Retinopathy of Prematurity: Advances in the Screening and Treatment of Retinopathy of Prematurity Using a Single Center Approach

Validation of the "TWO-ROP" Algorithm at a Multi-Neonatal Intensive Care Unit Tertiary Referral Center

PURPOSE

We aim to validate the previously published TWO-ROP algorithm on an external data set.

DESIGN

Retrospective consecutive study.

SUBJECTS

Infants screened for retinopathy of prematurity (ROP) between January 2013 and August 2023 at a tertiary referral multi-site.

METHODS

Infants with higher birth weight (BW) and greater gestational age (GA) were included and stratified into 3 groups as follows: group 1 (BW <1500 g, GA ≥30 weeks), group 2 (BW ≥1500 g, GA <30 weeks), and group 3 (BW ≥1500 g, GA ≥30 weeks).

MAIN OUTCOME MEASURES

The rate of ROP, treatment-warranted ROP (TW-ROP), and number of inpatient examinations were evaluated in the 3 groups.

RESULTS

In total, 1095 (33.8%) patients met the inclusion criteria. The number of patients in groups 1, 2, and 3 was 837 (76.4%), 72 (6.6%), and 186 (17.0%), respectively. Retinopathy of prematurity was detected in 120 (11.0%) patients; the rate was 9.8% in group 1, 20.8% in group 2, and 12.4% in group 3 (P = 0.013). The overall mean number of inpatient examinations for patients undergoing traditional, TWO-ROP 36-week, and TWO-ROP 40-week screening systems was 1.95, 1.43, and 0.99, respectively (P < 0.001). Stage 3 was found in 9 eyes of 5 patients (0.5%, all zone II). Three eyes of 2 patients (0.2%) had plus disease. Two patients had bilateral laser treatment at 44 and 39.4 weeks postconceptional age (PCA); 3 out of 4 of these eyes met type 1 treatment criteria. Overall, the ROP screening burden saved was 9.0% and 16.7% for the TWO-ROP 36-week and 40-week systems, respectively. The sensitivity for TW-ROP was 100% for TWO-ROP 36-week system and 99.4% for TWO-ROP 40-week system.

CONCLUSION

The TWO-ROP algorithm can reduce the number of inpatient examinations while maintaining safety. To ensure timely management, we recommend that the single first ROP examination occur at 38 to 39 weeks PCA.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Validation of WINROP algorithm as screening tool of retinopathy of prematurity among Egyptian preterm neonates

BACKGROUND

Retinopathy of prematurity (ROP) is a leading cause of preventable childhood blindness worldwide. Proper screening for ROP can prevent loss of vision. WINROP (weight, insulin-like growth factor 1, neonatal, retinopathy of prematurity) is an online surveillance system based on gestational age, birth weight and weekly weight gain that can predict infants at risk of sight-threatening retinopathy of prematurity.

AIMS

To evaluate the diagnostic accuracy of WINROP algorithm in detecting sight-threatening ROP in Egyptian preterm neonates.

METHODS

Birth weight (BW), gestational age (GA) and weekly weight measurement of 365 preterm infants were prospectively entered into WINROP algorithm. Based on these inputs, the algorithm would output and a screening was performed as is standard. Sensitivity, specificity, and predictive values were calculated by comparing WINROP outcomes with ROP screening outcomes.

RESULTS

Of the infants included in the study the mean GA was ±31.24 and mean BW was ±1508.78. A high risk WINROP alarm was triggered in 62 infants of whom 16 infants develop type 1 or type 2 ROP. These infants had associated comorbidities including sepsis, Intraventricular hemorrhage (IVH), Necrotizing enterocolitis (NEC), history of transfusion of packed red blood cells (RBCS) and history of platelet transfusion. A low risk WINROP alarm was triggered in 303 infants of whom 15 infants developed type 1 or type 2ROP. WINROP showed a sensitivity of 51.6%, a specificity of 86.2%, a positive predictive value (PPV) of 52.8% and a negative predictive value (NPV) of 95% for detection of type 1 or type 2 ROP.

CONCLUSION

WINROP has low sensitivity and high specificity for detection of ROP. It may help in ROP prediction but can't be used alone. Modification of WINROP algorithm taking into account other risk factors may improve sensitivity and reduce number for ROP examination.

The Incidence and Timing of Treatment-Requiring Retinopathy of Prematurity in Nanopremature and Micropremature Infants in the United States: A National Multicenter Retrospective Cohort Study

PARTICIPANTS

This article includes 7293 infants (14 586 eyes) screened for ROP across 5 centers in the United States (Austin Retina Associates, Austin, TX; Bascom Palmer Eye Institute, Miami, FL; Beaumont Eye Institute, Royal Oak, MI; Massachusetts Eye and Ear, Boston, MA; and Stanford Byers Eye Institute, Stanford, CA).

