Retinopathy of prematurity: a review of risk factors and their clinical significance

Correlation between apelin and VEGF levels in retinopathy of prematurity: a matched case-control study

Background

Although several clinical studies have analysed the relationship between the levels of vascular endothelial growth factor (VEGF) and apelin-13 in venous blood and retinopathy of prematurity (ROP), no definitive conclusions have been reached. This study aimed to investigate the relationship between apelin-13 levels and VEGF levels and ROP.

Methods

Differences in plasma apelin-13 and VEGF levels were analysed in two groups of infants born with birth weight < 1500 g and gestational age < 32 weeks at Peking University People’ s Hospital. One group comprised infants diagnosed with ROP and the other group was a control group comprising infants without ROP.

Results

Apelin-13 levels were significantly lower in the ROP group than in the control group, while VEGF levels showed the opposite result (both P < 0.001). Infants with severe ROP had lower apelin-13 levels and higher VEGF levels than with mild ROP (both P < 0.05).The receiver operating characteristic curve for apelin-13 level as the indicator of ROP showed that a cut-off value of 119.6 pg/mL yielded a sensitivity of 84.8% and a specificity of 63.6%, while for VEGF level, the cut-off value of 84.3 pg/mL exhibited a sensitivity of 84.8% and a specificity of 66.7%.

Conclusions

Plasma apelin-13 and VEGF levels at 4–6 weeks of age may play a role in assisting the diagnosis of ROP.

ADS-Net: attention-awareness and deep supervision based network for automatic detection of retinopathy of prematurity

Retinopathy of prematurity (ROP) is a proliferative vascular disease, which is one of the most dangerous and severe ocular complications in premature infants. Automatic ROP detection system can assist ophthalmologists in the diagnosis of ROP, which is safe, objective, and cost-effective. Unfortunately, due to the large local redundancy and the complex global dependencies in medical image processing, it is challenging to learn the discriminative representation from ROP-related fundus images. To bridge this gap, a novel attention-awareness and deep supervision based network (ADS-Net) is proposed to detect the existence of ROP (Normal or ROP) and 3-level ROP grading (Mild, Moderate, or Severe). First, to balance the problems of large local redundancy and complex global dependencies in images, we design a multi-semantic feature aggregation (MsFA) module based on self-attention mechanism to take full advantage of convolution and self-attention, generating attention-aware expressive features. Then, to solve the challenge of difficult training of deep model and further improve ROP detection performance, we propose an optimization strategy with deeply supervised loss. Finally, the proposed ADS-Net is evaluated on ROP screening and grading tasks with per-image and per-examination strategies, respectively. In terms of per-image classification pattern, the proposed ADS-Net achieves 0.9552 and 0.9037 for Kappa index in ROP screening and grading, respectively. Experimental results demonstrate that the proposed ADS-Net generally outperforms other state-of-the-art classification networks, showing the effectiveness of the proposed method.

The role of anti-vascular endothelial growth factor in treatment of retinopathy of prematurity-a current review

The review aims to evaluate the uses of conventional laser therapy and intravitreal injection of various anti-VEGF in terms of efficacy and side effects for the treatment of retinopathy of prematurity. A literature search of the publication, concerning conventional laser treatment and intravitreal injection of anti-VEGF for ROP. A total of 40 articles were reviewed after curation by the authors for relevance. Intravitreal anti-VEGF showed better ocular efficacy in zone I ROP while laser therapy had a lower recurrence rate in zone II. Comparing the two mainstay anti-VEGF agents, bevacizumab showed lower ROP recurrence rate than ranibizumab. Anti-VEGF has a higher chance in developing persistent peripheral avascularisation compared to conventional laser therapy, but a lower chance of developing high myopia. Ranibizumab has a lower systemic absorption than bevacizumab, despite having no difference in the incidence of persistent peripheral avascularisation. In conclusion, it is advised that intravitreal anti-VEGF should be used as the first-line treatment for zone I ROP while laser therapy should be the mainstay for zone II ROP owing to the different pathogenetic mechanisms. In patients with recurrence after initial anti-VEGF injection, that given ranibizumab may opt to repeat the injection while that given bevacizumab should consider supplement laser ablative treatment.

Association of platelet deficiency with severe retinopathy of prematurity: a review

AIM

The aim of this review was to compile existing evidence on the role of platelets in the development of severe retinopathy of prematurity (ROP), highlight the strengths and weaknesses of the available studies and critically discuss the reported data.

METHODS

A comprehensive literature search was conducted on PubMed from January 2000 to January 2022, and the reference lists of the included studies were screened manually.

RESULTS

There were 19 primary studies that fulfilled the eligibility criteria. Experimental research indicated lower platelet count in mice oxygen-induced retinopathy model compared with normoxia controls, while platelet transfusions suppressed neovascularisation. The latter finding was not consistently confirmed in clinical research, where a low platelet count, an increased number of thrombopenic episodes and of platelet transfusions have all been implicated in the development of ROP requiring treatment, either type I or aggressive posterior or both. However, existing studies exhibit significant clinical heterogeneity and present methodological limitations that imperil their reliability and validity.

CONCLUSION

Platelet deficiency has been associated with severe ROP. However, critical thresholds of platelet parameters are still unrecognised. Future research is required to determine whether platelet parameters can be predictive biomarkers for ROP requiring treatment and at what thresholds.

Using a Facebook Virtual Examination Room to Enhance ROP Training in Armenia

Purpose

Retinopathy of prematurity (ROP) is a leading cause of worldwide childhood blindness with increasing incidence in low and middle income countries (LMICs) due to advances in neonatal care. There are insufficient numbers of healthcare professionals specialized in ROP management and few local training opportunities in LMICs. Social media platforms provide a promising solution to enable interactive medical education across geographic and logistic barriers. As an adjunct to an ROP training program for ophthalmologists in Armenia, we implemented a Facebook Virtual Examination Room (VER) for case discussion with a global community of collaborators and preceptors. To evaluate training through VER, we operationalized engagement as a multilayer meta-construct that includes cognitive, behavioral, and social-emotional domains.

Methods

A concurrent mixed methods approach was taken to collect and analyze data from comments and activities within VER. Quantitative data was analyzed for descriptive statistics on group utilization, participant activity, and clinical metrics. Qualitative data was analyzed by conducting thematic analysis involving initial and pattern coding.

Results

Ten participants (7 trainees and 3 preceptors) interacted in the Facebook group across 153 unique cases, with 218 threads, 414 comments, and 216 likes. Of the 120 unique cases eligible for consensus evaluation, treatment was mentioned most frequently (87), followed by location (68), staging (65), and plus disease (31), with agreement ranging from 67% to 97%. Based on the qualitative analysis, the most common themes of discussion were clinical management, dilemma resolution, knowledge growth, and gratitude.

Conclusion

A closed Facebook group for case-based discussions can be a useful adjunct to an existing ROP training program by engaging learners across social-emotional, behavioral, and cognitive domains. For international training partnerships, the financial and logistical advantages can be significant, though focus should remain on the primary curriculum and training modality.

Incidence and Risk Factors for Retinopathy of Prematurity in a Portuguese Cohort

PURPOSE

To evaluate the incidence and risk factors for retinopathy of prematurity (ROP) in two Portuguese neonatal units with a sub-analysis of infants with a gestational age (GA) of 28 weeks or older.

METHODS

This was a retrospective case series of all infants who underwent ROP screening from 2012 to 2020. Demographic, clinical, and laboratory data were collected. Univariate logistic regression was used to examine the risk factors for ROP followed by multivariate regression.

RESULTS

A total of 475 infants were included with a median GA of 30 weeks (range: 23 to 36 weeks) and a median birth weight of 1,229 grams (range: 408 to 2,620 grams). ROP was diagnosed in 113 infants (23.8%) and 29 (6.1%) were treated. In the multivariate analysis, GA and hyperglycemia were significantly associated with severe ROP (P < .001). In the subgroup analysis of infants with a GA of 28 weeks or older, bronchopulmonary dysplasia, late-onset sepsis, and hyperglycemia were linked to severe ROP.

CONCLUSIONS

The incidence of ROP in the cohort falls within the range of other high-income countries. Hyperglycemia overpowered all of the other risk factors. Although rare, more mature infants are also at risk for severe ROP. Infants with older GA share the same group of risk factors, but bronchopulmonary dysplasia seems to play a greater role. [J Pediatr Ophthalmol Strabismus. 2022;59(4):254-260.].

