[Treated cases of retinopathy of prematurity in Germany : 5-year data from the Retina.net ROP registry]

Development of a joint set of database parameters for the EU-ROP and Fight Childhood Blindness! ROP Registries

BACKGROUND/AIMS

The incidence of retinopathy of prematurity (ROP) is increasing and treatment options are expanding, often without accompanying safety data. We aimed to define a minimal, patient-centred data set that is feasible to collect in clinical practice and can be used collaboratively to track and compare outcomes of ROP treatment with a view to improving patient outcomes.

METHODS

A multinational group of clinicians and a patient representative with expertise in ROP and registry development collaborated to develop a data set that focused on real-world parameters and outcomes that were patient centred, minimal and feasible to collect in routine clinical practice.

RESULTS

For babies receiving ROP treatment, we recommend patient demographics, systemic comorbidities, ROP status, treatment details, ophthalmic and systemic complications of treatment, ophthalmic and neurodevelopmental outcomes at initial treatment, any episodes of retreatment and follow-up examinations in the short and long-term to be collected for use in ROP studies, registries and routine clinical practice.

CONCLUSIONS

We recommend these parameters to be used in registries and future studies of ROP treatment, to reduce the variation seen in previous reports and allow meaningful assessments and comparisons. They form the basis of the EU-ROP and the Fight Childhood Blindness! ROP Registries.

Comparability of input parameters in the German Retina.net ROP registry and the EU-ROP registry - An exemplary comparison between 2011 and 2021

PURPOSE

The German Retina.net ROP registry and its Europe-wide successor, the EU-ROP registry, collect data from patients treated for ROP. This analysis compares input parameters of these two registries to establish a procedure for joint analyses of different registry data using exemplary datasets from the two registries.

METHODS

Exemplary datasets from the two databases over a 1-year period each (German Retina.net ROP Registry, 2011, 22 infants; EU-ROP Registry, 2021, 44 infants) were compared. The parameters documented in the two databases were aligned and analysed regarding demographic parameters, treatment modalities, complications within first 24 h and retreatments.

RESULTS

The current analysis showed that data can be aligned for joint analyses with some adjustments within the data structure. The registry with more detailed data collection (EU-ROP) needs to be reduced regarding granularity in order to align the different registries, as the registry with lower granularity determines the level of analyses that can be performed in a comparative approach. In the exemplary datasets, we observed that the overall most common ROP severity in both registries was zone II, 3+ (2011: 70.5%; 2021: 65%), with decreasing numbers of clock hours showing preretinal neovascularisations (2011: 10-12 clock hours in 29% of cases, 2021: 4-6 clock hours in 38%). The most prevalent treatment method was laser coagulation in 2011 (75%) and anti-VEGF therapy in 2021 (86.1%). Within the anti-VEGF group, all patients were treated with bevacizumab in 2011 and with ranibizumab in 2021. Retreatment rates were comparable in 2011 and 2021.

CONCLUSION

Data from two different ROP registries can be aligned and jointly analysed. The analysis reveals a paradigm shift in treatment modalities, from predominantly laser to anti-VEGF, and within the anti-VEGF group from bevacizumab to ranibizumab in Germany. In addition, there was a trend towards earlier treatment in 2021.

[10 years of screening for retinopathy of prematurity (2009-2019) : Results analysis of two German level-1 neonatal intensive care units (NICUs) with university on-site screening and a telemedical approach in the non-university NICU]

BACKGROUND

Retinopathy of prematurity (ROP) is one of the most common causes of childhood blindness in Germany and worldwide and adequate screening is essential. The telemedical approach with objective documentation of retinal findings opens up the possibility of reliably diagnosing all ROP stages independent of the examiner, if a team of ophthalmologists specialized in ROP evaluates the images.

OBJECTIVE

A 10-year comparison of ROP screening at two level‑1 neonatal intensive care units (NICU): university and on-site vs. non-university and telemedical.