PURPOSE

To analyze the incidence and timing of treatment requiring retinopathy of prematurity (ROP) in extremely small premature infants. We hypothesize that the smaller the infant by gestational age and birthweight, the higher their likelihood of requiring treatment for ROP.

DESIGN

Premature infants screened for Retinopathy of Prematurity from 2002-2022 were divided into cohorts based on the following criteria based on gestational age (GA) and birth weight (BW). "Micropremature infants" are infants born between 24-26 weeks GA and between 600-799 g BW. "Nanopremature infants" are born ≤ 24 weeks GA and ≤ 600 g BW.

METHODS

Retrospective chart review.

MAIN OUTCOME MEASURES

The incidence and timing of treatment-requiring ROP.

RESULTS

We found that infants defined as nanopremature had a ∼63% chance of requiring treatment at an average postmenstrual age (PMA) of 36.6 weeks, whereas those defined as micropremature had a 30% chance of requiring treatment at an average PMA of 36.3 weeks. This significantly contrasts with the risk of all screened babies for ROP where the risk of requiring treatment was 8.5%.

CONCLUSION

Micropremature and nanopremature infants are significantly more likely to require treatment for ROP. With demographic data matched to all 5 major US regions spanning the last decade, these results have the potential to inform neonatologists, pediatricians, and ophthalmologists of an important shift in the landscape of prematurity in the United States.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Global Prevalence and Severity of Retinopathy of Prematurity over the Last Four Decades (1985-2021): A Systematic Review and Meta-Analysis

BACKGROUND

Retinopathy of prematurity (ROP) is a vasoproliferative disease of the retina that occurs in premature infants. The prevalence of ROP reported so far is inconsistent.

AIM

To conduct a systematic review to describe the trend of ROP prevalence between 1985 and 2021, and to determine the influence of countries' economic conditions on ROP prevalence.

METHODS

We searched PubMed, Embase, and Google Scholar for studies published between January 1985 and December 2021 using the following MeSH terms: "retinopathy of prematurity", "ROP", "incidence", and "prevalence". Two independent reviewers examined the articles to select studies that met the selection criteria and performed data extraction and study quality assessment. For the meta-analysis, the pooled prevalence was calculated using a random-effects model and R software.

RESULTS

Of 5,250 titles and abstracts, 139 original studies met the inclusion criteria; a total of 121,618 premature infants were included in these studies. The pooled prevalence of ROP was 31.9% (95% confidence interval [CI] 29.0-34.8) and that of severe ROP was 7.5% (6.5-8.7). In general, no significant differences in prevalence were found over the four decades; however, we found a higher prevalence in premature infants ≤28 weeks of gestational age. In addition, the highest ROP prevalence was found in lower-middle-income countries with high mortality rates. In contrast, the highest severe ROP prevalence was found in high-income countries.

CONCLUSION

ROP remains a common cause of morbidity in premature infants worldwide. Therefore, it seems necessary to maintain early identification strategies for patients at higher risk, particularly in low- and middle-income countries.

Retinopathy of Prematurity-Targeting Hypoxic and Redox Signaling Pathways

Retinopathy of prematurity (ROP) is a proliferative vascular ailment affecting the retina. It is the main risk factor for visual impairment and blindness in infants and young children worldwide. If left undiagnosed and untreated, it can progress to retinal detachment and severe visual impairment. Geographical variations in ROP epidemiology have emerged over recent decades, attributable to differing levels of care provided to preterm infants across countries and regions. Our understanding of the causes of ROP, screening, diagnosis, treatment, and associated risk factors continues to advance. This review article aims to present the pathophysiological mechanisms of ROP, including its treatment. Specifically, it delves into the latest cutting-edge treatment approaches targeting hypoxia and redox signaling pathways for this condition.

Role of fetal hemoglobin in the development and progression of retinopathy of prematurity in preterm infants

Purpose

The objective of this study was to find the association between fetal hemoglobin (HbF) concentration and retinopathy of prematurity (ROP) in preterm infants.

Methods

In this observational, prospective, longitudinal study, a total of 410 preterm infants with <36 gestational weeks and <2.5 kg birth weight, who were attending ROP clinic in a tertiary care hospital of central India for 1 year duration were included. Dilated fundus examination was done as per ROP screening guidelines, and ROP was staged as per international classification for retinopathy of prematurity (ICROP) classification, 2021. HbF (%) was measured with high-performance liquid chromatography, and data was analyzed statistically. The relationship between HbF (%) and ROP was evaluated. Those infants who had ROP were further divided into treatment-requiring and non-treatment-requiring groups and HbF was compared in these groups at the first visit and after 1-month follow-up period. The outcome of ROP was studied with HbF levels.