Evaluation of clinical profile and screening guidelines of retinopathy of prematurity in an urban level III neonatal intensive care unit

Purpose

To evaluate the clinical profile and screening guidelines of retinopathy of prematurity (ROP) in an urban level III neonatal intensive care unit (NICU).

Methods

: Infants with ≤2000-gm birth weight or <34 weeks gestational age were prospectively screened for ROP in an urban level III NICU between January 2018 and December 2020, based on national screening guidelines. Standard guidelines were used for ROP classification and treatment.

Results

In total, 211 infants completed screening; 46 (21.8%) infants developed ROP and 13 (6.2%) had type 1 (laser treatable) ROP. Of the 46 infants with ROP, 44 (95.65%) had zone 2 and two (4.34%) had zone 1 disease. In the 102 infants with ≤1500-gm birth weight, the incidence of ROP and type 1 ROP were 41.18% and 11.76%, respectively. Out of the 109 infants with >1500-gm birth weight, four (3.67%) developed ROP and one (0.91%) infant (an outborn) required treatment.

Conclusion

The majority of infants developing ROP in a level III urban NICU had ≤1500-gm birth weight. Zone 1 ROP was uncommon. Incidence of ROP in heavier infants (>1500-gm birth weight) was low, and treatment was required in a rare instance. In an urban NICU, the burden of ROP screening and treatments shifts to small and low-birth-weight infants.

Treatment for Retinopathy of Prematurity in Twins: The Small Twin without High Birth Weight Discordant Is Not at Increased Risk

Purpose: As common retinopathy is observed in low-birth infants, the characteristics of ROP in twins are worth exploring. The present study tried to demonstrate the risk factors of treatment for retinopathy of prematurity (ROP) in twins both diagnosed with ROP. Methods: A retrospective, institution-based cohort study of 62 premature ROP twin pairs with a mean gestational age (GA) younger than 35 weeks and a birth weight (BW) lower than 2500 g. Only infants with a follow-up period longer than 6 months and complete treatment records were included. The demographic data, treatment requirements and further rescue treatments were all collected and analyzed for all infants according to whether they accepted treatments. Moreover, all twin infants were divided into small and large twin groups according to birth weight, and they were also categorized as three groups according to the treatment requirement including both twins receiving treatment (BT group), one of the twins receiving treatment (ST group) and none of the twins receiving treatment (NT group). Comparisons of demographic data, treatment requirements and further rescue treatments were all conducted according to the different grouping methods. Results: The mean GA of the enrolled infants was (29.29 ± 2.45) weeks with a mean BW of (1335.77 ± 390.36) grams. Among them, 110 infants were mechanically ventilated. Fifty-one of the infants did not receive any treatment and 73 infants received laser or intravitreal injection of anti-VEGF agents. In total, 64 infants only underwent intravitreal injection of anti-VEGF agents or laser treatment, while the other nine infants received scleral buckling or vitrectomy as a necessary treatment when the retinal detachment was observed. No significantly different mechanical ventilation or treatment requirements could be observed between the small twin group and the large twin group (p = 0.73, 0.94). The twins in the BT groups showed the lowest BW, while the NT group infants had the highest BW. The GA for the BT, ST and NT groups were (27.86 ± 1.87) weeks, (29.60 ± 1.52) weeks and (31.33 ± 2.39) weeks, respectively, and showed significant differences as well (p < 0.001). Conclusion: Being a small twin in twin-paired ROP without a high BW discordant will not increase the risk for treatment requirement or additional surgery necessity with a much more severe stage of ROP.

Unmet Need for ROP Screening in Peripheral Rural Areas

Aim

To study the incidence and risk factors associated with retinopathy of prematurity (ROP) at a tertiary care centre in Western India.

Methods

A retrospective review of records of both referred and babies born in our hospital who were screened for ROP within the last 21 months at a tertiary care centre was done. The newborns were screened as per National Neonatology Forum of India guidelines. ROP was classified according to the International Classification for Retinopathy of Prematurity criteria.

Results

A total of 167 neonates were screened with an incidence of ROP of 26.9%. The mean gestational age (GA) and mean birth weight (BW) were 31.89 ± 2.824 weeks and 1538.11 ± 530.84 gm. The mean BW of neonates having any ROP was significantly lower (1296.98gm, p < 0.001), and the mean GA was also significantly lower in ROP babies (30.67 weeks, p < 0.001). O2 supplementation, RDS, IVH, and NEC were the systemic risk factors that significantly correlated with ROP p-value <0.001. On analysis of the correlation of stage of ROP with BW and GA, a significant correlation of −0.307 (p < 0.001) and −0.283 (p < 0.001) was found.

Conclusion

The incidence of ROP in this study is similar to that reported in the literature from other regions. Other than LBW and GA, oxygen supplementation, RDS, IVH, and NEC were significant risk factors associated with ROP.

Portable boom-type ultrahigh-resolution OCT with an integrated imaging probe for supine position retinal imaging

To expand the clinical applications and improve the ease of use of ultrahigh-resolution optical coherence tomography (UHR-OCT), we developed a portable boom-type ophthalmic UHR-OCT operating in supine position that can be used for pediatric subjects, bedridden patients and perioperative conditions. By integrating the OCT sample arm probe with real-time iris display and automatic focusing electric lens for easy alignment, coupling the probe on a self-locking multi-directional manipulator to reduce motion artifacts and operator fatigue, and installing the OCT module on a moveable cart for system mobility, our customized portable boom-type UHR-OCT enables non-contact, high-resolution and high-stability retinal examinations to be performed on subjects in supine position. The spectral-domain UHR-OCT operates at a wavelength of 845 nm with 130 nm FWHM (full width at half maximum) bandwidth, achieving an axial resolution of ≈2.3µm in tissue with an A-line acquisition rate up to 128 kHz. A high-definition two-dimensional (2D) raster protocol was used for high-quality cross-sectional imaging while a cube volume three-dimensional (3D) scan was used for three-dimensional imaging and en-face reconstruction, resolving major layer structures of the retina. The feasibility of the system was demonstrated by performing supine position 2D/3D retinal imaging on healthy human subjects, sedated infants, and non-sedated awake neonates.

Targeted drug delivery to the retinal pigment epithelium: Untapped therapeutic potential for retinal diseases

The retinal pigment epithelium (RPE) plays a crucial part in sight-threatening diseases. In this review, we shed light on the pivotal implication of the RPE in age-related macular degeneration, diabetic retinopathy and retinopathy of prematurity; and explain why a paradigm shift toward targeted RPE therapy is needed to efficiently fight these retinal diseases. We provide guidance for the development of RPE-specific nanotherapeutics by giving a comprehensive overview of the possibilities and challenges of drug delivery to the RPE and highlight successful nanotherapeutic approaches targeting the RPE.

Trends in Neonatal Ophthalmic Screening Methods

Neonatal ophthalmic screening should lead to early diagnosis of ocular abnormalities to reduce long-term visual impairment in selected diseases. If a treatable pathology is diagnosed within a few days after the birth, adequate therapy may be indicated to facilitate the best possible conditions for further development of visual functions. Traditional neonatal ophthalmic screening uses the red reflex test (RRT). It tests the transmittance of the light through optical media towards the retina and the general disposition of the central part of the retina. However, RRT has weaknesses, especially in posterior segment affections. Wide-field digital imaging techniques have shown promising results in detecting anterior and posterior segment pathologies. Particular attention should be paid to telemedicine and artificial intelligence. These methods can improve the specificity and sensitivity of neonatal eye screening. Both are already highly advanced in diagnosing and monitoring of retinopathy of prematurity.