MATERIAL AND METHODS

Retrospective analysis of screened premature infants by gestational age (GA), birth weight (BW), sex, multiple births, time of ROP occurrence, treatment needs and time as well as examination frequency.

RESULTS

From 2009 to 2019, we screened 1191 infants of whom 29 had been screened before by an external clinic. The internal 1162 infants were screened on-site with 3713 retinal examinations. We diagnosed 34% with ROP and treated 5.4% (3.7% in Giessen, 7.2% in Siegen). Mean GA was 28.9 weeks (± 2.5 weeks); mean BW 1155 g (± 417.5 g). The number of ROP diagnoses increased by 227.3% in Giessen and by 111.1% in Siegen due to the increasing number of premature births in neonatal care.

CONCLUSION

Comparative analysis confirmed nationally and internationally increasing ROP screening and children with acute ROP. Telemedical screening was equivalent to on-site screening and safe. Both screening methods identified infants requiring treatment on time. No child with GA > 29 weeks required treatment, analogous to Swedish ROP registry results; however, in the German ROP registry some premature babies with GA ≥ 30 weeks required treatment.

Safety profile of anesthetic modalities during laser treatment for retinopathy of prematurity: a systematic review

OBJECTIVE

To determine the anesthetic approach with the least adverse events and better cardiorespiratory stability profile, used in infants undergoing laser photocoagulation for retinopathy of prematurity.

STUDY DESIGN

A systematic review was conducted. PubMed, Scopus, and Cochrane Library were searched until 27th October 2021. Reference lists of relevant studies, and abstract books of international annual meetings of pediatric Οphthalmology for the years 2020 and 2021 were also looked at, as well as Clinical trials registry ( https://clinicaltrials.gov/ ).

RESULT

Overall 18 primary studies (3 randomized controlled trials, 3 cohorts, 12 case series) were included, investigating different anesthetic modalities. Cardiopulmonary instability was more common, and hypothermia was less common in the sedation groups of pentazocine/midazolam and fentanyl/midazolam, compared to the general anesthesia group of air/oxygen/sevoflurane (AOS). Cardiorespiratory instability was also more common in sedation with propofol/ketamine compared to general anesthesia with AOS, while postoperative mechanical ventilation was more frequently needed in the latter. Αpnea, need for supplemental oxygen and cardiorespiratory instability was more frequent in infants receiving fentanyl as opposed to ketamine. Fentanyl compared to morphine presented no differences in safety parameters. Finally, topical anesthesia showed the greatest instability with a higher mean postoperative cardiorespiratory index, compared to both sedation and general anesthesia. Episodes of life-threatening events were reported after topical anesthesia, while hypothermia and oliguria presented less often after topical, compared to general anesthesia and sedation.

CONCLUSION

Significant heterogeneity among studies precludes direct comparisons and generalizability of the results. No specific anesthetic modality for treatment of ROP with laser photocoagulation was shown to be superior in terms of safety. Well-designed studies are required to establish the optimal anesthetic approach, considering that laser photocoagulation still remains one of the main therapeutic modalities for ROP.

[Late sequelae of retinopathy of prematurity in infancy]

BACKGROUND

Retinopathy of prematurity (ROP) is one of the most frequent causes of severe visual impairment or blindness in childhood and can lead to severe late complications in children even after the initial disease has resolved.

PURPOSE

The present study summarizes possible late effects in childhood after treated and untreated ROP. A special focus is on the development of myopia, retinal detachment, as well as neurological and pulmonary development after anti-vascular endothelial growth factor (VEGF) treatment.

MATERIAL AND METHODS

This work is based on a selective literature search on late effects in childhood of treated or untreated ROP.

