Visual outcomes after lens-sparing vitrectomy for stage 4A retinopathy of prematurity

Long-Term Visual Prognosis of Patients Following Lens-Sparing Vitrectomy for Stage 4A Retinopathy of Prematurity

This study evaluated the long-term visual outcomes of patients in whom at least one eye underwent successful lens-sparing vitrectomy (LSV) for stage 4A retinopathy of prematurity (ROP). A retrospective chart review was conducted using the data of 61 eyes of 42 patients with a minimum 4-year follow-up after successful LSV, with or without anti-vascular endothelial growth factor (VEGF) therapy, and whose best-corrected visual acuity (BCVA) was measurable using Landolt rings at the final visit. The mean age at the final follow-up was 10.1 ± 3.3 years. Before LSV, all eyes underwent laser ablation therapy. Twenty eyes (32.8%) with high vascular activity received anti-VEGF therapy before LSV. The mean decimal BCVA at the final follow-up was 0.23 ± 0.26 (range: hand motion to 1.2). Twenty-three eyes (54.1%) had a decimal BCVA of ≥0.4. Among 49 phakic eyes at the final examination, the mean refractive error was -10.1 ± 5.0 D, with 37 eyes (75.5%) having high myopia (>-6.0 D). No significant differences were observed in terms of decimal BCVA and refractive errors between eyes with and without anti-VEGF therapy. Approximately half of the patients had a decimal BCVA of ≥0.4, despite myopic refraction after successful LSV for stage 4A ROP. LSV for stage 4A ROP seemed to be associated with good visual function, despite myopic refraction.

Outcomes of near confluent laser versus combined less dense laser and bevacizumab treatment of prethreshold ROP Type 1 Zone 2: a randomized controlled trial

BACKGROUND

To evaluate the results of near confluent laser therapy versus combined less dense laser and intra vitreal bevacizumab in treatment of infants with type 1 retinopathy of prematurity (ROP) in zone II.

METHODS

This is a prospective double-blinded randomized clinical trial study. Infants with Type 1 ROP in Zone 2 were randomized into case and control groups. Conventional laser therapy was executed for control group and combination of IVB and laser treatment was employed for the case group.

RESULTS

Eighty-six eyes from 43 infants were analyzed in this trial. The first group included 42 eyes from 21 infants receiving a combination of laser ablation and IVB. The second group contained 44 eyes from 22 infants who received only conventional laser therapy. The combined IVB and laser ablation group demonstrated the neovascularization regression (20 out of 21 infants) one week after the procedure. In the conventional laser therapy group, this regression was found in (12 out of 22 infants) within one week after laser therapy (P = 0.001). Plus disease regression was observed in 20 (20/21) of combined treatment group and 7 infants (7/22) of conventional laser treatment group after one week.

CONCLUSION

Combined less dense laser and bevacizumab treatment resulted in more rapid regression in comparison with the conventional laser treatment.

TRIAL REGISTRATION

IRCT20201120049450N1, 27/12/2021.

Evaluation of segmental scleral buckling surgery for stage 4A retinopathy of prematurity in China

Aims

To describe the long-term effect of scleral buckling (SB) surgery for stage 4A retinopathy of prematurity (ROP).

Methods

A retrospective chart review was conducted for patients with a diagnosis of stage 4A ROP who underwent SB between October 2010 and October 2021. Basic data were collected from patient charts, including gender, birth weight, gestational age at birth, disease stage, presence of plus disease, preoperative treatment [laser photocoagulation, intravitreal anti-vascular endothelial growth factor (VEGF) agent therapy, or a combination of both] and complications (vitreous hemorrhages), postmenstrual age at surgery, intraoperative combined treatment, and total length of follow-up. Retinal attachment status after surgery, postoperative complications (glaucoma, cataract), date and type of subsequent retinal surgeries (if performed), and refractive status 1 year after surgery were evaluated. The follow-up time after the first procedure was over 1 year.

Results

Six-two eyes from forty-eight patients met the inclusion criteria for this study. The initial reattachment rate was 93.5% (58/62 eyes), and the final reattachment rate was 100% after two procedures at the end of follow-up. The incidence of cataracts was 3.2% (2/62), with no eye subsequently needing lensectomy surgery. None of the patients developed glaucoma during the follow-up time. The average spherical equivalent refraction value for patients was −3.00 ± 2.51 D (−7.60 D to +2.75 D) 1 year after surgery.

Conclusion

SB, especially segmental buckling, which induces less myopia and does not require buckle removal, has the potential to provide a significant positive impact in the treatment of stage 4A ROP.

Development and Validation of a Deep Learning Model to Predict the Occurrence and Severity of Retinopathy of Prematurity

Importance

Retinopathy of prematurity (ROP) is the leading cause of childhood blindness worldwide. Prediction of ROP before onset holds great promise for reducing the risk of blindness.

Objective

To develop and validate a deep learning (DL) system to predict the occurrence and severity of ROP before 45 weeks' postmenstrual age.

Design, Setting, and Participants

This retrospective prognostic study included 7033 retinal photographs of 725 infants in the training set and 763 retinal photographs of 90 infants in the external validation set, along with 46 characteristics for each infant. All images of both eyes from the same infant taken at the first screening were labeled according to the final diagnosis made between the first screening and 45 weeks' postmenstrual age. The DL system was developed using retinal photographs from the first ROP screening and clinical characteristics before or at the first screening in infants born between June 3, 2017, and August 28, 2019.

Exposures

Two models were specifically designed for predictions of the occurrence (occurrence network [OC-Net]) and severity (severity network [SE-Net]) of ROP. Five-fold cross-validation was applied for internal validation.

Main Outcomes and Measures

Area under the receiver operating characteristic curve (AUC), accuracy, sensitivity, and specificity to evaluate the performance in ROP prediction.