Long use of continuous positive airway pressure protects against the development of treatment-requiring retinopathy of prematurity

Although preterm infant mortality is low, the proportion of patients with treatment-requiring retinopathy of prematurity (TR-ROP) is high in Japan. Various multicenter studies have reported the risk factors for TR-ROP; however, no large-scale studies have been conducted in Japan. We retrospectively analyzed 13,645 infants born at < 28 weeks’ gestation (January 1, 2009–December 31, 2018), and registered in the Neonatal Research Network of Japan database. TR-ROP was defined as ROP requiring retinal laser photocoagulation and/or intravitreal anti-vasoendothelial growth factor drugs. Multivariable logistic regression analysis was performed to identify factors associated with TR-ROP development. The median gestational age of enrolled infants was 26 weeks (interquartile range [IQR], 24–27 weeks), median birth weight was 760 g (IQR, 620–918 g). Proportion of patients with TR-ROP was 30.3%. TR-ROP was significantly associated with birth at < 26 weeks’ gestational age (adjusted odds ratio [aOR] 1.54), blood transfusion (aOR 1.49), invasive ventilation ≥ 28 days (aOR 1.41), sepsis (aOR 1.29), birth weight < 750 g (aOR 1.28), intraventricular hemorrhage (aOR 1.33), delayed achievement of full enteral feeding > 14 days (aOR 1.28), and continuous positive airway pressure (CPAP) therapy ≥ 28 days (aOR 0.79). Supplemental oxygen ≥ 28 days was not associated with TR-ROP development. Lower gestational age at birth and birth weight, blood transfusion, prolonged invasive ventilation, sepsis, intraventricular hemorrhage, and delayed achievement of full enteral feeding were risk factors for TR-ROP, whereas CPAP use was protective against TR-ROP.

Postnatal administration of systemic steroids increases severity of retinopathy in premature infants

BACKGROUND

Postnatal systemic steroids are known to increase the risk of developing retinopathy of prematurity (ROP). However, whether the total dosage and type of postnatal systemic steroids are related to the development and severity of ROP in premature infants remains unclear. This study was conducted to identify the risk factors for ROP and investigate the relationship between photocoagulation (PC)-demanding severe ROP and the postnatal dosage of any type of systemic steroids.

METHODS

A total of 75 infants born at <28 weeks of postmenstrual age (PMA) were enrolled. The number of PC procedures for ROP was evaluated as the objective variable. This study analyzed the following independent variables: gestational age; birth weight; sex; Apgar scores; duration of mechanical ventilation; duration of nasal intermittent positive pressure ventilation; mean saturation and mean oxygen concentration administration until 36 weeks of PMA; total accumulation dosage of hydrocortisone, dexamethasone, and systemic steroids; dosage number of times of erythropoietin; total dosage of red cell concentrates (RCC); incidence of necrotizing enterocolitis (NEC) and focal intestinal perforation; sepsis; bronchopulmonary dysplasia (BPD); and intraventricular hemorrhage (IVH). Logistic regression was used to estimate the relative risk (odds ratio (OR)) associated with risk factors for PC-demanding severe ROP.

RESULTS

Compared with infants in the non-PC group, PC-treated infants had younger gestational age, longer mechanical ventilation periods, and higher dosage of systemic steroids and dexamethasone. Multivariate logistic regression analysis revealed total dosage of systemic steroids as the only risk factor for PC-demanding severe ROP. Based on receiver operating characteristic (ROC) curve analysis, a cutoff value of 8.95 mg/kg of postnatal systemic steroid administration was identified as a useful marker to predict PC-demanding severe ROP.

CONCLUSION

By focusing on the method of systemic steroid administration and avoiding excessive doses for infants born at <28 weeks of PMA, preventing the development of severe ROP is possible.

Association Between Social Determinants of Health and Retinopathy of Prematurity Outcomes

Importance

Previous studies suggest that race or ethnicity may be associated with risk for developing retinopathy of prematurity (ROP). Little is known about how socioeconomic factors mediate the relationship between race or ethnicity and ROP outcomes.

Objective

To evaluate how socioeconomic factors, in the context of race and ethnicity, are associated with ROP outcomes.

Design, Setting, and Participants

This retrospective cohort study used US Census Bureau income data and electronic medical records from neonatal intensive care units at 4 hospitals, UCLA Mattel Children's Hospital, UCLA Santa Monica Hospital, Cedars-Sinai Medical Center, and Harbor-UCLA Medical Center. Eligible participants included neonates born at a gestational age (GA) of 30 weeks or less, birth weight less than 1500 g, or a GA at birth greater than 30 weeks but with an unstable clinical course. Participants were screened for ROP between January 1, 2010, and December 31, 2020.

Exposures

Race and ethnicity data, GA, demographic and clinical information, proxy household income, and health insurance status were collected as risk factors.

Main Outcomes and Measures

Diagnosis and severity of ROP were the main study outcomes. Severity was determined according to a classification system developed by the Early Treatment for Retinopathy of Prematurity Cooperative Group.

Results

In a crude model, Hispanic neonates were more likely to be diagnosed with ROP (OR, 1.70; 95% CI, 1.20-2.42) and had more severe ROP (OR, 2.24; 95% CI, 1.21-4.15) compared with non-Hispanic White neonates; these associations were no longer found when adjusting for GA and socioeconomic factors (OR, 1.12; 95% CI, 0.68-1.82, and OR, 1.67; 95% CI, 0.80-3.52, for ROP diagnosis and severity, respectively). In a fully adjusted model, lower GA was the primary predictor of ROP incidence (OR, 0.52; 95% CI, 0.48-0.57; P < .001), and higher median household income was associated with higher GA (OR, 0.26; 95% CI, 0.09-0.43; P = .002).

Conclusions and Relevance

In this cohort study, GA was the primary driver of disparities in ROP outcomes in a heterogeneous population of neonates in Los Angeles, California. When examined in the context of socioeconomic factors, GA did not differ between racial and ethnic groups. Studies of disparities associated with race and ethnicity should consider these constructs in conjunction with other sociodemographic factors and social determinants of health.

Incidence of retinopathy of prematurity treatment in extremely preterm infants in China

BACKGROUND

Retinopathy of prematurity (ROP) continues to be a major cause of visual impairment and blindness in premature infants and children.

OBJECTIVES

To investigate the incidence of severe ROP receiving treatment in extremely preterm (EP) infants in China over time. The risk factors for ROP treatment were also assessed.

METHODS

This was a multicentre retrospective study and a subanalysis of baseline data from the "Outcomes of EP infants in China 2010-2019" study. This study was conducted in 68 tertiary neonatal care centres from 31 provinces of China. Infants with a gestational age of 23⁰ -27⁶  weeks and admitted to a neonatal unit within the first 72 h of life between 2010 and 2019 were enrolled. Incidence of ROP was analysed in infants who survived to 32 weeks postmenstrual age and screened for ROP. Multivariable modified Poisson regression models were used to identify risk factors for ROP treatment.

RESULTS

Among 7295 eligible infants, 4701 (64.5%) survived to 32 weeks postmenstrual age and met ROP screening criteria. Of the 3756 infants who screened and with ROP data, 2320 (61.8%) developed ROP of any stage. The overall incidence of ROP treatment was 12.6%, decreasing from 45.5% at 23 weeks to 8.3% at 27 weeks. During the 10-year period, the incidence of ROP treatment did not change, although the incidence of any ROP increased over time. Independent risk factors associated with ROP treatment included lower gestational age, small for gestational age, multiple birth, severe intraventricular haemorrhage, patent ductus arteriosus and supplemental oxygen duration.

CONCLUSIONS

The incidence of EP infants receiving ROP treatment showed no change during this 10-year period in China. Prevention of prematurity and foetal growth restriction, judicious use of oxygen and reducing comorbidities are promising factors that may reduce the incidence of ROP needing treatment in these high-risk infants.

Validation of the Postnatal Growth and Retinopathy of Prematurity Screening Criteria in a Taiwanese Cohort

PURPOSE

To validate the performance of Postnatal Growth and Retinopathy of Prematurity (G-ROP) screening criteria in a Taiwanese cohort.

DESIGN

Screening evaluation with retrospective data.

METHOD

Premature infants who underwent retinopathy of prematurity (ROP) screening between January 2015 and April 2019 at a tertiary hospital were examined. Infants with known final ROP results and complete longitudinal weight records were included. G-ROP screening criteria, both original and simplified (G-ROP 180 g), were applied as the prediction model for type 1 ROP; sensitivity and specificity were analyzed. The reduction in the number of infants requiring ROP screening and the number of funduscopic examinations were calculated.

RESULT

A total of 303 infants with documented ROP outcomes and complete weight gain records were examined. Of these, 103 infants developed ROP, of whom 29 developed type 1 ROP, whereas the other 200 did not develop ROP. For the detection of type 1 ROP, the sensitivity and specificity of the original G-ROP screening criteria were 96.6% and 42.3%, and 100% and 31%, for the simplified G-ROP 180 g model, respectively. The reduction in the number of infants requiring screening and funduscopic examinations was 32.6% and 33.5% for the original G-ROP criteria, and 28.1% and 23.2% for the G-ROP 180 g model, respectively.