Results

A total of 410 preterm infants were included, out of which 110 infants had ROP (26.8%). Infants with ROP had significantly lower percentage of HbF with gestational age groups and birth weight groups, compared to infants without ROP. Higher percentage of HbF was associated with a lower prevalence of ROP. Higher concentration of HbF was found in the ROP infants who regressed spontaneously without treatment and less concentration was found in those who progressed to a severe disease and those who required treatment. The predictive ability of HbF (%) was 0.976 for ROP.

Conclusion

Low fraction of HbF was found to be significantly associated with the development and progression of ROP.

The Effects of Early Enteral and Parental Nutrition on Retinopathy of Prematurity: A Systematic Review

The management of preterm newborns must consider the severe problem of retinopathy of prematurity (ROP). A systematic review has been conducted to effectively acknowledge how enteral and parenteral early nutrition affect the growth and progression of ROP. The study summarizes recent findings from various sources to give insight into the relationship between dietary practices and ROP risks. When untreated, retinopathy of prematurity (ROP) may cause severe vision loss or blindness in premature newborns. The latter two phases of ROP progression are the most serious. A child's early nutrition, both orally and intravenously, significantly impacts the severity and progression of ROP. This systematic review aims to examine the evidence linking early nutrition to ROP in premature infants. The study used Embase, Scopus, and PubMed to conduct our search. ROP, premature newborns, and nutrition were keywords used to find relevant papers. Nine research studies made it through the screening process and offered important information on the impact of diet on ROP. These studies support the idea that poor nutrition is a driving force behind the onset of ROP. The risk of ROP has been associated with postnatal development, hyperglycemia, polyunsaturated fatty acid levels, and the presence of breast milk. The outlook for ROP has also been discovered to be affected by the length of time the patient has received parenteral feeding. The incidence and severity of ROP may be mitigated by providing better nutrition to premature newborns. This comprehensive study concludes that early nutrition, both enteral and parenteral, substantially influences the development and progression of ROP in premature newborns. The significance of nutrition in newborn care is highlighted by the possibility that improved dietary methods might aid in preventing and treating this vision-threatening illness.

An Animal Model of Neonatal Intensive Care Unit Exposure to Light and Sound in the Preterm Infant

According to the World Health Organization, ∼15 million children are born prematurely each year. Many of these infants end up spending days to weeks in a neonatal intensive care unit (NICU). Infants who are born prematurely are often exposed to noise and light levels that affect their auditory and visual development. Children often have long-term impairments in cognition, visuospatial processing, hearing, and language. We have developed a rodent model of NICU exposure to light and sound using the Mongolian gerbil (Meriones unguiculatus), which has a low-frequency human-like audiogram and is altricial. To simulate preterm infancy, the eyes and ears were opened prematurely, and animals were exposed to the NICU-like sensory environment throughout the gerbil's cortical critical period of auditory development. After the animals matured into adults, auditory perceptual testing was carried out followed by auditory brainstem response recordings and then histology to assess the white matter morphology of various brain regions. Compared to normal hearing control animals, NICU sensory-exposed animals had significant impairments in learning at later stages of training, increased auditory thresholds reflecting hearing loss, and smaller cerebellar white matter volumes. These have all been reported in longitudinal studies of preterm infants. These preliminary results suggest that this animal model could provide researchers with an ethical way to explore the effects of the sensory environment in the NICU on the preterm infant's brain development.

Retinopathy of prematurity: risk stratification by gestational age

OBJECTIVE

To identify gestational age (GA) specific risk factors for severe ROP (sROP).

STUDY DESIGN

Single-center cohort stratified by GA into <24 weeks, 24-26 weeks and ≥27 weeks.

RESULTS

132/1106 (11.9%) developed sROP. Time to full feeds was the only risk factor [HR 1.003 (1.001-1.006), p = 0.04] for infants<24 weeks GA. For infants 24-26 weeks GA, a higher GA was protective [HR 0.66 (0.51-0.85), p < 0.01], whereas steroids for bronchopulmonary dysplasia (BPD) [HR 2.21 (1.28-3.26), p < 0.01], patent ductus arteriosus (PDA) ligation [HR 1.99 (1.25-3.11), p < 0.01] and use of nitric oxide [HR 1.96 (1.11-3.30), p = 0.01] increased the hazard of sROP. Increasing birthweight was protective [HR 0.70 (0.54-0.89), p < 0.01] in infants ≥27 weeks GA. Cumulative hazard of sROP reached 1.0 by fifteen weeks for <24 weeks GA, 0.4 by twenty weeks for 24-26 weeks GA, and 0.05 by twenty weeks after birth for ≥27 weeks GA.