Results

This study included 815 infants (450 [55.2%] boys) with mean birth weight of 1.91 kg (95% CI, 1.87-1.95 kg) and mean gestational age of 33.1 weeks (95% CI, 32.9-33.3 weeks). In internal validation, mean AUC, accuracy, sensitivity, and specificity were 0.90 (95% CI, 0.88-0.92), 52.8% (95% CI, 49.2%-56.4%), 100% (95% CI, 97.4%-100%), and 37.8% (95% CI, 33.7%-42.1%), respectively, for OC-Net to predict ROP occurrence and 0.87 (95% CI, 0.82-0.91), 68.0% (95% CI, 61.2%-74.8%), 100% (95% CI, 93.2%-100%), and 46.6% (95% CI, 37.3%-56.0%), respectively, for SE-Net to predict severe ROP. In external validation, the AUC, accuracy, sensitivity, and specificity were 0.94, 33.3%, 100%, and 7.5%, respectively, for OC-Net, and 0.88, 56.0%, 100%, and 35.3%, respectively, for SE-Net.

Conclusions and Relevance

In this study, the DL system achieved promising accuracy in ROP prediction. This DL system is potentially useful in identifying infants with high risk of developing ROP.

Comparison of heads up three dimensional visualization system to conventional microscope in retinopathy of prematurity related tractional retinal detachment

To report the outcomes, advantages and disadvantages of a heads-up three-dimensional (3D) visualization system compared to the conventional microscope in pediatric tractional retinal detachment (TRD) surgery secondary to advanced stage retinopathy of prematurity (ROP). Medical records of patients with ROP stage 4 or 5 who underwent surgery for tractional retinal detachment at King Khaled Eye Specialist Hospital between September 2017 and July 2019 were identified and reviewed. Eyes were divided into 2 groups, eyes that underwent surgery with a 3D heads-up platform (3D group) and eyes that underwent surgery with a conventional microscope (conventional group). Data were collected on neonatal history, visual acuity, intraoperative complications and success rates between groups.Eighteen eyes of 14 patients who underwent surgical repair of TRD related to ROP. Postoperative outcomes were compared between 10 eyes (7 patients) in the 3D group and 8 eyes (7 patients) in the conventional group There was no statistically significant difference in success rate between both groups (75% conventional group vs 70% 3D group). Partial or complete reattachment was achieved in 7 eyes in 3D group compared to 6 eyes in conventional group. Lower postmenstrual age at the time of the first surgery and presence of retinal breaks were associated with poorer surgical outcome. Heads up 3D visualization system is feasible in tractional retinal detachment related to ROP with similar success rate and no increased risk of complications when compared to conventional microscope. This system may be advantageous in advanced pediatric tractional retinal detachment surgeries.

Scleral buckling surgery for stage 4A and 4B retinopathy of prematurity in critically ill neonates

PURPOSE

To determine the efficacy of scleral buckling in eyes with stage 4A and 4B retinopathy of prematurity (ROP).

METHODS

Seven eyes of five premature infants underwent scleral buckling for stage 4 ROP in zone II. Five eyes had stage 4A ROP, and two eyes had stage 4B ROP. Six eyes had previous diode laser photocoagulation, and one eye had received an intravitreal ranibizumab injection. Scleral buckling was the procedure of choice due to lack of access to specialized pediatric vitrectomy instrumentation. Average age at surgery was 3.4 months. Postoperative anatomic retinal status, visual acuity outcome and refractive error were assessed.

RESULTS

The scleral buckle was removed on average 8 months after surgery. Retinal reattachment was achieved in all seven eyes. At final follow-up one eye had macular ectopia and disc dragging, one eye had a macular traction fold and two eyes had optic disc pallor. Average myopic error after buckle removal was -7.5 D.

CONCLUSION

Scleral buckling can be performed safely and effectively in 4A and 4B stage ROP in critically ill infants, when access to specialized pediatric vitrectomy instrumentation is limited. This surgical technique may provide adequate relief of vitreoretinal traction with improved visual potential.

Lens-sparing vitrectomy for stage 4A retinopathy of prematurity in infants with aggressive-posterior ROP: Anatomic and functional results

AIM

To assess long-term anatomic and functional outcomes of early lens-sparing vitrectomy (LSV) for stage 4A retinopathy of prematurity (ROP) in infants with aggressive-posterior ROP (AP-ROP) which progressed to retinal detachment despite laser treatment.

METHODS

Chart review of infants who underwent early 25-gage LSV for stage 4A ROP. Outcomes were anatomic success, mean visual acuity (VA), development of postoperative complications, and refractive changes. Follow-up examinations were performed at 1, 3, 6, 12, and then every 6 months.

RESULTS

Ten eyes of seven preterm infants who underwent LSV were included. Mean follow-up was 36 ± 13.4 months and mean postmenstrual age (PMA) at last follow-up was 37 ± 13.7 months. Mean gestational age (GA) and weight at birth was 26 ± 1.4 weeks and 639 ± 180 g. Two eyes had vitreous hemorrhage 4 and 14 days after surgery, respectively. At last follow-up anatomic success was 100%, mean VA was 20/80 and eight eyes (80%) had high myopic refractive correction (mean spherical equivalent -11.25 D).

CONCLUSION

Early LSV for stage 4A ROP with AP-ROP and progression to retinal detachment is efficacious in terms of anatomic and functional outcomes. Anatomic success is associated with visual improvement despite possible myopic refraction changes during follow-up.

A review of treatment for retinopathy of prematurity

Introduction

Retinopathy of prematurity (ROP) is a leading cause of childhood blindness worldwide.

Areas covered

Recent methods to identify and manage treatment-warranted vascularly active ROP are recognized and being compared to standard care by laser treatment in prospective large-scale clinical studies. Pharmacologic anti-angiogenic (anti-VEGF) treatment has changed the natural history of vascularly active ROP by reducing stage 3 intravitreal neovascularization and extending physiologic retinal vascularization in many infants. Tractional retinal detachments in stage 4 ROP after treatment with anti-VEGF agents show additional fibrovascular complexity compared to eyes treated with laser only. We review current management and outcomes for vascularly active and fibrovascular retinal detachment in ROP (stages 3, 4, 5 ROP), highlighting the evidence from recent clinical studies. Included are technical details important in surgery for retinal detachment in ROP. Literature searches were employed through PubMed.

Expert opinion

Methods in pediatric imaging, safer pharmacologic treatments, and surgical techniques continue to advance to improve future ROP outcomes.

Evolving Concepts in the Management of Retinopathy of Prematurity

PURPOSE

The introduction of anti-vascular endothelial growth factor (VEGF) agents has stimulated considerable reexamination of treatment strategies for the management of retinopathy of prematurity (ROP). Herein we summarize and review evolving concepts and provide a personal perspective on clinical management today and future directions of treatment.