CONCLUSION

Both the original G-ROP and G-ROP 180 g criteria attained high sensitivities in detecting type 1 ROP in the current Taiwanese cohort, with the G-ROP 180-g model outperforming the original one. Validation and modification may be required before applying G-ROP screening criteria to different populations.

The retinal vascular growth rate in babies with retinopathy of prematurity could indicate treatment need

Purpose

To analyze the weekly rate of retinal vascular growth in treatment-naïve babies with various stages of retinopathy of prematurity (ROP) and validate if this could be a predictor of treatment need.

Methods

Retrospective review of medical charts and retinal images of babies with various stages of ROP. The images were enhanced using red-green image enhancement software. Using the length of the horizontal disc diameter (DD) of each eye, the vessel growth was measured from the disc margin up to the vessel tip in fixed quadrants. The rate of vessel growth was the ratio of vessel length to the number of weeks it took to reach this length. The babies were divided into treatment warranting ROP (group 1), low-risk pre-threshold (type II) ROP (group 2,), and no-ROP (group 3) for analysis. The "no-ROP" group acted as normal control. Group 1 was further subdivided into 1A (threshold ROP), IB (aggressive posterior ROP), 1C (hybrid ROP), and ID (high-risk pre-threshold ROP).

Results

Out of 436 eyes, groups 1, 2, and 3 had 238, 108, and 90 eyes, respectively. The mean rate of vascular outgrowth along with 95% confidence interval (CI) was 0.490 [0.487,0.520], 0.612 [0.599, 0.638], and 0.719 [0.703, 0.740] DD/week, respectively, for babies with "treatment warranting," "low risk pre-threshold" and "no ROP" groups, respectively. In our estimate, more than 80% of eyes with a vessel growth rate of 0.54 DD/week or less required treatment.

Conclusion

A rate of retinal vascular growth less than 0.54 DD/week can be used to determine treatment requirements in babies with ROP.

Automatic zoning for retinopathy of prematurity with semi-supervised feature calibration adversarial learning

Retinopathy of prematurity (ROP) is an eye disease, which affects prematurely born infants with low birth weight and is one of the main causes of children's blindness globally. In recent years, there are many studies on automatic ROP diagnosis, mainly focusing on ROP screening such as "Yes/No ROP" or "Mild/Severe ROP" and presence/absence detection of "plus disease". Due to the lack of corresponding high-quality annotations, there are few studies on ROP zoning, which is one of the important indicators to evaluate the severity of ROP. Moreover, how to effectively utilize the unlabeled data to train model is also worth studying. Therefore, we propose a novel semi-supervised feature calibration adversarial learning network (SSFC-ALN) for 3-level ROP zoning, which consists of two subnetworks: a generative network and a compound network. The generative network is a U-shape network for producing the reconstructed images and its output is taken as one of the inputs of the compound network. The compound network is obtained by extending a common classification network with a discriminator, introducing adversarial mechanism into the whole training process. Because the definition of ROP tells us where and what to focus on in the fundus images, which is similar to the attention mechanism. Therefore, to further improve classification performance, a new attention mechanism based feature calibration module (FCM) is designed and embedded in the compound network. The proposed method was evaluated on 1013 fundus images of 108 patients with 3-fold cross validation strategy. Compared with other state-of-the-art classification methods, the proposed method achieves high classification performance.

Health Equity and Disparities in ROP Care: A Need for Systematic Evaluation

Retinopathy of prematurity (ROP) is a vasoproliferative retinal disorder that can have devastating visual sequelae if not managed appropriately. From an ophthalmology standpoint, ROP care is complex, since it spans multiple care settings and providers, including those in the neonatal intensive care unit (NICU), step down nurseries, and the outpatient clinic setting. This requires coordination and communication between providers, ancillary staff, and most importantly, effective communication with the patient's family members and caregivers. Often, factors related to the social determinants of health play a significant role in effective communication and care coordination with the family, and it is important for ophthalmologists to recognize these risk factors. The aim of this article is to (1) review the literature related to disparities in preterm birth outcomes and infants at risk for ROP; (2) identify barriers to ROP care and appropriate follow up, and (3) describe patient-oriented solutions and future directions for improving ROP care through a health equity lens.

Association of fish oil containing lipid emulsions with retinopathy of prematurity: a retrospective observational study

Background

Retinopathy of prematurity (ROP) remains a leading cause of childhood blindness worldwide. This study aimed to investigate whether supplementation of n-3 polyunsaturated fatty acids (n-3 PUFAs) in parenteral nutrition may have beneficial effects on ROP in preterm infants.

Methods

A total of 89 preterm infants, admitted to Neonatal Intensive Care Unit (NICU) in Anhui Provincial Children’s Hospital from September 2017 to August 2020, were recruited in the study. Based on the medical documents, the subjects were categorised into two groups: administration of the fish oil emulsion (n=43) containing soy oil, medium-chain-triglycerides (MCT), olive oil and fish oil (6g/dL, 6g/dL, 5g/dL and 3g/dL respectively), and the soy oil emulsion (n=46) containing 10g/dL of soy oil and MCT each. At 4 weeks of hospitalization, ROP was screened and diagnosed. Fatty acids in erythrocytes were determined using gas chromatography.

Results

The averaged birth weight and gestational age were 1594±296 g and 31.9±2.3 wk, 1596±263 g and 31.6±2.3 wk respectively for preterm infants in the fish oil group and soy oil group. After 4 to 6 weeks of hospitalization, among all the preterm infants, 52 developed ROP (all stages) indicating an incidence of ROP at 58.43%. Although the incidence of ROP with any stages showed no differences between the two groups, the severe ROP incidence in the group with fish oil emulsions (2.33%) was significantly lower than that in the group with soy oil emulsions (23.91%) (P<0.05). After 14 days of nutrition support, the preterm infants administered fish oil emulsions had an increase in erythrocyte DHA content, with a reduction in ratio of arachidonic acid (AA) to DHA and an increase of n-3 index.

Conclusion

Supplementation of n-3 PUFAs through parenteral fish oil containing lipid emulsions resulted in an increase in erythrocyte DHA, and this might have beneficial effects on prevention of severe ROP in preterm infants.

Novel Potential Biomarkers for Retinopathy of Prematurity

Retinopathy of prematurity (ROP) is the main risk factor for vision-threatening disease in premature infants with low birth weight. An accumulating number of independent studies have focused on ROP pathogenesis and have demonstrated that laser photocoagulation therapy and/or anti-VEGF treatment are effective. However, early diagnosis of ROP is still critical. At present, the main method of ROP screening is based on binocular indirect ophthalmoscopy. However, the judgment of whether ROP occurs and whether treatment is necessary depends largely on ophthalmologists with a great deal of experience. Therefore, it is essential to develop a simple, accurate and effective diagnostic method. This review describes recent findings on novel biomarkers for the prediction, diagnosis and prognosis of ROP patients. The novel biomarkers were separated into the following categories: metabolites, cytokines and growth factors, non-coding RNAs, iconography, gut microbiota, oxidative stress biomarkers, and others. Biomarkers with high sensitivity and specificity are urgently needed for the clinical applications of ROP. In addition, using non-invasive or minimally invasive methods to obtain samples is also important. Our review provides an overview of potential biomarkers of ROP.

Prediction model to predict type 1 retinopathy of prematurity using gestational age and birth weight (PW-ROP)

PURPOSE

To develop a prediction model for type 1 retinopathy of prematurity (ROP) from an Asian population.

METHODS

This retrospective cohort study included 1043 premature infants who had ROP screening in a tertiary hospital in Hong Kong from year 2006 to 2018. The ROP prediction model was developed by multivariate logistic regression analyses on type 1 ROP. The cut-off value and the corresponding sensitivity and specificity were determined by receiver operating characteristic curve analysis. A validation group of 353 infants collected from another tertiary hospital in another region of Hong Kong from year 2014 to 2017 was used for external validation.

RESULTS

There were 1043 infants in the study group. The median gestational age (GA) was 30 weeks and 1 day and median birth weight (BW) was 1286 g. The prediction model required only GA and BW as parameters (prematurity-birth weight ROP (PW-ROP)). The area under curve value was 0.902. The sensitivity and specificity were 87.4% and 79.3%, respectively. Type 1 ROP developed in 0.9%, 17.4% and 50% of infants with PW-ROP scores<0, between 0 and <300, and ≥300 respectively (p<0.001). On external validation, our prediction model correctly predicted 95.8% of type 1 ROP (sensitivity=95.8%, specificity=74.8%) in the validation group.