CONCLUSIONS

Risk factors, cumulative hazard, and time to sROP vary by GA.

The role of hepatic and renal functions in the development of retinopathy of prematurity: Is proteinuria a new risk factor?

PURPOSE

To investigate the association of hepatic and renal parameters with the development of retinopathy of prematurity (ROP) in premature infants with a gestational age ≤ 32 weeks.

METHODS

Medical records of 240 preterm infants were reviewed retrospectively, 85 of them were grouped as type 1, type 2 ROP, and control group. The 4th week hepatic and renal function test results of the groups, on the day of their first ROP examinations, were compared for the risk of development of ROP and the development of type 1 ROP.

RESULTS

In this study, 12, 35, and 38 infants were enrolled in the type 1, type 2 ROP, and control group, respectively. The average gestational age and birth weight were higher; however, the duration of oxygen treatment was lower in the control group (p < 0.001). The blood glucose level was significantly higher in the type 1 ROP group than in the other groups (p = 0.023). The mean of total serum bilirubin of the type 1 ROP group was significantly lower than those of the type 2 ROP and control group (p = 0.032). Proteinuria was present in 85.7% of preterms with treatment-requiring ROP and proteinuria increased the risk of ROP by 3.9 times (OR with 95% CI 3.9 (1.19-12.75), p = 0.042).

CONCLUSION

We found significantly higher blood glucose and lower total bilirubin level in the type 1 ROP group. Moreover, our findings suggest that proteinuria may not be only a comorbidity factor but also related to a higher frequency of ROP and type 1 ROP in preterm infants.

Latest Trends in Retinopathy of Prematurity: Research on Risk Factors, Diagnostic Methods and Therapies

Retinopathy of prematurity (ROP) is a vasoproliferative disorder with an imminent risk of blindness, in cases where early diagnosis and treatment are not performed. The doctors' constant motivation to give these fragile beings a chance at life with optimal visual acuity has never stopped, since Terry first described this condition. Thus, throughout time, several specific advancements have been made in the management of ROP. Apart from the most known risk factors, this narrative review brings to light the latest research about new potential risk factors, such as: proteinuria, insulin-like growth factor 1 (IGF-1) and blood transfusions. Digital imaging has revolutionized the management of retinal pathologies, and it is more and more used in identifying and staging ROP, particularly in the disadvantaged regions by the means of telescreening. Moreover, optical coherence tomography (OCT) and automated diagnostic tools based on deep learning offer new perspectives on the ROP diagnosis. The new therapeutical trend based on the use of anti-VEGF agents is increasingly used in the treatment of ROP patients, and recent research sustains the theory according to which these agents do not interfere with the neurodevelopment of premature babies.

Structural and refractive outcomes of intravitreal ranibizumab followed by laser photocoagulation for type 1 retinopathy of prematurity

PURPOSE

To evaluate refractive and structural outcomes for patients treated for retinopathy of prematurity (ROP) with the anti-vascular endothelial growth factor (anti-VEGF) agent ranibizumab and "delayed laser," defined as any laser photocoagulation treatment administered at least 2 weeks and <1 year after the initial anti-VEGF injection.

METHODS

The medical records of infants with type 1 ROP treated between 2015 and 2020 with intravitreal 0.25 mg ranibizumab followed by delayed laser photocoagulation, with a minimum of 6 months' follow-up, were reviewed retrospectively. Refractive and structural outcomes were extracted from the record.

RESULTS

A total of 68 eyes of 34 neonates were included, with median gestational age of 24 weeks and birthweight of 657 g. Patients were aged 0.9 to 4.4 years at last follow-up; mean follow-up interval was 2.7 ± 1.02 years. There was no progression to stage 4 or 5 following treatment during the study period. At 2 years' follow-up (mean age, 2.41 ± 0.23 years), median spherical equivalent (SE) was -0.13 D (IQR, 4.20 D). At most recent examination (mean age, 2.70 ± 1.02 years), the most common ocular findings included strabismus (32%), optic atrophy (24%), amblyopia (21%), high myopia (7%), and nystagmus (4%).

CONCLUSIONS

In our small cohort, neonates with type 1 ROP treated with intravitreal ranibizumab and delayed laser demonstrated good structural outcomes, with no progression to retinal detachment. We found lower rates of high myopia compared with previous reports of laser photocoagulation monotherapy.

