Anatomic Success Rate after 3-Port Lens-Sparing Vitrectomy in Stage 4A or 4B Retinopathy of Prematurity

Outcomes of Modified Limbal Lensectomy-Vitrectomy in Stages 4B and 5 Retinopathy of Prematurity with Extended Retrolental Fibroplasia

PURPOSE

To report on the anatomical and functional outcomes of a modified limbal lensectomy-vitrectomy (LV) approach for stages 4B and 5 retinopathy of prematurity (ROP) as defined in the International Classification of Retinopathy of Prematurity, 3rd Edition (ICROP 3).

DESIGN

Retrospective, monocentric, consecutive case series.

PATIENTS

Infants with ROP that underwent limbal LV for diffuse retrolental fibroplasia.

METHODS

Clinical charts and Retcam photographs were reviewed. Surgical approach consisted of a limbal LV through peripheral iridectomies with centripetal dissection of the preretinal fibrosis.

MAIN OUTCOME MEASURES

Anatomical success and visual function at last follow-up were evaluated. Multivariate logistic regression was used to explore potential prognostic factors affecting the anatomical outcome.

RESULTS

A total of 128 eyes of 81 patients with a mean gestational age of 28.7 ± 3.0 weeks and a mean birthweight of 1244 ± 429 g were included. Eighteen eyes (14.1%) had a stage 4B, 24 (18.8%) a stage 5B, and 86 a stage 5C (67.2%) ROP. Mean age at surgery was 57.4 ± 36.3 weeks and mean postoperative follow-up was 22.7 ± 20.4 months. Only 5 eyes (3.9%) had prior peripheral retinal ablation. Macular reattachment was achieved in 74 eyes (57.8%). Controlling for other baseline factors, a stage 5C (versus stage 4B, odds ratio [OR] = 6.9 [1.5-32.1], P = 0.01 and versus stage 5B, OR = 7.4 [1.5-37.1], P = 0.02), the presence of vascular activity (OR = 6.4 [2.3-18.1], P < 0.001), and the presence of Schlieren sign (OR = 13.0 [2.1-82.2], P = 0.006) were associated with a failure of macular reattachment. Visual acuity was assessed in 92 eyes (71.9%), among which 59 eyes (64.1%) had light perception or better.

CONCLUSIONS

Modified limbal LV resulted in macular reattachment in more than half of eyes with ROP-related retinal detachment and diffuse retrolental fibrosis. A stage 5C based on ICROP 3, the presence of vascular activity, and a Schlieren sign were significantly associated with a failure of macular reattachment.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Surgical exposure for vitrectomy in retinopathy of prematurity

Our purpose was to evaluate the efficacy of lateral canthotomy, sub-tenon anesthesia injection, and the use of modified speculum for gaining adequate surgical exposure during surgery for retinopathy of prematurity (ROP). Fourteen eyes of 10 consecutive patients undergoing microincisional vitrectomy surgery (MIVS) for stage 4 and stage 5 ROP were included. There was a significant widening of the palpebral fissure height and length using this technique. No patient developed a lens injury during the surgery. All the canthotomy incisions completely healed at a four-week follow-up visit. This is a safe and effective technique for increasing surgical exposure in cases of ROP requiring vitrectomy.

Global Disparities in Retinopathy of Prematurity: A Literature Review

PURPOSE

To provide an overview of the impact of retinopathy of prematurity (ROP), and the challenges in the screening, diagnosis, and treatment of ROP worldwide.

METHODS

A comprehensive search was conducted using the PubMed database from January 2011 to October 2021 using the following keywords: retinopathy of prematurity, laser, and anti-vascular endothelial growth factor (VEGF). Data on patient characteristics, ROP treatment type, and recurrence rates were collected. The countries included in these studies were classified based on 2021-2022 World Bank definitions of high, upper-middle, lower-middle, and low-income groups. Moreover, a search for surgical outcomes for ROP and screening algorithms and artificial intelligence for ROP was conducted.

RESULTS

Thirty-nine studies met the inclusion criteria. ROP treatment and outcomes showed a trend towards intravitreal anti-VEGF injections as the initial treatment for ROP globally and the treatment of recurrent ROP in high-income countries. However, laser remains the treatment of choice for ROP recurrence in middle-income countries. Surgical outcomes for ROP stage 4A, 4B and 5 are similar worldwide. The incidence of ROP and ROP-related visual impairment continue to increase globally. Although telemedicine and artificial intelligence offer potential solutions to ROP screening in resource-limited areas, the current models require further optimization to reflect the global diversity of ROP patients.

CONCLUSION

ROP screening and treatment paradigms vary widely based on country income group due to disparities in resources, limited access to care, and lack of universal guidelines.

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.

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.

Clinical profile and management outcomes of posterior zone 1 retinopathy of prematurity

BACKGROUND

To analyse the varied clinical profile and treatment outcomes of posterior zone 1 retinopathy of prematurity (ROP).

METHODS

This retrospective case-series included 54 eyes of 27 infants of posterior zone 1 ROP treated at our centre from January 2018 to June 2019. Three clinical patterns were observed at presentation - Posterior zone 1 ROP without detachment (group 1), with subtotal detachment (group 2) and total detachment (group 3) of the vascularised retina. Their profile, treatment options and outcomes were studied.