CONCLUSION

The PW-ROP model is a simple model which could predict type 1 ROP with high sensitivity and specificity. Incorporating this model to ROP examination would help identify infants at risk for ROP treatment.

Perinatal risk factors associated with central retinal changes in former preterm children on optical coherence tomography angiography

PURPOSE

To assess the association between perinatal risk factors for retinopathy of prematurity (ROP) and central retinal structures of former preterm children seen on optical coherence tomography angiography (OCTA).

METHODS

This prospective cohort study included 40 children with a history of preterm birth and 33 healthy full-term children. We documented their birth weight, gestational age, other significant risk factors for ROP development and presence of ROP. Imaging was performed using swept-source OCTA, and quantitative evaluation was performed. Analytic parameters included the area of foveal avascular zone (FAZ), foveal depth (FD), central subfoveal retinal thickness (CSFT) and capillary density index (CDI) of the deep and superficial capillary plexus.

RESULTS

Preterm children had significantly smaller FAZ, lower FD and higher CSFT compared to controls (all p < 0.001). Both groups exhibited no differences in total CDI at the superficial (p = 0.969) and deep capillary plexus (p = 0.370). The duration of mechanical ventilation correlated negatively with FAZ and FD but positively with CSFT. The duration of supplemental oxygen treatment correlated negatively with FD. The presence of intraventricular haemorrhage correlated negatively with FAZ and FD but positively with CSFT. Regression analysis found that the duration of mechanical ventilation and the presence of bronchopulmonary dysplasia were associated with lower FD (p = 0.002 and 0.01, respectively) and higher CSFT (p = 0.002 and 0.028, respectively).

CONCLUSION

Central retinal anomalies were identified in former preterm children using OCTA. Macular changes were associated with several risk factors for ROP development.

Vitreous opacities in infants born full-term and preterm by handheld swept-source optical coherence tomography

PURPOSE

To compare vitreous opacity density in infants born at term and in infants born prematurely using an investigational handheld swept-source optical coherence tomography (SS-OCT).

METHODS

Infants born at term underwent imaging once between 12 and 48 hours after birth; infants born prematurely were imaged at each routine retinopathy of prematurity (ROP) examination. Three masked, trained graders analyzed images. Semiautomated methods were used to quantify vitreous opacity density, which was correlated with ROP severity based on indirect ophthalmoscopy, other SS-OCT findings, and medical comorbidities.

RESULTS

Between April 2018 and June 2019, 251 SS-OCT imaging sessions were performed on 78 infants (49% female; 36% preterm, with mean birth weight of 1018 ± 338 g and gestational age of 28.6 ± 3.2 weeks). All SS-OCT sessions produced images of adequate quality. Punctate vitreous opacities were present in 25 of 28 term infants (89%) and 41 of 50 premature infants (82%). Dice coefficient and F1 scores for intergrader agreement were 0.99 ± 0.03 and 0.77 ± 0.31, respectively. Vitreous opacity density was 0.118 ± 0.187 in prematurely born infants and 0.031 ± 0.118 in infants born at term (P = 0.009). In the former, vitreous opacity density was associated with ROP zone (P = 0.044) and stage (P = 0.031), intraventricular hemorrhage (P = 0.028), subchorionic hemorrhage (P = 0.026), and African American race (P = 0.023). In the latter, vitreous opacity density was associated with maternal diabetes (P = 0.049).

CONCLUSIONS

Our investigational handheld SS-OCT achieved high-quality vitreoretinal images. In our study cohort, punctate vitreous opacities were a frequent finding in infants born at term and those born prematurely, with increased density in those born prematurely, particularly those with severe ROP.

Eye disease and mortality, cognition, disease, and modifiable risk factors: an umbrella review of meta-analyses of observational studies

Globally, 2.2 billion people live with some form of vision impairment and/or eye disease. To date, most systematic reviews examining associations have focused on a single eye disease and there is no systematic evaluation of the relationships between eye diseases and diverse physical and mental health outcomes. Moreover, the strength and reliability of the literature is unclear. We performed an umbrella review of observational studies with meta analyses for any physical and/or mental comorbidities associated with eye disease. For each association, random-effects summary effect size, heterogeneity, small-study effect, excess significance bias and 95% prediction intervals were calculated, and used to grade significant evidence from convincing to weak. 34 studies were included covering 58 outcomes. No outcomes yielded convincing evidence, six outcomes yielded highly suggestive results (cataract positively associated with type 2 diabetes, open-angled glaucoma positively associated with myopia and diabetes, diabetic retinopathy positively associated with cardiovascular disease and cardiovascular mortality, and retinopathy of prematurity positively associated with chorioamnionitis), eight outcomes yielded suggestive results (diabetic retinopathy positively associated with all-cause mortality and depression, diabetic macular oedema positively associated with dyslipidaemia, cataract positively associated with gout, nuclear sclerosis positively associated with all-cause mortality, open angled glaucoma positively associated with migraine and hypertension, and age-related macular degeneration positively associated with diabetes), and 18 outcomes yielded weak evidence. Results show highly suggestive or suggestive evidence for associations between several types of eye diseases with several comorbid outcomes. Practitioners and public health policies should note these findings when developing healthcare policies.

Beyond Fetal Immunity: A Systematic Review and Meta-Analysis of the Association Between Antenatal Corticosteroids and Retinopathy of Prematurity

Background: Retinopathy of prematurity (ROP) is a major cause of childhood blindness. Antenatal corticosteroids (ACS) exposure is known to ameliorate the risk of and mortality of neonatal morbidities. However, the effect of ACS on ROP development is currently unknown. We conducted a meta-analysis with up-to-date evidence to assess the association between ACS exposure and the development of ROP in at-risk preterm infants.

Methods: PubMed, EMBASE, Scopus, Web of Science, and the Cochrane Library were systematically searched from inception to May 2021, supplemented with manual search from reference lists. Studies with a control group reporting ROP rate in ACS-exposed infants were included. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated utilizing a random-effects model. The Newcastle-Ottawa Scale was used for assessment of risk of bias in the included studies. Meta-regressions were performed to explore the predictive role of confounders for between-study variance.

Results: A total of 63 studies, involving 196,264 infants, were included. Meta-analysis showed ACS exposure was not associated with ROP occurrence (uOR 0.92, 95% CI 0.80–1.07; aOR 0.87, 95% CI 0.7–1.08). Results from extremely immature subgroups revealed significant reduced risks of ROP occurrence in ACS-exposed infants. ACS exposure was associated with significantly lower odds of ROP progression in adjusted analysis (aOR 0.48, 95% CI 0.26–0.89) instead of unadjusted analysis (uOR 0.86, 95% CI 0.68–1.08). Meta-regression showed birth weight and patent ductus arteriosus of the cohort were associated with ROP occurrence, sample size and study design strongly associated with ROP progression in ACS-exposed infants.

Conclusion: ACS treatment may decrease, but not prevent, the severity of ROP. Findings from severe ROP should be interpreted with caution owing to limited studies and the possibility of false-positive results. Considering the particular benefits in extremely immature infants, we recommend routine usage of ACS in mothers with threatened delivery to this particular birth cohort to prevent ROP occurrence. Future studies adjusting for major confounders are warranted to mitigate risk of bias in such observational evidence.

Different Types of Hyperfluorescence Observed in Post Anti-VEGF Fluorescein Angiographic Patterns in Retinopathy of Prematurity Patients

Purpose

To demonstrate that the demographic and treatment characteristics of retinopathy of prematurity (ROP) eyes showed different types of hyperfluorescence in fluorescein angiography (FA) initially treated with anti-vascular endothelial growth factor (VEGF) agents.

Methods

A consecutive case series of ROP treated with anti-VEGF agents was retrospectively studied. All the patients underwent FA examinations at least 6 months later after treatment. The demographic and treatment characteristics of eyes with or without hyperfluorescence in FA were analyzed. The different types of hyperfluorescence were divided into three groups, including vascular leakage, fibrous membrane, and vascular abnormality.