DESIGN

Literature review.

METHODS

To synthesize the evolving management concepts for diagnosis and treatment of retinopathy of prematurity and to provide interpretation and perspective on current emerging therapies.

RESULTS

Although initial treatment strategies focused on ablative therapy for threshold ROP, earlier treatment for type 1 or pre-threshold disease has been found to decrease unfavorable visual and structural outcomes. Vascular endothelial growth factor has emerged as a significant contributor to retinal-vascular diseases in the previous 2 decades. The potential role of anti-VEGF treatment for type 1 ROP has become a focus in recent years, but the protracted recurrence of disease and unknown adverse ocular and systemic effects have caused concern from some clinicians. In addition, the use of telemedicine technologies may provide the ability to screen remote areas with a shortage of ROP providers, thereby reducing the burden of disease.

CONCLUSIONS

The diagnosis and management of ROP has changed over the past 40 years; the role of anti-VEGF therapy remains to be established in current treatment strategies. Screening for initial disease and progression will likely be impacted by the increasing prevalence of telemedicine and relative shortage of clinicians.

Current concepts and techniques of vitrectomy for retinopathy of prematurity

Retinopathy of prematurity (ROP) is a leading cause of childhood blindness worldwide. ROP screening and interventions (e.g., laser ablation and anti-vascular endothelial growth factor [VEGF] therapy) at the right time can reduce disease activity and prevent retinal detachment. However, sometimes, ROP is refractory to treatment, leading to tractional retinal detachment (TRD), requiring surgical intervention, such as vitrectomy. Vitrectomy for Stage 5 ROP (total retinal detachment) is beneficial in preventing total blindness in some patients. However, it has poor anatomical and functional results. Vitrectomy (lens-sparing vitrectomy, if possible) should be performed at Stage 4A ROP (partial TRD not involving the macula) because the anatomical and functional results are much better.

Paediatric retinal detachment: a review

Paediatric retinal detachment (PRD) is an uncommon and challenging disease; it differs from adult detachments in etiology, anatomical characteristics, management and prognosis. PRDs can be particularly challenging, even for the most expert paediatric surgeons due to the higher prevalence of total retinal detachments, late diagnosis and bilateral involvement with respect to those which occur in adulthood. Moreover, the anatomical success, when achieved, is frequently not related to a functional recover. Postsurgical adverse events, refractive errors and amblyopia may additionally undermine the final outcome. Up to date there are few reviews regarding the approach of retinal detachment in children, mainly dealing with rhegmatogenous retinal detachment. In this review, rhegmatogenous, retinopathy of prematurity-related and Coats'-related PRDs were considered. The available literature from the last decades were reviewed and summarized. Epidemiology, etiology and clinical presentation, together with therapeutic approaches and outcomes have been reviewed and discussed.

Plasmin Enzyme-Assisted Vitrectomy in Pediatric Patients with Vitreoretinal Diseases

PURPOSE

To evaluate the efficacy and safety of using plasmin-assisted vitrectomy in pediatric patients with vitreoretinal diseases.

METHODS

We prospectively recruited children aged 16 years or younger who presented with vitreoretinopathies and underwent plasmin-assisted vitrectomy between 2012 and 2013. The main outcome measure was the induction of posterior vitreous detachment (PVD) using a suction power of 200 mm Hg or less during surgery.

RESULTS

Eleven eyes of 11 patients (mean age: 3.7 years; average follow-up duration: 14.1 months) were included. Of these 11 patients, there were 3 (27%) cases of stage 5 retinopathy of prematurity, 2 (18%) cases of persistent fetal vasculature, 2 (18%) cases of rhegmatogenous retinal detachment, 2 (18%) cases of idiopathic epiretinal membrane, 1 (9%) case of traumatic macular pucker, and 1 (9%) case of traumatic vitreous hemorrhage (9%). PVD was achieved in all cases (100%) during surgery using low suction after plasmin treatment (mean: 150 ± 39 mm Hg; range: 100-200). Overall, anatomical success was achieved in 8 eyes (73%). Visual acuity improved in all 5 (100%) patients for whom vision could be measured at 6 months after the operation. Cataracts were found in 4 eyes (36%), and a rise in transient intraocular pressure was observed in 1 eye (9%).

CONCLUSIONS

Plasmin-assisted vitrectomy offers an effective and less traumatic intervention for a variety of pediatric vitreoretinal diseases.

COMPLETE RESOLUTION OF LARGE RETINAL FOLD AFTER TRANSECTION OF RETROLENTAL MEMBRANE DURING LENS-SPARING VITRECTOMY FOR RETINOPATHY OF PREMATURITY: A 15-YEAR FOLLOW-UP

PURPOSE

To describe the long-term anatomical and visual outcomes of a patient with retinopathy of prematurity characterized by a prominent retinal fold adherent to the posterior lens capsule, treated by lens-sparing vitrectomy with surgical transection of the retrolental membrane.

CASE SUMMARY

A premature infant was born at a gestational age of 25 weeks and birthweight of 636 g. She developed threshold retinopathy of prematurity bilaterally and was subsequently treated with laser ablative therapy. The left eye responded favorably, with regression of neovascularization; however, the right eye progressed to Stage 4A with a prominent retinal fold adherent to the posterior lens capsule. The patient underwent lens-sparing vitrectomy with dissection of the retrolental membrane at postmenstrual age of 44 weeks. At 15-year follow-up, the patient has maintained a best-corrected visual acuity of 20/60 and, of note, demonstrated complete resolution of the previous retinal fold.

CONCLUSION

Surgical treatment for retinopathy of prematurity was considerably advanced by the introduction of lens-sparing vitrectomy techniques; however, cases developing retrolental membranes often persisted with poor visual outcomes, and lensectomy is conventionally performed. However, in select cases of Stage 4A retinopathy of prematurity, careful transection of retrolental membranes during lens-sparing vitrectomy using the appropriate technique may provide very good anatomical and visual outcomes.

Buckling surgery and supplemental intravitreal bevacizumab or photocoagulation on stage 4 retinopathy of prematurity eyes

PURPOSE

To report the results of scleral buckling (SB) with or without photocoagulation (PC) and intravitreal bevacizumab (IVB) for stage 4 retinopathy of prematurity (ROP) eyes.