RESULTS

Preterm infants have an increased risk of developing high-grade myopia. Interestingly, several studies indicate that the risk of myopia is reduced following anti-VEGF treatment. With anti-VEGF treatment, however, late recurrences after initial response are possible even after several months, making long-term and frequent follow-up examinations essential. Controversy exists regarding the possible negative effects of anti-VEGF treatment on neurological and pulmonary development. After both treated and untreated ROP, rhegmatogenous, tractional or exudative retinal detachment, vitreous hemorrhage, high myopia and strabismus are possible late complications.

DISCUSSION

Children with a history of ROP with or without treatment have an increased risk for late ocular sequelae, such as high myopia, retinal detachment, vitreous hemorrhage and strabismus. A seamless transition from ROP screening to pediatric and ophthalmological follow-up care is therefore essential for timely detection and treatment of possible refractive errors, strabismus, or other amblyogenic changes.

Comparison of adverse events between intravitreal anti-VEGF and laser photocoagulation for treatment-requiring retinopathy of prematurity: a systematic review

PURPOSE

To synthesize existing evidence on adverse events, complications, and unfavorable outcomes of current treatment modalities for treatment-requiring retinopathy of prematurity (TR-ROP).

METHODS

PubMed, Cochrane Central Register of Controlled Trials, Scopus, EMBASE, Trip Database, and the gray literature available were searched. Randomized Clinical Trials and observational studies comparing the adverse events of intravitreal anti-VEGF injections (bevacizumab, ranibizumab, aflibercept, pegaptanib, conbercept) and laser photocoagulation (LPC) as treatment modalities for infants with TR-ROP were included. The main outcomes compared between the two treatment modalities were: 1. Refractive Errors and Biometry Parameters, 2. Adverse events, complications, and unfavorable outcomes, 3. Disease Recurrence/Disease Regression/Need for retreatment, 4. Neurodevelopmental Outcomes.

RESULTS

Higher quality studies concluded that LPC leads to greater rates of myopia than intravitreal anti-VEGF treatment while the rate of adverse events and of unfavorable neurodevelopmental outcomes is similar. However, there was controversy among the included studies concerning the rate of ROP recurrence between intravitreal anti-VEGF injections and LPC.

CONCLUSION

There is need for future primary studies assessing the adverse events of intravitreal anti-VEGF injections compared with LPC as treatment modalities for infants with TR-ROP.

[Epidemiology and treatment of retinopathy of prematurity. The Hannover data in the Retina.net ROP registry from 2001-2017]

BACKGROUND

The Retina.net ROP registry documents data of preterm infants developing stages of retinopathy of prematurity (ROP) that need ROP treatment. The aim of this analysis was to investigate data regarding epidemiology, therapy and changes over time (15 years) in a single participating center (Hannover Medical School, MHH).

METHODS

Analysis of data of infants treated for ROP at a single center over time (birth 2001-2016, ROP treatment in 2002-2017).

RESULTS

Overall, 65 infants were treated (23 female). In 11 infants (16.9%) ROP screening was conducted externally and infants were transferred to the MHH for ROP treatment. Between 2006 and 2016, incidence of ROP requiring treatment among infants screened for the development of ROP was 4.1%. Mean gestational age was 25.7 weeks (standard deviation, SD 1.8), mean birth weight 763 g (SD 235), postmenstrual age at treatment 38.2 weeks (SD 3.2), postnatal age 12.4 weeks (SD 3.2). There was no significant change in parameters over time. ROP zone II, stage 3+ was most frequently treated (57 eyes of 31 infants). 58 infants were treated with laser (114 eyes), 7 infants were treated with anti-VEGF (bevacizumab, bilateral, 14 eyes) from 2014 onwards. Retreatment due to recurrence of ROP was necessary in one infant after initial laser coagulation. Infants with ROP requiring treatment often presented with neonatal comorbidities, ventilation in more than 90%, bronchopulmonary dysplasia, and received transfusions.

CONCLUSION

This is the first monocentric analysis over 15 years originating from the Retina.net ROP registry. In this cohort we see a change in ROP therapy from laser coagulation to anti-VEGF (bevacizumab) from 2014 onwards, demographic data and treatment parameters remained relatively stable over time.