Results

Two hundred and forty-two eyes of 123 patients with treatment-required ROP were included. Hyperfluorescence was defined in 51/242 eyes, and 2.08 ± 1.11 injections were performed for them, while the eyes without hyperfluorescence received 1.65 ± 0.80 injections (P = 0.013). Vascular leakage was defined in 26/51 hyperfluorescence eyes. The postmenstrual age (PMA) of first injection for the hyperfluorescence group was 38.56 ± 3.24 weeks, which is earlier than that of infants without hyperfluorescence (P = 0.011). More additional treatments were performed in eyes with hyperfluorescence (23.53 vs. 3.66%, P = 0.000). Among them, the eyes with vascular leakage required more additional treatment than eyes without vascular leakage (42.31 vs. 4.00%, P = 0.004). For the 26 eyes with vascular leakage, 11 eyes of 8 patients received further treatments during further follow-up. No significant difference of refractive errors can be defined between different groups.

Conclusion

Eyes with persistent hyperfluorescencein FA after treatment required more anti-VEGF and additional treatments, including laser and PPV. Not all hyperfluorescences were vascular leakage and required additional treatment.

Decoupling Oxygen Tension From Retinal Vascularization as a New Perspective for Management of Retinopathy of Prematurity. New Opportunities From β-adrenoceptors

Retinopathy of prematurity (ROP) is an evolutive and potentially blinding eye disease that affects preterm newborns. Unfortunately, until now no conservative therapy of active ROP with proven efficacy is available. Although ROP is a multifactorial disease, premature exposition to oxygen concentrations higher than those intrauterine, represents the initial pathogenetic trigger. The increase of oxygenation in a retina still incompletely vascularized promotes the downregulation of proangiogenic factors and finally the interruption of vascularization (ischemic phase). However, the increasing metabolic requirement of the ischemic retina induces, over the following weeks, a progressive hypoxia that specularly increases the levels of proangiogenic factors finally leading to proliferative retinopathy (proliferative phase). Considering non-modifiable the coupling between oxygen levels and vascularization, so far, neonatologists and ophthalmologists have "played defense", meticulously searching the minimum necessary concentration of oxygen for individual newborns, refining their diagnostic ability, adopting a careful monitoring policy, ready to decisively intervene only in a very advanced stage of disease progression. However, recent advances have demonstrated the possibility to pharmacologically modulate the relationship between oxygen and vascularization, opening thus the perspective for new therapeutic or preventive opportunities. The perspective of a shift from a defensive towards an attack strategy is now at hand.

Functional Ophthalmic Factors Associated With Extreme Prematurity in Young Adults

IMPORTANCE

Children born preterm (<37 weeks' gestation) have a higher risk of visual impairment and ocular morbidities compared peers born at full term. However, the long-term ocular sequelae in adulthood for those born extremely preterm (EP), who have the highest risk of neonatal retinopathy, are unknown.

OBJECTIVE

To evaluate visual function and ocular morbidity in young adults born EP compared with controls born full term.

DESIGN, SETTING, AND PARTICIPANTS

This prospective cohort study of a geographically based birth cohort in the UK and Ireland born from March 1 through December 31, 1995, included 128 participants aged 19 years (born at 22-25 weeks' gestation) and 65 age-matched controls born at full term. Statistical analysis was performed from March 1, 2020, to November 26, 2021.

EXPOSURES

Participants underwent eye examinations as part of a comprehensive outcome evaluation.

MAIN OUTCOMES AND MEASURES

Best-corrected visual acuity, refractive status, contrast sensitivity, color vision, prevalence of strabismus and nystagmus, and patient-reported visual function, measured using the Health Utilities Index Mark 3.

RESULTS

The study comprised 128 participants (256 eyes; 68 female participants [53%]; mean [SD] age, 19.3 [0.5] years) and 65 age-matched controls born at full term (130 eyes; 40 female participants [62%]; mean [SD] age, 19.2 [0.5] years). Compared with control eyes, the mean (SD) best-corrected visual acuity among eyes in the EP group was significantly worse (monocular vision: -0.06 [0.14] logMAR in the control group vs 0.14 [0.38] logMAR in the EP group; P < .001; binocular vision: -0.14 [0.15] logMAR in the control group vs 0.06 [0.37] logMAR in the EP group; P < .001). Participants in the EP group had a significantly higher prevalence of strabismus (36% [46 of 127] vs 0%; P < .001), abnormal ocular motility (15% [19 of 125] vs 0%; P < .001), and nystagmus (13% [16 of 127] vs 0%; P < .001) than the control group. No significant differences between participants in the EP group and controls were observed for refractive error, contrast sensitivity, color vision, or patient-reported visual function. Among the participants in the EP group, 48% of eyes (120 of 250) had no retinopathy of prematurity (ROP), 39% (98 of 250) had ROP not requiring neonatal treatment, and 13% (32 of 250) received cryotherapy or laser ablation for ROP. Within the EP group, there was no significant difference in binocular visual function parameters, prevalence of ocular morbidity, and patient-reported visual function by neonatal ROP status.

CONCLUSIONS AND RELEVANCE

Extreme prematurity is associated with an increased prevalence of visual and ocular deficits in young adulthood; this study suggests that, for individuals born EP, visual and ocular deficits appear to be partially independent of ROP status in the neonatal period but reports similar overall visual function.

Flicker electroretinogram in newborn infants

PURPOSE

To develop and validate a flicker electroretinogram (ERG) protocol in term-born neonates as a potential tool for assessing preterm infants at risk of developing retinopathy of prematurity.

METHODS

A custom flicker ERG protocol was developed for use with the hand-held RETeval® electrophysiology device. Feasibility of measuring flicker ERG through closed eyelids and without mydriasis was established in a pilot study enabling optimisation of the test protocol. Following this, healthy term-born neonates (gestational age 37-42 weeks) were recruited at the Neonatology clinic of the University Hospital Zurich. Flicker ERG recordings were performed using proprietary disposable skin electrodes during the first four days of life when the infants were sleeping. Flicker stimuli were presented at 28.3 Hz for a stimulus series at 3, 6, 12, 30, and 50 cd·s/m², with two measurements at each stimulus level. Results were analysed offline. Flicker ERG peak times and amplitudes were derived from the averaged measurements per stimulus level for each subject.

RESULTS

28 term-born neonates were included in the analysis. All infants tolerated the testing procedure well. Flicker ERG recording was achieved in all subjects with reproducible flicker ERG waveforms for 30 and 50 cd·s/m² stimuli. Reproducible ERGs were recorded in the majority of infants for the weaker stimuli (with detectable ERGs in 20/28, 25/28, and 27/28 at 3, 6, and 12 cd·s/m², respectively). Flicker ERG amplitudes increased with increasing stimulus strength, with peak times concurrently decreasing slightly.

CONCLUSION

Flicker ERG recording is feasible and reliably recorded in sleeping neonates through closed eyelids using skin electrodes and without mydriasis. Flicker ERG amplitude decreases for lower luminance flicker but remains detectable for 3 cd·s/m² flicker in the majority of healthy term-born neonates. These data provide a basis to study retinal function in premature infants using this protocol.

Refractive status and optical components in premature infants with and without retinopathy of prematurity: A 4- to 5-year cohort study

This study was aimed to investigate the characteristics of refractive parameters in premature infants and children aged 3-8 years with mild retinopathy of prematurity (ROP) and to explore the effects of premature delivery and mild ROP on the development of refractive status and ocular optical components. Premature infants who underwent ocular fundus oculi screening in our hospital between January 2009 and February 2011 were included and divided into the ROP group and the non-ROP group. Full-term infants were the controls. The results of the annual ocular examination conducted between 2014 and 2018 were analysed, and the refractive status, optical components, and developmental trends were compared among the three groups. The total follow-up time was 4-5 years. The prevalence of myopia and astigmatism was high in the ROP group (P < 0.05). In the non-ROP group, the prevalence of myopia was also higher than that in the control group. The prevalence of myopia increased with age in the ROP and non-ROP groups, while the prevalence of astigmatism remained unchanged. In the ROP group, the corneal refractive power was the largest, the lens was the thickest and the ocular axis was the shortest; in the control group, the corneal refractive power was the smallest, the lens was the thinnest, and the ocular axis was the longest. These parameters in the non-ROP group were between those in the two groups mentioned above (P < 0.05). The corneal refractive power was relatively stable at 3-8 years old in the three groups. The change in lens thickness was small in both the ROP group and the non-ROP group (P = 0.75, P = 0.06), and the lens became thinner in the control group (P < 0.001). The length of the ocular axis increased in the three groups. Preterm infants are more likely to develop myopia than full-term infants, and children with ROP are more likely to develop both myopia and astigmatism. Thicker lenses were the main cause of the high prevalence of myopia in premature infants with or without ROP.