METHODS

Forty-two eyes of 28 patients with SB and/or PC or IVB were studied. Twenty-nine eyes had stage 4A and 13 eyes had stage 4B ROP. Seventeen eyes underwent SB combined with additional intraoperative or postoperative treatments (combined group). Twenty-five eyes underwent SB without additional therapy (non-combined group). The concentrations of vascular endothelial growth factor (VEGF) in the aqueous humor determined by enzyme-linked immunosorbent assay were compared between the two groups. The initial and final reattachment rates were also compared.

RESULTS

The gestational age and birth weight were 25.0 ± 2.0 weeks and 786 ± 222 g in the combined group, and 25.5 ± 2.1 weeks and 899 ± 315 g in the non-combined group. The postmenstrual age at the time of initial surgery was 38.0 ± 1.9 in the combined and 44.1 ± 4.0 weeks in the non-combined group (P < 0.001). The initial reattachment rate was 92% in stage 4A and 75% in stage 4B of ROP eyes in the combined group, and the rate was 93% in stage 4A and 33% in stage 4B of ROP eyes in the non-combined group. The mean VEGF concentration in aqueous humor was 1923 ± 779 pg/ml in the combined group and 985 ± 303 pg/ml in the non-combined group (P < 0.05).

CONCLUSION

Our results show that the retinal reattachment rate after combined therapy was comparable to that in the non-combined group. We conclude that combined therapy may be effective even in ROP eyes with high activity.

Long-term outcomes on lens clarity after lens-sparing vitrectomy for retinopathy of prematurity

OBJECTIVE

To describe the long-term effect of lens-sparing vitrectomy surgery for advanced retinopathy of prematurity (ROP) on lens clarity.

DESIGN

Retrospective case series at a single tertiary referral pediatric vitreoretinal practice.

PARTICIPANTS

Four hundred ninety-six eyes from 351 patients were included.

METHODS

A retrospective chart review was conducted of patients with diagnosis of ROP stage 4A, 4B, and 5 who underwent lens-sparing vitrectomy (LSV) between 1992 and 2013. Data were collected from patient charts, including gender, date of birth, gestational age at birth, birthweight, stage of ROP at presentation, initial treatment (laser or cryotherapy), date of LSV, date of lensectomy (if performed), lens status at time of lensectomy, date of last visit, lens status at last visit, subsequent retinal surgeries, and retinal attachment status at last visit. Patients were excluded if any surgery had been performed at an outside institution before referral, or if a scleral buckle had been placed. Eyes with a concurrent anatomic abnormality, such as coloboma or microcornea, or a known family history of familial exudative vitreoretinopathy (FEVR), were also excluded.

MAIN OUTCOME MEASURES

Retinal reattachment after LSV, lensectomy after LSV, lens opacity at the time of lensectomy, and lens clarity at last follow-up.

RESULTS

Four hundred ninety-six eyes from 351 patients met inclusion criteria for this study. The reattachment rate after a single LSV surgery was 82.1% for stage 4A, 69.5% for stage 4B, and 42.6% for stage 5. Subsequent retinal surgeries were required in 19.8% of eyes, with 88.7% of them including a lensectomy. Among eyes requiring lensectomy, 75% occurred within the first year after LSV surgery. Lens opacities were present in 26.6% of eyes at the time of lensectomy. Of all eyes in this series, 5.9% required lensectomy because of lens opacity.

CONCLUSIONS

This study demonstrates that lens clarity is observed in most eyes after LSV surgery for advanced ROP for the patient's childhood. Within the first decade of life, if necessary, lensectomy after LSV occurred mostly within 1 year following LSV.

[Current therapeutic options in retinopathy of prematurity]

Retinopathy of prematurity is one of only few potentially blinding retinal diseases of infancy amenable to prevention of visual loss by appropriate and timely therapeutic measures. Retinal ablative therapies, such as laser coagulation eliminate the disease-causing secretion of vascular endothelial growth factor (VEGF) by the avascular peripheral retina. Blockage of VEGF activity by intravitreal administration of VEGF-inhibitory drugs has likewise proven effective in recent clinical studies. Advanced stages of the disease may require surgical intervention. Knowledge of indications and techniques of the different currently available treatment options is crucial to ensure an optimal visual outcome for the affected children.

Early vitreoretinal surgery on vascularly active stage 4 retinopathy of prematurity through the preoperative intravitreal bevacizumab injection

PURPOSE

To evaluate the effect of early vitreoretinal surgery on vascularly active stage 4 ROP through the preoperative use of intravitreal bevacizumab.

METHODS

This was a retrospective study. Eighteen patients with vascularly active stage 4 ROP who underwent primary vitrectomy from April 2007 to March 2010 were enrolled. Twelve eyes from eight patients received one-time intravitreal injection of 0.625 mg bevacizumab 7 days prior to vitrectomy (bevacizumab group), and 11 eyes from 10 patients underwent the surgical procedure without bevacizumab (control group). Demographical information of all patients was recorded. The patients were followed up for 12-36 months after the surgery. The postmenstrual age at vitrectomy, surgical procedure, anatomical and visual outcome, adverse effects and surgical complications were compared.

RESULTS

There was no statistically significant difference between the two groups in gender, birthweight and gestational age. The bevacizumab group showed remarkable regression of vascular activity after the injection. The mean postmenstrual age at the time of vitrectomy was significantly earlier in the bevacizumab group (40 versus 47 weeks, p = 0.002) compared with the controls. The mean surgery time was shorter in the bevacizumab group (74.81 versus 101.70 min, bevacizumab group versus control, p = 0.002). At the final follow-up, all patients in the bevacizumab group achieved anatomical retinal attachment, compared with 70% in the control group. Eighty-eight per cent patients in the bevacizumab group obtained pattern vision, while it was 30% in the control group (p = 0.015).

CONCLUSION

Intravitreal bevacizumab administrated prior to vitrectomy effectively reduced active neovascularization in vascularly active stage 4 ROP patients, thus advancing the timing of vitrectomy and facilitating pars plicata vitrectomy (PPV).