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.

Incidence of retinopathy of prematurity in Germany: evaluation of current screening criteria

OBJECTIVE

To evaluate current screening criteria for retinopathy of prematurity (ROP) by investigating the incidence of ROP requiring treatment in infants with gestational age (GA) ≥30 weeks or postmenstrual age (PMA) <32 weeks in Germany.

METHODS

Three patient databases were analysed, that is, the German Quality Assurance Procedure in Neonatology (years 2011-2017; n=52 461 infants screened for ROP, 1505 infants treated for ROP), the German Retina.net ROP Registry (years 2011-2018; n=281 treated infants) and the ROP screening programme of two German university hospitals (years 2012-2016; n=837 screened infants).

RESULTS

In the analysed cohorts, infants with GA ≥30 weeks represented 33.1%-38.5% of the screening populations but only 1.40%-1.42% of the cases requiring ROP treatment. In a cohort of 281 infants treated for ROP, all 4 infants with GA ≥30 weeks had additional risk factors for ROP including prolonged oxygen supplementation and/or significant comorbidities. Five infants (1.8%) were treated at 32 weeks PMA and none at PMA <32 weeks.

CONCLUSIONS

In the investigated cohorts, preterm infants with GA ≥30 weeks carried a very low or no risk for developing treatment-requiring ROP unless additional risk factors were present, and no treatment was performed earlier than 32 weeks PMA. These findings are of relevance for the ongoing re-evaluation of ROP screening criteria.

Management of retinopathy of prematurity (ROP) in a Polish cohort of infants

Retinopathy of prematurity (ROP) is potentially blinding, but screening and timely treatment can stop its progression. The data on treatment outcomes of ROP from Central and Eastern Europe are scarce. Therefore, we aimed to analyze the latest results of ROP management in Poznan medical center to update the data from this world region. In the years 2016–2019, 178 patients (350 eyes) received treatment for ROP (6.1% of the screened population). The mean gestational age was 26 weeks (range 22–31 weeks), the mean birth weight was 868 g (range 410–1890 g). The most frequent ROP stage at treatment was zone II, stage 3 + (34.9%). As the first line of treatment, 115 infants (226 eyes, 64.6%) underwent laser photocoagulation (LP); 61 infants (120 eyes, 34.3%) received intravitreal ranibizumab injections (IVR); and 2 infants (4 eyes, 0.6%) were treated simultaneously with LP and IVR. One hundred twenty-six eyes (36%) of 63 patients required retreatment: 20.4% treated with LP and 66.7% treated with IVR. Retinal detachment occurred in 14 eyes (4%). The incidence of ROP, ROP requiring treatment, and reoccurrence rates are higher in the Polish population than in Western Europe and the USA. The identified treatment patterns find increasing use of anti-VEGF agents.

Lutein Supplementation for Eye Diseases

Lutein is one of the few xanthophyll carotenoids that is found in high concentration in the macula of human retina. As de novo synthesis of lutein within the human body is impossible, lutein can only be obtained from diet. It is a natural substance abundant in egg yolk and dark green leafy vegetables. Many basic and clinical studies have reported lutein's anti-oxidative and anti-inflammatory properties in the eye, suggesting its beneficial effects on protection and alleviation of ocular diseases such as age-related macular degeneration, diabetic retinopathy, retinopathy of prematurity, myopia, and cataract. Most importantly, lutein is categorized as Generally Regarded as Safe (GRAS), posing minimal side-effects upon long term consumption. In this review, we will discuss the chemical structure and properties of lutein as well as its application and safety as a nutritional supplement. Finally, the effects of lutein consumption on the aforementioned eye diseases will be reviewed.