Severe Retinopathy of Prematurity Associated With Neurodevelopmental Disorder in Children

OBJECTIVE

This study aimed to investigate whether severe retinopathy of prematurity (ROP) could be an association factor for neurodevelopmental disorders in premature infants without other risk factors-such as congenital anomalies, birth injuries, and neurological diseases-that may cause developmental delay.

METHODS

We used health claims data recorded between 2007 and 2018 in the Korean National Health Insurance Service (KNHIS) database. We recruited a total of 18,256 premature infant born between 2007 and 2008 without congenital anomaly or birth injury (with ROP 6,995, without ROP 11,261) and divided them into four groups as follows: Group A, 209 extremely premature infants [gestational age (GA) < 28] with mild ROP; Group B, 75 extremely premature infants (GA < 28) with severe ROP; Group C, 6,510 other premature infants (28 ≤ GA <37)with mild ROP; and Group D, 201 other premature infants (28 ≤ GA < 37) with severe ROP. Using regression analysis, we analyzed whether there was a correlation between ROP prevalence, severity, and developmental delay in premature infants without other risk factors.

RESULTS

The prevalence of developmental delay, according to GA and ROP severity, was higher in patients with severe ROP than in the other patients. The prevalence gradually decreased after birth. Among extremely premature infants with ROP, those with severe ROP had a 3.082-fold higher association with neurodevelopmental complications than those with mild ROP (p < 0.001). Compared with other premature infants with ROP, those with severe ROP had a 3.269-fold higher association with neurodevelopmental complications than those with mild ROP.

CONCLUSION

The severity of ROP may be associated with neurodevelopmental disorders in premature infants.

The Role of Thrombocyte Parameters in Retinopathy of Prematurity Development

PURPOSE

To investigate the role of thrombocyte parameters in retinopathy of prematurity (ROP) development.

MATERIALS AND METHODS

This retrospective study included 120 preterm infants in total. Group 1 was formed by infants who developed type-1 ROP and received treatment. Group 2 was formed by infants who developed ROP and were not treated for ROP. Infants who did not develop ROP and whose retinal vascularization was completed in their follow-up formed Group 3. Gestational age, birth weight, and genders of groups were recorded. Platelet (PLT) count, mean platelet volume (MPV), and platelet distribution width (PDW) values were obtained from complete blood count. Platelet mass index (PMI) was calculated by multiplying the PLT count by MPV value. Thrombocytopenia was defined as PLT count <150 × 1000/μL. All parameters were compared between the groups.

RESULTS

There were 40 preterm infants in each group. The mean PLT count was 272.43 ± 122.67 in Group 1, 333.32 ± 133.06 in Group 2, and 310.03 ± 119.41 in Group 3. The difference in PLT count between the groups was not significant (p=0.094). Thrombocytopenia was observed in 25% of Group 1, 10% of Group 2, and 10% of Group 3 (p=0.095). No statistically significant difference was found in terms of MPV, PDW, and PMI values between the groups (p=0.102, p=0.097, and p=0.298, respectively).

CONCLUSIONS

Although PLT count was lower and thrombocytopenia rate was higher in the type-1 ROP group, the differences were not found to be significant. Further prospective studies are required to evaluate the role of thrombocytes in ROP pathogenesis.

Transscleral vs transpupillary diode laser photocoagulation for the treatment of zone II type 1 retinopathy of prematurity: Anatomical and refractive outcomes

Purpose

To compare the anatomical and refractive outcomes of transscleral diode versus transpupillary laser photocoagulation for the treatment of zone II type 1 retinopathy of prematurity (ROP).

Methods

In this prospective comparative interventional case series, infants with type 1 ROP in zone II were assigned to either transpupillary or transscleral laser based on the surgeons' expertise area. The rate of regression, need for retreatment, and structural and biometric outcomes at month 6 were evaluated and compared between the two treatment groups.

Results

In total, 209 eyes were enrolled; 145 eyes of 77 infants and 64 eyes of 33 infants and were in transscleral and transpupillary groups, respectively. There was no significant difference in baseline characteristics between the groups. There was no significant difference in retreatment rates (1.6% vs. 3.4%; P = 0.669) and progression to stage 4 (1.6% vs. 2.8%; P = 0.999) between the transpupillary and transscleral groups, respectively. At month 6, the mean spherical equivalent was 0.31 ± 3.57 and 0.44 ± 2.85 diopters, and the axial length was 18.28 ± 6.22 and 18.36 ± 6.87 mm in the transpupillary and transscleral groups, respectively, without a significant difference between groups. There was no significant difference in the rate of myopia (43.8% vs. 33.8%; P = 0.169) and high myopia (4.7% vs. 4.8%; P = 0.965) in transpupillary and transscleral groups at month 6.

Conclusion

The transpupillary and transscleral laser photocoagulation routes are both effective in the treatment of zone II type 1 ROP and show no significant differences in anatomical or refractive outcomes in relation to the route chosen.

The Utility of Universal Newborn Eye Screening: A Review

Universal newborn eye screening can identify ocular abnormalities early and help mitigate long-term visual impairment. Traditional neonatal and infant eye screening is administered by neonatologists and pediatricians using the red reflex test. If this test identifies an ocular abnormality, then the patient is examined by an ophthalmologist. Notably, the red reflex test may be unable to detect amblyogenic posterior segment pathology. Recent studies using fundus imaging and telemedicine show reduced cost of human resources and increased sensitivity compared with traditional approaches. In this review, the authors discuss universal newborn eye screening pilot programs with regard to disease prevalence, referral-warranted disease, and cost-effectiveness. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:S6-S16.].

Aggressive Retinopathy of Prematurity in a Larger and Less Preterm Infant: A Review of Possible Risk Factors

Aggressive retinopathy of prematurity (A-ROP), formerly known as aggressive posterior retinopathy of prematurity (APROP), occurs generally in extremely premature infants less than 28 weeks gestational age with extreme low birth weight of ≤1000g. We report a case of A-ROP occurring in a larger and less preterm infant. The possible risk factors that lead to the occurrence of A-ROP in this infant will be discussed. An infant born vaginally at 30 weeks gestational age weighing 1550g was diagnosed with A-ROP. Retinopathy of prematurity (ROP) screening was performed due to the presence of risk factors: prematurity, low birth weight, received supplemental oxygen, intraventricular hemorrhage and history of maternal chorioamnionitis. Following a single injection of intravitreal ranibizumab, significant regression of A-ROP was observed. A-ROP was unexpected in this infant and was believed to have developed as a result of receipt of supplemental oxygen, maternal chorioamnionitis, and Ureaplasma infection.

A Review of Very-Low-Birth-Weight Infants Admitted to the Kangaroo Mother Care Unit in Johannesburg, South Africa

Background

Kangaroo Mother Care (KMC) is a widely implemented intervention developed as an alternative form of care in low- and middle-income countries (LMICs) for neonates. The implementation of KMC has significantly reduced morbidity and mortality in very-low-birth-weight infants (VLBWIs).

Aim

To describe the maternal and neonatal characteristics and clinical outcomes in VLBWIs who received KMC at a tertiary hospital.

Methods

This is a retrospective descriptive study of 981 VLBWIs admitted at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) over a six-year period (January 1, 2014, to December 31, 2019).

Results

The mean gestational age of infants admitted to the unit was 29.6 weeks (standard deviation (SD): 2.4), with a mean birth weight of 1185 g (SD: 205.6). The average duration of admission in the neonatal unit was 37 days. The mean rate of weight gain was 37.6 g/kg/day (SD: 57.6). The majority of infants were breastfed (61.4%). In our study, the prevalences of the complications of prematurity were as follows: respiratory distress syndrome (RDS), 84.2%; late-onset sepsis (LOS), 26.1%; and retinopathy of prematurity (ROP), 10.6%. The mortality rate was 3.1%. Maternal comorbidities include human immunodeficiency virus (HIV) (26.4%), syphilis (2.9%) and gestational hypertension (33.7%). The antenatal clinic attendance rate was good (84.7%).

Conclusion

KMC is a cost-effective alternative to conventional care for VLBWIs in limited-resource countries, with evidence of increased weight gain, less rates of complications of prematurity and low overall mortality. The provision of KMC facilities is urgently required in LMICs.