Outcome of retinopathy of prematurity

In prematurely born children, various visual and ophthalmologic sequelae occur because of both retinopathy of prematurity (ROP) and preterm birth per se. Several long-term follow-up studies have described the outcome of ROP. Visual impairment and blindness are well-known consequences, but the prevalence varies globally because of differing neonatal and ophthalmologic care. Improving treatment options and criteria for the treatment of ROP are continuously changing the ophthalmologic outcome. The anatomic outcome has improved with treatment, but good anatomic outcome in treated severe ROP does not always reflect the functional outcome. There is no consensus regarding long-term follow-up of prematurely born children.

Optical coherence tomography in retinopathy of prematurity: looking beyond the vessels

Retinopathy of Prematurity (ROP) is a leading cause of childhood blindness in the United States. Optical Coherence Tomography (OCT) is a relatively new imaging technology capable of imaging ocular structures in cross section at high resolution. We present an age-customized approach to perform Spectral Domain OCT in neonates and infants, and from SDOCT, the in-vivo development of the human fovea during the premature period up through term birth along with retinal changes unique to premature infants with ROP. Finally, we explore how this novel information may affect our understanding of ROP and the possible implications in vision and retinal development.

Intraocular pressure elevation is a delayed-onset complication after successful vitrectomy for stages 4 and 5 retinopathy of prematurity

PURPOSE

To determine the incidence and risk factors for delayed-onset intraocular pressure (IOP) elevations after vitrectomy for Stages 4 and 5 retinopathy of prematurity and, in addition, to determine the results of treating the IOP elevations.

METHODS

Fifty-five consecutive eyes with successful retinal reattachment and at least 24 months of follow-up after vitrectomy were studied. The ophthalmic examinations included slit-lamp biomicroscopy, wide-field digital retinal imaging, and IOP measurements. Eyes were classified into 2 groups: eyes with a postoperative IOP elevation to ≥ 21 mmHg and eyes whose IOP was always <21 mmHg.

RESULTS

Eight eyes (14.5%) developed an IOP elevation to ≥ 21 mmHg from 2 months to 4 months (median: 2.5 months) after the vitrectomy. In two of these eyes, the IOP was controlled with antiglaucoma medications. In the other six eyes, trabeculotomy for eyes with open angles and trabeculectomy or goniosynechialysis for eyes with closed angles were performed. The IOPs were successfully controlled after an average of 1.5 glaucoma surgeries. Multivariate logistic regression analyses identified that a young gestational age (odds ratio = 1.147, 95% confidence interval: 1.024-1.346) and lensectomy (odds ratio = 8.795, 95% confidence interval: 1.262-183.3) were significantly associated with the IOP elevation.

CONCLUSION

Delayed-onset IOP elevation after vitrectomy for retinopathy of prematurity occurs in 14.5% of the eyes, and it is significantly associated with a young gestational age and presence of lensectomy.

Long-term results of lens-sparing vitrectomy for progressive posterior-type stage 4A retinopathy of prematurity

Purpose

To assess the long-term anatomic and visual outcomes and associated complications of lens-sparing vitrectomy (LSV) in infants with progressive posterior-type tractional retinal detachment (TRD) associated with stage 4A retinopathy of prematurity (ROP).

Methods

In a retrospective case series, the medical records of consecutive patients who presented with progressive posterior-type stage 4A ROP and underwent LSV between 1999 and 2007 were reviewed. Retinal attachment status, visual acuity, and development of postoperative complications were assessed.

Results

Eleven eyes of 9 patients were included. The mean follow-up period was 4.6 years. In 8 eyes (73%), plus disease was present at the time of LSV. In 3 eyes (27%), 2 (66%) without plus disease and 1 (13%) with plus disease, the retina remained reattached in the end, while 8 eyes (73%) had TRD on final examination. Two eyes with reattached retinas showed favorable visual acuity. In those eyes with detached retinas, 5 (68%) showed no light perception. When surgery for ROP was unsuccessful, development of cataract, corneal opacity, or glaucoma was common.

Conclusions

The long-term anatomic success rate of LSV for progressive posterior-type stage 4A ROP was low, especially in the presence of plus disease at the time of LSV. Anatomical reattachment is very important for preventing complications and gaining better visual outcomes.

Laser treatment for retinopathy of prematurity

Retinal development involves a complex coordination of events that may be affected by premature delivery, leading to retinopathy of prematurity (ROP), a potential blinding childhood disease. The avascular retina drives further disease progression, with laser ablation reducing unfavorable anatomic outcomes as well as maintaining visual acuity. Trials have stressed the importance of early identification and treatment of threshold and high-risk prethreshold disease to improve outcomes. Retinal ablation with laser photocoagulation should involve entire treatment of avascular retina with a confluent laser spot density, avoiding skip lesions. The current review highlights the use of laser photocoagulation in the treatment of ROP.

Outcome of eyes developing retinal detachment during the Early Treatment for Retinopathy of Prematurity study

OBJECTIVE

To describe the structural and visual outcomes at age 6 years of retinal detachment (RD) from retinopathy of prematurity (ROP) in the Early Treatment for Retinopathy of Prematurity (ETROP) study.

METHODS

Prospective multicenter nonrandomized series of infants with high-risk prethreshold ROP who developed an RD by 6 months corrected age treated with observation or vitreoretinal surgery.

RESULTS

Of 401 patients, 63 (89 eyes) experienced RD. Follow-up at age 6 years was available for 70 eyes (79%) of 49 surviving patients. The RDs were stage 4A in 28 eyes (40%), stage 4B in 14 (20%), stage 5 in 13 (19%), and not classified in 15 (21%). The macula was attached in 17 of 50 eyes (34%) after vitrectomy with or without scleral buckle, in 6 of 9 (67%) after scleral buckle only, and in 2 of 11 eyes (18%) observed. An attached macula at age 6 years after vitreoretinal surgery was present in 5 of 16 eyes (31%) with stage 4A, 6 of 10 (60%) with stage 4B, and 0 of 10 with stage 5. Favorable visual acuity (>20/200) was found in 6 of 70 eyes (9%); 5 had stage 4A, and 1 was not classified.

CONCLUSIONS

Macular attachment was achieved in approximately one-third of eyes with RD and favorable visual acuity in some eyes with stage 4A.