Practice Patterns and Outcomes of Intravitreal Anti-VEGF Injection for Retinopathy of Prematurity: An International Multicenter Study

PURPOSE

To report practice patterns of intravitreal injections of anti-VEGF for retinopathy of prematurity (ROP) and outcomes data with a focus on retreatments and complications.

DESIGN

Multicenter, international, retrospective, consecutive series.

SUBJECTS

Patients with ROP treated with anti-VEGF injections from 2007 to 2021.

METHODS

Twenfty-three sites (16 United States [US] and 7 non-US) participated. Data collected included demographics, birth characteristics, examination findings, and methods of injections. Comparisons between US and non-US sites were made.

MAIN OUTCOME MEASURES

Primary outcomes included number and types of retreatments as well as complications. Secondary outcomes included specifics of the injection protocols, including types of medication, doses, distance from limbus, use of antibiotics, and quadrants where injections were delivered.

RESULTS

A total of 1677 eyes of 918 patients (43% female, 57% male) were included. Mean gestational age was 25.7 weeks (range, 21.2-41.5 weeks), and mean birth weight was 787 g (range, 300-2700 g). Overall, a 30-gauge needle was most commonly used (51%), and the quadrant injected was most frequently the inferior-temporal (51.3%). The distance from the limbus ranged from 0.75 to 2 mm, with 1 mm being the most common (65%). Bevacizumab was the most common anti-VEGF (71.4%), with a dose of 0.625 mg in 64% of cases. Overall, 604 (36%) eyes required retreatment. Of those, 79.8% were retreated with laser alone, 10.6% with anti-VEGF injection alone, and 9.6% with combined laser and injection. Complications after anti-VEGF injections occurred in 15 (0.9%) eyes, and no cases of endophthalmitis were reported. Patients in the United States had lower birth weights and gestational ages (665.6 g and 24.5 weeks, respectively) compared with non-US patients (912.7 g and 26.9 weeks, respectively) (P < 0.0001). Retreatment with reinjection and laser was significantly more common in the US compared with the non-US group (8.5% vs. 4.7% [P = 0.0016] and 55% vs. 7.2% [P < 0.001], respectively). There was no difference in the incidence of complications between the 2 geographic subgroups.

CONCLUSIONS

Anti-VEGF injections for ROP were safe and well tolerated despite a variance in practice patterns. Infants with ROP receiving injections in the US tended to be younger and smaller, and they were treated earlier with more retreatments than non-US neonates with ROP.

The Male to Female Ratio in Treatment-Warranted Retinopathy of Prematurity: A Systematic Review and Meta-analysis

Importance

Literature and anecdotal evidence suggest a relationship between male sex and retinopathy of prematurity (ROP). It is not known whether a difference, if present, is sex-related pathophysiologic predisposition or sex difference in meeting ROP screening criteria.

Objective

To evaluate the association of sex with the development of treatment-warranted ROP.

Data Sources

PubMed, Embase, and Web of Science databases were searched from 2000 to 2022. The search strategy used keywords including retinopathy of prematurity or ROP or retrolental fibroplasia and treatment or anti-VEGF or bevacizumab or ranibizumab or aflibercept or conbercept or laser or cryotherapy and gender or sex or male or female and medical subject headings terms.

Study Selection

All studies reporting on treatment with anti-vascular endothelial growth factor, laser photocoagulation, and/or cryotherapy for ROP were identified. Studies reporting sex distribution in the treatment group were included in the meta-analysis. Exclusion criteria included case reports, case series of fewer than 10 treated patients, systematic reviews, conference abstracts, letters to the editor, animal studies, and non-English records.

Data Extraction and Synthesis

Two reviewers independently screened and extracted the data following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The proportions of treated male and female infants were combined using random-effects meta-analysis.

Main Outcomes and Measures

Numbers and percentages of male and female infants treated for ROP.

Results

Of 11 368 identified studies, 316 met inclusion criteria, yielding a total of 31 026 treated patients. A higher percentage of male infants were treated for ROP (55% [95% CI, 0.54%-0.55%]), with low heterogeneity between studies (I2 = 34%; P < .001). Thirty-eight studies reported sex distribution in the screened population (170 053 patients; 92 612 [53%] male vs 77 441 [47%] female). There was no significant difference in the odds of receiving treatment between screened male and female infants (pooled odds ratio, 1.04 [95% CI, 0.91-1.18]; P = .67).

Conclusions and Relevance

More male infants are treated for ROP than female infants. This could be due to a known relative pathophysiological fragility of preterm male infants in addition to a difference in ROP screening rates, with more male infants meeting the criteria than female infants. These findings have implications for future studies and may prompt more careful clinical monitoring of male neonates.