Single-Examination Risk Prediction of Severe Retinopathy of Prematurity

BACKGROUND AND OBJECTIVES

Retinopathy of prematurity (ROP) is a leading cause of childhood blindness. Screening and treatment reduces this risk, but requires multiple examinations of infants, most of whom will not develop severe disease. Previous work has suggested that artificial intelligence may be able to detect incident severe disease (treatment-requiring retinopathy of prematurity [TR-ROP]) before clinical diagnosis. We aimed to build a risk model that combined artificial intelligence with clinical demographics to reduce the number of examinations without missing cases of TR-ROP.

METHODS

Infants undergoing routine ROP screening examinations (1579 total eyes, 190 with TR-ROP) were recruited from 8 North American study centers. A vascular severity score (VSS) was derived from retinal fundus images obtained at 32 to 33 weeks' postmenstrual age. Seven ElasticNet logistic regression models were trained on all combinations of birth weight, gestational age, and VSS. The area under the precision-recall curve was used to identify the highest-performing model.

RESULTS

The gestational age + VSS model had the highest performance (mean ± SD area under the precision-recall curve: 0.35 ± 0.11). On 2 different test data sets (n = 444 and n = 132), sensitivity was 100% (positive predictive value: 28.1% and 22.6%) and specificity was 48.9% and 80.8% (negative predictive value: 100.0%).

CONCLUSIONS

Using a single examination, this model identified all infants who developed TR-ROP, on average, >1 month before diagnosis with moderate to high specificity. This approach could lead to earlier identification of incident severe ROP, reducing late diagnosis and treatment while simultaneously reducing the number of ROP examinations and unnecessary physiologic stress for low-risk infants.

MicroRNAs and the HIF/VEGF axis in ocular neovascular diseases

Ocular neovascular diseases, such as proliferative diabetic retinopathy, retinopathy of prematurity and neovascular age-related macular degeneration, are the leading causes of visual impairment worldwide. The hypoxia-inducible factors and vascular endothelial growth factors are key molecular promoters of ocular neovascularization. Moreover, the role of microRNAs as regulators of angiogenesis has been expanding, particularly hypoxia-associated microRNA; hypoxamiRs. This review provides a summary of hypoxamiRs that directly and specifically target HIF1A and VEGF mRNAs, thus critically involved in the regulation of ocular neovascular pathologies. The discussed microRNAs highlight putative diagnostic markers and therapeutic agents in choroidal and retinal angiogenic diseases, including proliferative diabetic retinopathy, retinopathy of prematurity and neovascular age-related macular degeneration.

Quantification of Early Neonatal Oxygen Exposure as a Risk Factor for Retinopathy of Prematurity Requiring Treatment

Purpose

Retinopathy of prematurity (ROP) is a leading cause of childhood blindness related to oxygen exposure in premature infants. Since oxygen monitoring protocols have reduced the incidence of treatment-requiring ROP (TR-ROP), it remains unclear whether oxygen exposure remains a relevant risk factor for incident TR-ROP and aggressive ROP (A-ROP), a severe, rapidly progressing form of ROP. The purpose of this proof-of-concept study was to use electronic health record (EHR) data to evaluate early oxygen exposure as a predictive variable for developing TR-ROP and A-ROP.

Design

Retrospective cohort study.

Participants

Two hundred forty-four infants screened for ROP at a single academic center.

Methods

For each infant, oxygen saturations and fraction of inspired oxygen (FiO₂) were extracted manually from the EHR until 31 weeks postmenstrual age (PMA). Cumulative minimum, maximum, and mean oxygen saturation and FiO₂ were calculated on a weekly basis. Random forest models were trained with 5-fold cross-validation using gestational age (GA) and cumulative minimum FiO₂ at 30 weeks PMA to identify infants who developed TR-ROP. Secondary receiver operating characteristic (ROC) curve analysis of infants with or without A-ROP was performed without cross-validation because of small numbers.

Main Outcome Measures

For each model, cross-validation performance for incident TR-ROP was assessed using area under the ROC curve (AUC) and area under the precision-recall curve (AUPRC) scores. For A-ROP, we calculated AUC and evaluated sensitivity and specificity at a high-sensitivity operating point.

Results

Of the 244 infants included, 33 developed TR-ROP, of which 5 developed A-ROP. For incident TR-ROP, random forest models trained on GA plus cumulative minimum FiO₂ (AUC = 0.93 ± 0.06; AUPRC = 0.76 ± 0.08) were not significantly better than models trained on GA alone (AUC = 0.92 ± 0.06 [P = 0.59]; AUPRC = 0.74 ± 0.12 [P = 0.32]). Models using oxygen alone showed an AUC of 0.80 ± 0.09. ROC analysis for A-ROP found an AUC of 0.92 (95% confidence interval, 0.87–0.96).

Conclusions

Oxygen exposure can be extracted from the EHR and quantified as a risk factor for incident TR-ROP and A-ROP. Extracting quantifiable clinical features from the EHR may be useful for building risk models for multiple diseases and evaluating the complex relationships among oxygen exposure, ROP, and other sequelae of prematurity.

Prospective study of clinical characteristics of melanoma patients with retinopathy caused by a high-dose interferon α-2b

Retinopathy is a rare side effect of interferon α-2b treatment. The goal of this study was to prospectively investigate the clinical characteristics of Chinese patients with melanomas who developed retinopathy following high doses of interferon α-2b (HD-IFN) therapy. The study included 56 melanoma stage I-III patients that were treated with HD-IFN. Fourty-three patients developed HD-IFN-induced retinopathies. Forty-three melanoma patients (76%) developed retinopathy after being treated with HD-IFN. Among these patients, 49% had cotton-wool spots, 19% had retinal hemorrhage, and 30% had retinal hemorrhage. The median time of occurrence of retinopathy was 4 weeks after treatment, and the median time of duration was 4 weeks. No patient showed other symptoms except one who had blurred vision. A comparison of clinical characteristics (age, gender, primary site, stage, and ulceration) and laboratory examinations (white blood cell and platelet counts, hemoglobin, serum lactate dehydrogenase, alanine transaminase, aspartate aminotransferase, triiodothyronine, thyroxine, thyroid-stimulating hormone, and lipid) between the HD-IFN-induced retinopathy patients and nonretinopathy patients did not show any significant differences (P > 0.05). Although all patients that developed retinopathy had diabetes or hypertension, an equal percentage of patients were without retinopathy had diabetes or hypertension. HD-IFN therapy in patients with melanomas may induce mild retinopathy. Our results; however, do not necessarily suggest to discontinue the HD-IFN treatment because retinopathy is a reversible disorder.

The clinical use of ultra - Wide field imaging and intravenous fluorescein angiography in infants with retinopathy of prematurity

PURPOSE

To investigate the potential benefits and practicality of ultra - wide field (UWF) imaging and intravenous UWF fluorescein angiography (IV UWF - FA) in infants with retinopathy of prematurity (ROP) using an Optos® California device.

METHODS

This retrospective study involved 46 infants with a history of ROP who underwent UWF imaging with or without IV UWF - FA. ROP characteristics were identified using UWF color imaging. Retinal vascular findings following treatment were also assessed at IV UWF - FA analysis. All imaging sessions were performed under topical anesthesia without sedation. Main outcomes were the appearance of ROP at UWF color imaging and IV UWF-FA analysis, including status of ROP, neovascularizations, presence of plus disease, retinal vascular details, and resolution after treatment.

RESULTS

Seven (three girls) of the 46 infants (22 girls) underwent IV UWF-FA. Twelve IV UWF-FA sessions were performed in total. The oldest infant during IV UWF-FA analysis was at 55 postmenstrual weeks. Clinical characteristics of disease were easily identified at UWF color imaging. IV UWF-FA images also clearly revealed non-perfused retinal areas, fluorescein leakage, macular edema, retinal vascular abnormalities, and the status of the peripheral vascular termini. Complications of IV UWF-FA occurred in one infant in the form of patchy yellow skin discoloration around the injection site which completely disappeared on the first day following the procedure.

CONCLUSIONS

Providing a high resolution panoramic view of the retina in a single image capture with no need for contact with the cornea appear to represent potential advantages of UWF imaging in infants with ROP. IV UWF-FA also seems to be a safe procedure which can be performed under topical anesthesia and that shows detailed retinal vascular alterations in patients with ROP.