Long-term results of lens-sparing vitrectomy for stages 4B and 5 retinopathy of prematurity

PURPOSE

To assess long-term anatomic and visual outcomes and associated complications of lens-sparing vitrectomy (LSV) for treatment of tractional retinal detachments (TRDs) associated with stages 4B and 5 retinopathy of prematurity (ROP).

METHODS

We performed a retrospective review of medical records and data analyses of consecutive patients who presented with stages 4B and 5 ROP and underwent LSV from 1999 to 2007. Retinal reattachment status, visual acuity and postoperative complications were evaluated.

RESULTS

Twenty-one eyes of 20 patients, including 13 eyes with stage 4B ROP and 8 eyes with stage 5 ROP, were examined. The mean follow-up period was 5.6 years. In 9 (43%) out of 21 eyes, retinas were eventually reattached. The anatomic success rates were 62% in stage 4B and 13% in stage 5 ROP. In eyes with reattached retinas, visual acuity better than form vision was shown in 7 eyes (78%), whereas no light perception was present in 10 eyes (83%) among eyes with TRD on final examination. Postoperative intraocular hemorrhage occurred in nine eyes (43%). Long-term complications of cataract, corneal opacity, glaucoma and strabismus developed in 4 (19%), 6 (29%), 7 (33%) and 8 (38%) eyes, respectively, and were more common in eyes with TRD.

CONCLUSIONS

After following-up for a mean of 5.6 years, the anatomical success rate of LSV was encouraging for the correction of TRD associated with stage 4B ROP but not for stage 5 ROP. Retinal reattachment is important for obtaining better visual outcomes and preventing the development of late complications.

Treatment of type 1 retinopathy of prematurity with intravitreal bevacizumab (Avastin)

PURPOSE

The purpose of this study was to report a noncomparative consecutive case series of eyes with type 1 retinopathy of prematurity treated only with intravitreal bevacizumab (Avastin).

METHODS

Twelve consecutive eyes of 7 premature infants, with type 1 retinopathy of prematurity as stated in the Results of the Early Treatment for Retinopathy of Prematurity Randomized Trial, were treated with only one intravitreal injection of bevacizumab (0.625 mg). RetCam pictures were used to document the cases.

RESULTS

Nine eyes had zone I and 3 eyes had zone II retinopathy of prematurity. The infants weighed between 600 and 1,100 grams (mean, 846.57 g). The gestational age ranged from 23 weeks to 28 weeks (mean, 25.57 weeks). All eyes showed regression of the disease with no additional treatment needed.

CONCLUSION

Intravitreal bevacizumab is a useful therapy for type 1 retinopathy of prematurity. However, additional studies are needed to define the role of Avastin as the first-line therapy, in combination, or after the failure of laser photocoagulation.

Aggressive posterior retinopathy of prematurity

PURPOSE

The purpose of this study was to review the anatomic and functional outcomes of aggressive posterior retinopathy of prematurity occurring at the authors' institution.

METHODS

This is a retrospective chart review of inborn infants developing aggressive posterior retinopathy of prematurity from January 2004 through January 2008. Birth histories, interventions, and outcomes were reviewed.

RESULTS

Twenty-two infants were identified as having aggressive posterior retinopathy of prematurity. All eyes underwent peripheral laser ablation. Seven infants (14 eyes) required a second session of laser. Five infants (eight eyes) progressed to retinal detachment that was successfully repaired by lens-sparing vitrectomy. Seven eyes developed stage 4a detachments, and 1 eye developed a stage 4b detachment. Forty-three eyes (43 of 44) demonstrated a good anatomic outcome with minimal posterior pole distortion.

CONCLUSION

The management of aggressive posterior retinopathy of prematurity requires frequent screening examinations and timely intervention as outlined in the Early Treatment Retinopathy of Prematurity Study. Eyes progressing to retinal detachment may still have a good structural outcome with lens-sparing vitrectomy.

Functional and anatomical outcomes after primary lens-sparing pars plana vitrectomy for Stage 4 retinopathy of prematurity

Background:

While lens-sacrificing vitrectomy is the standard approach to manage Stage 5 retinopathy of prematurity (ROP), scleral buckling has been used to manage some cases of Stage 4. Lens-sparing vitrectomy was popularized by Maguire and Trese in selected cases of Stage 4 disease.

Purpose:

To assess the functional and visual outcomes after primary lens-sparing pars plana vitrectomy for Stage 4 ROP.

Materials and Methods:

In a retrospective, interventional, consecutive case series, the records of 39 eyes of 31 patients presenting with Stage 4 retinal detachment secondary to ROP who underwent primary two or three-port lens-sparing vitrectomy from January 2000 to October 2006 were evaluated. The outcomes studied at the final follow-up visit were the retinal status, lens and medial clarity and visual acuity. Favorable anatomical outcome was defined as the retinal reattachment of the posterior pole at two months after the surgery; and favorable functional outcome was defined as a central, steady and maintained fixation, with the child following light.

Results:

At mean follow-up of 15 months, 74% of the eyes had a favorable anatomical outcome with single procedure. The visual status was favorable in 63%. The lens remained clear in all the eyes at the last follow-up, and the media clarity was maintained in 87%. Intraoperative complications included vitreous hemorrhage, pre-retinal hemorrhage and retinal break formation.

Conclusions:

Lens-sparing vitrectomy helps to achieve a favorable anatomical and functional outcome in selected cases of Stage 4 ROP.

Evaluation of scleral buckling for stage 4A retinopathy of prematurity by fluorescein angiography

PURPOSE

To determine the early efficacy of scleral buckling for active neovascularization by fundus fluorescein angiography (FA) in eyes with stage 4A retinopathy of prematurity.

DESIGN

A retrospective, nonrandomized, observational case series.

METHODS

Patients who underwent scleral buckling for stage 4A ROP at the National Center for Child Health and Development, Tokyo, Japan, from October 2007 through November 2008 were included. Preoperative and postoperative FA and fundus photographs obtained with a wide-field digital pediatric imaging system were reviewed. Three patients (5 eyes; gestational ages at birth, 23 to 25 weeks; birth weights, 574 to 811 g) with zone II stage 4A ROP who underwent postoperative FA, 2 weeks or less after scleral buckling (range, 7 to 12 days; postmenstrual ages at postoperative FA, 41 to 45 weeks) were evaluated. Patients who underwent postoperative FA 2 weeks or more after scleral buckling were excluded.