A Quantitative Severity Scale for Retinopathy of Prematurity Using Deep Learning to Monitor Disease Regression After Treatment

Importance

Retinopathy of prematurity (ROP) is a leading cause of childhood blindness worldwide, but treatment failure and disease recurrence are important causes of adverse outcomes in patients with treatment-requiring ROP (TR-ROP).

Objectives

To apply an automated ROP vascular severity score obtained using a deep learning algorithm and to assess its utility for objectively monitoring ROP regression after treatment.

Design, Setting, and Participants

This retrospective cohort study used data from the Imaging and Informatics in ROP consortium, which comprises 9 tertiary referral centers in North America that screen high volumes of at-risk infants for ROP. Images of 5255 clinical eye examinations from 871 infants performed between July 2011 and December 2016 were assessed for eligibility in the present study. The disease course was assessed with time across the numerous examinations for patients with TR-ROP. Infants born prematurely meeting screening criteria for ROP who developed TR-ROP and who had images captured within 4 weeks before and after treatment as well as at the time of treatment were included.

Main Outcomes and Measures

The primary outcome was mean (SD) ROP vascular severity score before, at time of, and after treatment. A deep learning classifier was used to assign a continuous ROP vascular severity score, which ranged from 1 (normal) to 9 (most severe), at each examination. A secondary outcome was the difference in ROP vascular severity score among eyes treated with laser or the vascular endothelial growth factor antagonist bevacizumab. Differences between groups for both outcomes were assessed using unpaired 2-tailed t tests with Bonferroni correction.

Results

Of 5255 examined eyes, 91 developed TR-ROP, of which 46 eyes met the inclusion criteria based on the available images. The mean (SD) birth weight of those patients was 653 (185) g, with a mean (SD) gestational age of 24.9 (1.3) weeks. The mean (SD) ROP vascular severity scores significantly increased 2 weeks prior to treatment (4.19 [1.75]), peaked at treatment (7.43 [1.89]), and decreased for at least 2 weeks after treatment (4.00 [1.88]) (all P < .001). Eyes requiring retreatment with laser had higher ROP vascular severity scores at the time of initial treatment compared with eyes receiving a single treatment (P < .001).

Conclusions and Relevance

This quantitative ROP vascular severity score appears to consistently reflect clinical disease progression and posttreatment regression in eyes with TR-ROP. These study results may have implications for the monitoring of patients with ROP for treatment failure and disease recurrence and for determining the appropriate level of disease severity for primary treatment in eyes with aggressive disease.

[Screening for retinopathy of prematurity: Trends over the past 5 years in two German university hospitals]

BACKGROUND

The number of preterm births in Germany has been increasing continuously over the past decades. Retinopathy of prematurity (ROP) is a major complication of preterm birth and one of the leading causes of blindness in children.

OBJECTIVES

This study analyzes the development of the incidence of ROP over the past 5 years at two German university hospitals, utilizing data from ROP screening examinations.

MATERIAL AND METHODS

We assessed all children born in the years 2012-2016 who were included in the ROP screening program at two German university hospitals according to the criteria of the German ROP screening guidelines. Parameters such as gestational age, birth weight, ROP stage and zone, and need for therapeutic intervention were assessed.

RESULTS

We analyzed the data of 863 children who had undergone a total of 4117 screening examinations. The number of children included in the screening program per study year increased continuously over the study period by a total of 43.1% (137 in 2012, 196 in 2016). Likewise, the number of screening examinations per year increased by 58.4% (608 in 2012, 963 in 2016). Overall, 27.5% of screened infants were diagnosed with ROP of any stage and 2.5% required treatment for ROP. The number of children diagnosed with ROP of any stage per year increased by 100.0% (32 in 2012, 64 in 2016). Mean gestational age (29.0 ± 3.0 weeks) and mean birth weight (1192 ± 513 g) remained stable over the study period.

CONCLUSION

Screening data for ROP from two German university hospitals demonstrates a significant increase in both the number of screened infants and the number of infants affected by ROP over the past 5 years.