We conducted this retrospective case series study at King Abdul Aziz Medical City, Riyadh, Saudi Arabia. Seventy-four eyes of 37 preterm infants with ROP stage III with plus disease in zone I, posterior zone II, and aggressive posterior ROP received a single injection of 0.3 mg intravitreal ranibizumab. The favorable outcome measure was complete regression of the disease with normal vascularization of the retina of those infants.

RESULTS

The gestational age of the 37 included cases was in the range of 23-28 weeks and their body weight at birth was between 510 and 1,235 g except for one case with 2,550 g under oxygen therapy <7days with severe hypoglycemia. All eyes showed a favorable response in terms of regression of plus disease from the first day after treatment, followed by regression of stage III retinopathy. All patients developed complete vascularization over variable periods of time.

CONCLUSION

One injection of 0.3 mg intravitreal ranibizumab is effective in treating ROP stage III mainly in zones I and II.

Automated Analysis for Retinopathy of Prematurity by Deep Neural Networks

Retinopathy of Prematurity (ROP) is a retinal vasproliferative disorder disease principally observed in infants born prematurely with low birth weight. ROP is an important cause of childhood blindness. Although automatic or semi-automatic diagnosis of ROP has been conducted, most previous studies have focused on "plus" disease, which is indicated by abnormalities of retinal vasculature. Few studies have reported methods for identifying the "stage" of the ROP disease. Deep neural networks have achieved impressive results in many computer vision and medical image analysis problems, raising expectations that it might be a promising tool in the automatic diagnosis of ROP. In this paper, convolutional neural networks with a novel architecture are proposed to recognize the existence and severity of ROP disease per-examination. The severity of ROP is divided into mild and severe cases according to the disease progression. The proposed architecture consists of two sub-networks connected by a feature aggregate operator. The first sub-network is designed to extract high-level features from images of the fundus. These features from different images in an examination are fused by the aggregate operator, then used as the input for the second sub-network to predict its class. A large data set imaged by RetCam 3 is used to train and evaluate the model. The high classification accuracy in the experiment demonstrates the effectiveness of the proposed architecture for recognizing the ROP disease.

Is human milk feeding protective for Retinopathy of Prematurity?

Objective:

To find the association between breast milk feeding with retinopathy of prematurity (ROP) in preterm infants.

Methods:

This was a cross sectional study to examine the effects of breast milk feeding on ROP. Premature newborns below 34 weeks from neonatal unit retinopathy of prematurity program during the years 2015 to 2017 of The Lahore General Hospital were included. We recorded the gestational age, birth weight, presence of ROP and the type of feeding (breastfeeding vs. formula milk).

Results:

Out of 428 preterm babies 210 (49%) were males. More babies were between 32-34 weeks of gestation 229 (53.5%) as compared to < 32 weeks 199 (46.5%). Among all 428 preterm infants 19(4.4%) developed ROP. Majority 13 (68.4%) who developed ROP were <32 weeks of gestation (p=0.042). The mean birth weight of infants without ROP was 1.51± 0.36 kg (95%CI; 1.47-1.55), while it was 1.36 ± 0.29 kg (95%CI; 1.22-1.50) with ROP and all who developed ROP were < 2kg. The estimated odds ratio of developing ROP for breast fed versus top feeding was (ORs: 0.571, 95% CI; 0.222- 1.489). There was a trend toward lower incidence of ROP in the group of newborns who received breast-feeding (36.8%) as compared to top feeding (63.2%) but almost similar percentage who didn’t develop ROP were breast fed or top fed with statistically insignificant results (p= 0.24).

Conclusions:

Slightly lesser percentage of preterm babies who were breast fed developed retinopathy of prematurity.

Feline Neovascular Vitreoretinopathy and Anterior Segment Dysgenesis With Concurrent Glaucoma in Domestic Cats

Feline neovascular vitreoretinopathy (FNV) is a newly recognized rare condition affecting kittens and young domestic cats. This study investigated the clinical and pathologic findings in 22 cats with FNV. In affected cats, ophthalmoscopy of the fundus (when visible) revealed avascular peripheral retinae and epiretinal vascular membranes. Frequent nonspecific clinical findings were buphthalmos ( n = 21), medically uncontrollable glaucoma ( n = 22), and lenticular abnormalities ( n = 13). Anterior segment dysgenesis (ASD) was detected clinically in affected cats ( n = 6). The fellow eye was affected in 11 of 18 cats to a variable degree or appeared clinically normal in 7 of 18 cats. The globes were examined histologically and using immunohistochemistry for vimentin, glial fibrillary acidic protein (GFAP), synaptophysin, neurofilament, laminin, factor VIII-related antigen (FVIII-RA), and smooth muscle actin (SMA). Histologically, diagnostic features included laminin-positive epiretinal vascular membranes affecting the central retina, with an avascular peripheral retina and gliosis. Enucleated globes exhibited multiple additional abnormalities, including corneal disease ( n = 15), anterior segment dysgenesis ( n = 21), lymphoplasmacytic anterior uveitis ( n = 19), peripheral anterior synechiae ( n = 20), retinal degeneration ( n = 22), and retinal detachment ( n = 19). Gliotic retinae labeled strongly for GFAP and vimentin with reduced expression of synaptophysin and neurofilament, consistent with degeneration or lack of differentiation. While an avascular peripheral retina and epiretinal fibrovascular membranes are also salient features of retinopathy of prematurity, there is no evidence to support hyperoxic damage in cats with FNV. The cause remains unknown.

Differentially expressed miRNAs in premature infants with retinopathy-a bioinformatics analysis

AIM

To reveal the role of miRNAs in retinopathy of prematurity (ROP) by bioinformatics analysis.

METHODS

The raw data of this study came from the researches of Wang et al and Zhao et al who analyzed the microRNA (miRNA) expression profile between ROP and controls. Based on the identified differentially expressed miRNAs, the related target genes, lncRNA and circRNA were predicted. Then we performed functional enrichment analysis to further analyze the functions of target genes.

RESULTS

Hsa-miRNA-128-3p and hsa-miRNA-9-5p showed significantly different expression in both studies. LncRNA of POLDIP2, GAS5, NEFL and UHRF1, circRNA of ZNF280C_hsa_circ_001211 and SIAE_hsa_circ_002083, tar-get gene of QKI showed meaningful differential expression in ROP. Enrichment analysis showed that TGF-β signaling pathway, PI3K-Akt signaling pathway and MAPK signaling pathway might play important roles in the prog-ress of ROP.

CONCLUSION

This research may provide a comprehensive bioinformatics analysis of differentially expressed miRNAs which are possibly involved in ROP.