RESULTS

Despite fluorescein leakage from fibrovascular tissue in all eyes before surgery, markedly decreased leakage occurred only between 7 to 12 days after surgery. The retinas were reattached completely in all eyes after surgery.

CONCLUSIONS

Scleral buckling may prevent progression of retinal detachment in stage 4A ROP by reducing the tractional force and stabilizing the neovascular activity of the fibrovascular tissue.

Insights into advanced retinopathy of prematurity using handheld spectral domain optical coherence tomography imaging

PURPOSE

To elucidate the subclinical anatomy of retinopathy of prematurity (ROP) using spectral domain optical coherence tomography (SD OCT).

DESIGN

Prospective, observational case series.

PARTICIPANTS

Three low-birth-weight, severely premature infants.

METHODS

Clinical examination was performed using a portable slit lamp and indirect ophthalmoscope. Imaging was performed by using a handheld SD OCT device and Retcam (Clarity Medical Systems, Pleasanton, CA) or video-indirect recording. Spectral domain optical coherence tomography imaging was conducted without sedation at the bedside in the neonatal intensive care unit on 1 patient. The other 2 patients had an examination under anesthesia with SD OCT imaging in the operating room.

MAIN OUTCOME MEASURES

In vivo determination of vitreoretinal morphology, anatomy, and pathology by clinical examination, imaging, and SD OCT.

RESULTS

Linear and volumetric imaging was achieved with the handheld system in infant eyes despite tunica vasculosa lentis and vitreous bands. Imaging was not possible in eyes with notable vitreous hemorrhage. Analysis of SD OCT images revealed preretinal structures (ranging from 409 to 2700 microm in width and 212 to 440 microm in height), retinoschisis, and retinal detachment in the posterior pole of patients with advanced ROP. Both the retinoschisis and the preretinal structures were not identified on conventional examination or imaging by expert pediatric ophthalmologists. The preretinal structures varied in location and size, and may represent preretinal fibrovascular proliferation. Some were found in close proximity to blood vessels, whereas others were near the optic nerve.

CONCLUSIONS

Handheld SD OCT imaging can be performed on the sedated or nonsedated neonate and provides valuable subclinical anatomic information. This novel imaging modality can reveal the location and extent of posterior ROP pathology not evident on standard examination. This could affect future clinical decision-making if studies validate a management strategy based on findings from this imaging technique.

Retinopathy of prematurity

This article briefly reviews the history of ROP followed by a discussion of the pathogenesis of this complex disorder. We describe the International Classification System for ROP and identify risk factors and screening recommendations. Finally, we discuss some of the measures that have been used in an attempt to both prevent and treat ROP.

[Current ophthalmic aspects of acute retinopathy of prematurity]

Acute retinopathy of prematurity (ROP) is still a sight-threatening disease of impaired retinal vascular maturation. In Germany, it is estimated that about 400-600 infants per year develop ROP which requires treatment. Increasing survival rates of even extremely low birth weight preterm infants have resulted in a changing disease pattern. In recent years, the classification, screening guidelines and therapeutic strategies have been modified because of disappointing functional results in a significant proportion of infants. Digital wide-angle photography combined with telemedicine opens new opportunities to improve ophthalmic care and for scientific research. In addition to laser photocoagulation, which at present is the recognised treatment of choice, the use of growth factor inhibitors is now under debate.

Late recurrence of retinal detachment following successful vitreous surgery for stages 4B and 5 retinopathy of prematurity

PURPOSE

To determine the incidence and possible causes of a late recurrence of a retinal detachment (RD) in eyes with stages 4B and 5 retinopathy of prematurity (ROP), in which the retina was once reattached by lensectomy and vitrectomy.

DESIGN

Retrospective, comparative case series.

METHODS

The medical records of 124 eyes of 99 infants and children <2 years of age at the time of initial vitrectomy, in which the retina had been reattached for at least 1 year, were reviewed. The incidence of a recurrence of the RD >1 year after the initial surgery for eyes at stage 4B ROP (42 eyes) was compared with that in eyes at stage 5 ROP (82 eyes). The onset and symptoms were evaluated.

RESULTS

A recurrent RD occurred in 2 eyes (5%) at stage 4B ROP and 18 eyes (22%) at stage 5 ROP (P = .01). The recurrence developed at 2 to 10 years of age (median, 4 years). Prior to the recurrence, clear signs of traction on the peripheral retina were detected in 10 eyes (50%): localized residual RDs in 8 eyes, and peripheral retinal breaks in 2 eyes. Dense vitreous hemorrhage was present in 5 eyes (25%) at the time of the recurrence.

CONCLUSIONS

The retina of eyes at stage 5 ROP is more vulnerable to a recurrence of the RD than in eyes at stage 4B after being attached by vitrectomy. The time of recurrence varies widely, and the presence of traction on the peripheral retina may be a sign of a recurrence.

A change in oxygen supplementation can decrease the incidence of retinopathy of prematurity

PURPOSE

To determine the incidence of retinopathy of prematurity (ROP) over a 2-year period before and after a change in the practice of oxygen supplementation.

DESIGN

Nonrandomized, retrospective study.

PARTICIPANTS

All infants in a single Level III neonatal intensive care unit between the years of 2005 and 2007.

METHODS

A prospective database recorded the gestational age, birth weight, stage and zone of ROP, threshold disease, treatment, final outcome and date of examination, maternal and infant demographics, and neonatal intensive care unit course. Year 1 (August 1, 2005 to July 31, 2006) includes a patient cohort who received the standard oxygen supplementation protocol, which has oxygen targets of 95% to 100% saturation. Year 2 (August 1, 2006 to July 31, 2007) includes a patient cohort who has strictly monitored oxygen targets of <34 weeks corrected gestational age oxygen limits of 80% to 95% and target 85% to 92% oxygen saturation and >34 weeks corrected gestational age limits of 85% to 100% and target 92% to 97% saturation.

MAIN OUTCOME MEASURE

Incidence of ROP in year 1 before a change in oxygen protocol compared with the incidence of ROP in year 2 after a change in the oxygen protocol.

RESULTS

A total of 114 children in year 1 and 108 children in year 2 were identified as having been born or transferred to the Fairview Nursery. Ninety-eight infants were examined before and 92 infants were examined after the change in oxygen standards, comprising 190 consecutive patients examined between September 2005 and October 2007. ROP was present in 35% of infants in group 1 before the change in oxygen protocol compared with 13% after the change in oxygen standards (P=0.001); stage 3 decreased from 11% to 2% (P=0.021); threshold disease decreased from 7% to 1% (P=0.066). Stage 0 (immature vessels, no ROP) incidence increased (pre/post-oxygen change 30%/51% stage 0, P=0.001). There were statistically significant differences in mode of delivery (P=0.007), sepsis <3 days of life (P=0.01), and oxygen at discharge (P=0.003).

CONCLUSIONS

Lower oxygen targets at early gestational age and higher oxygen targets at older gestational age decrease the severity and incidence of ROP while inducing normal retinal development.

Three-year anatomic and visual outcomes after vitrectomy for stage 4B retinopathy of prematurity

PURPOSE

To assess anatomic and visual outcome following vitrectomy for stage 4B retinopathy of prematurity (ROP) after 3 years follow-up.

METHODS

Retrospective analysis of 56 eyes (46 infants) with stage 4B ROP-related retinal detachment. Eyes underwent either lens-sparing vitrectomy (LSV) or combined lensectomy and vitrectomy (LV). Visual outcome after a minimum follow-up of 36 months was ascertained by using either Teller or Snellen acuities, or sweep visual evoked potential.

RESULTS

LSV was performed in 42.9% and LV in 57.1% of eyes. Retinal reattachment was achieved in 73.2% overall (LV 71.8% versus LSV 75%) (P = 0.96). Ambulatory vision (VA better than 20/1900) and near reading vision (better than 20/800) were attained in 97.4% and 42.8% of eyes respectively. Attached retina, LSV, and pretreatment with retinal ablation were associated with a higher incidence of near reading or better vision compared to detached (P < 0.001), undergoing LV (P < 0.001), and non pretreated eyes (P = 0.011).

CONCLUSION

After 3 years, more than 40% of eyes operated for ROP stage 4B in this series had a visual acuity compatible for near reading or better. Eyes undergoing LSV and with prior peripheral retinal ablation had better visual outcomes.

Subretinal hemorrhage after lens-sparing vitrectomy in infants born at or under 24 weeks gestation

PURPOSE

To describe short term outcomes in a case series of infants with rapidly progressive retinopathy of prematurity (ROP) requiring laser and lens-sparing vitrectomies (LSV) at early postmenstrual ages (PMAs).

METHODS

Retrospective chart review of infants born at or under 24 0/7 weeks consecutively referred for management of severe ROP between August 2006 and January 2007.

RESULTS

Five female infants (mean gestational age 23 4/7 weeks, mean birthweight 514.4 g) required laser treatment bilaterally for zone 1 or posterior zone II ROP at 35-37 weeks PMA. LSV was performed for progressive stage 4 ROP in eight eyes at 37-39 weeks PMA (mean 38.2 weeks). Subretinal hemorrhage occurred after LSV in five eyes, with three developing subretinal fibrosis preventing complete retinal reattachment.

CONCLUSION

Premature infants in this series had rapidly progressive ROP requiring laser and LSV at early PMAs. Subretinal hemorrhage occurred and may be related to the amount of laser necessary to treat large zones of avascular retina, and the early timing of vitrectomy when postoperative contracting preretinal vitreous no longer has the natural tamponading force of formed gel against it. Improved therapies for premature infants of very young gestational ages and large avascular zones are needed.

25-gauge lens-sparing vitrectomy for stage 4A retinopathy of prematurity

PURPOSE

To evaluate the feasibility of performing lens-sparing vitrectomies using 25-gauge instruments for the management of stage 4A retinal detachments in Retinopathy of Prematurity (ROP).

METHODS

13 eyes of 10 patients with stage 4A retinal detachments underwent a lens-sparing pars plicata vitrectomy. All patients were operated using a three port transconjunctival 25-gauge sutureless technique. The sclerotomies were made 0.5 to 1.0 mm posterior to the limbus through the pars plicata. Core vitrectomy and membrane peeling were performed. A partial fluid-air exchange was used at the end of the procedure in the majority of the cases. The anatomic status of the retina was determined by ophthalmoscopy during routine follow up visits or under general anesthesia. Per-operative complications were recorded.

RESULTS

Eight of the infants were female and two were male. The average postmenstrual age at birth was 26.4 weeks and the average postgestational age at time of surgery was 39.3 weeks (range, 33-44). Three out of the 13 eyes (23%) had zone I ROP. With a mean follow-up of 17 months (range, 4-36) 12 out of the 13 eyes (92%) achieved successful retinal reattachment. One eye developed post operative hypotony with a small choroidal detachment that resolved spontaneously.

CONCLUSIONS

Surgical intervention with a three port 25-gauge transconjunctival sutureless vitrectomy is an effective technique to attach the retina in patients with stage 4A retinal detachment in ROP.

Foveal dysplasia evident by optical coherence tomography in patients with a history of retinopathy of prematurity

PURPOSE

To describe the optical coherence tomography (OCT) findings for patients with a history of retinopathy of prematurity (ROP).

METHODS

Clinical records, fundus photographs, and OCT findings for consecutive patients aged 8 years and older who had a history of ROP were reviewed. The main outcome measures were best-corrected visual acuity, central foveal thickness (CFT), macular anatomy, and foveal contour by OCT.

RESULTS

Twenty eyes of 12 patients (median age, 15 years) were studied. Median gestational age at birth was 25 weeks. Six eyes had received peripheral retinal ablation for threshold ROP. Median best-corrected visual acuity was 20/40 (range, 20/20 to counting fingers). CFT was >220 microm in 70% of eyes and >240 microm in 35% of eyes. In all eyes, foveal contour was abnormal, with foveal depression either absent (n = 7 [35%]) or shallow (n = 13 [65%]). Preservation of multiple inner retinal layers within the fovea was seen in 14 eyes (70%). Vitreomacular traction or subretinal fluid was not seen in any eye.

CONCLUSIONS

Anomalies in foveal anatomy by OCT may be a vestige of prematurity, appear to be independent of prior retinopexy, and can still be associated with excellent visual acuity.