RESULTS

The mean birth weight was 1204 ± 262 gm and mean gestational age was 28.8 ± 2 weeks. Clinical presentation as per group 1, 2 and 3 was seen in 33/54 (61.1%), 9/54 (16.6%) and 12/54 (22.2%) eyes, respectively. All the eyes received intravitreal ranibizumab as primary intervention. In group 1, 25/33 (75.7%) eyes had laser and 8/33 (24.2%) had surgery whereas, in group 2, 2/9 (22.2%) eyes had laser and 7/9 (77.7%) underwent surgery as a second intervention. In group 3, only 3 /12 (25%) eyes had second intervention (surgery). Surgical outcomes of group 1 and 2 were better than group 3. At last follow-up, macular vascularisation was noted in 33/54 (61.1%) eyes.

CONCLUSION

A customised and multifaceted treatment approach is required to treat posterior zone 1 ROP.

Sequential Short Interval Anti-VEGF for the Treatment of Stage 4 Retinopathy of Prematurity

A 23-month-old girl born at 23 weeks' gestational age with a birth weight of 453 g and retinopathy of prematurity (ROP) stage 4A in 360° and plus disease in both eyes was treated in another institution with laser; her treatment was complicated with two cardiac arrests during the procedure. The patient was referred and treated at 31 weeks with repeated intravitreal bevacizumab injection in both eyes secondary to progressive ROP. Treatment with multiple anti-vascular endothelial growth factor (VEGF) therapy as monotherapy led to the resolution of a retinal detachment and full vascularization of the retina in both eyes. To the best of the authors' knowledge, this is the first description of a patient with stage 4A ROP treated solely with anti-VEGF after failed laser treatment that led to complete resolution of a retinal detachment without surgical intervention. [Ophthalmic Surg Lasers Imaging Retina. 2022;53:159-163.].

VISUAL AND ANATOMIC OUTCOMES OF PEDIATRIC ENDOSCOPIC VITRECTOMY IN 326 CASES

PURPOSE

To report on the indications, outcomes, and complications of endoscopic vitrectomy in a large cohort of pediatric vitreoretinal patients.

METHODS

This is a retrospective interventional case series consisting of 244 eyes of 211 patients aged 18 years or younger undergoing a total of 326 endoscopic vitrectomies from 2008 to 2017. A 23-gauge vitrectomy was performed with use of a 19-gauge endoscope.

RESULTS

Two hundred and eleven patients with a mean age of 7.5 years (range: 0-18 years) and median follow-up since last surgery of 28 months (range: 3 months-8.7 years) were included. The most common indication for endoscopic vitrectomy was retinal detachment (234/326; 72%) with proliferative vitreoretinopathy (162/234; 69%). Other diagnoses included trauma (25%), retinopathy of prematurity (15%), and glaucoma (9%). Twenty-five percent of surgeries (80/326) were performed on eyes with significant corneal opacities. Retinal reattachment was achieved in 67% of eyes with retinal detachment (119/178). Visual acuity improved in 26% of retinal detachment eyes versus 53% of nonretinal detachment eyes (P = 0.005). Surgical complications included band keratopathy (15%), hypotony (8%), cataract (7%), and elevated intraocular pressure (3%).

CONCLUSION

In this large series of pediatric endoscopic vitreoretinal surgeries, anatomic outcomes and complication rates were comparable with previous studies.

Incidence and Factors of Postoperative Lens Opacity after Lens-Sparing Vitrectomy for Retinopathy of Prematurity

PURPOSE

To determine the incidence and factors associated with lens opacity after lens-sparing vitrectomy (LSV) for retinopathy of prematurity (ROP).

DESIGN

Retrospective, comparative case series.

PARTICIPANTS

Among the 141 eyes of 94 patients who underwent LSV for ROP between 2006 and 2019, 108 eyes of 71 patients with a minimum follow-up of 12 months after LSV were investigated.

METHODS

Data were collected from patients' charts, including gender, gestational age at birth, birth weight, stage of ROP, postmenstrual age (PMA) at LSV, surgical procedure, preoperative injection of anti-vascular endothelial growth factor (VEGF) agents, subsequent retinal surgeries, and lensectomy during follow-up.

MAIN OUTCOME MEASURES

Lens status at last visit, incidence and timing of lensectomy, and risk factors for lens opacity requiring lensectomy.

RESULTS

Stages of ROP at LSV were 4A, 4B, and 5 in 92 eyes, 13 eyes, and 3 eyes, respectively. The median PMA at LSV was 40.6 weeks. Thirty-two eyes received anti-VEGF therapy before LSV. Lens opacity was found in 17 eyes (15.7%), of which 10 eyes (9.3%) underwent lensectomy. The period between LSV and lensectomy ranged from 21 days to 131.9 months (median, 21.1 months). Eleven other eyes (10.2%) underwent lensectomy as part of a reoperation for worsening of ROP. A total of 80 eyes (74.1%) preserved clear lenses at the latest follow-up examination after surgery (median, 6.8 years; range, 1-14 years). The Kaplan-Meier estimate showed that the proportion of patients with phakia at 5 and 10 years was 92.4% and 89.0%, respectively. Multivariate Cox regression analysis revealed that eyes with the use of tamponade at LSV (P = 0.005; odds ratio [OR], 25.68; 95% confidence interval [CI], 4.187-157.5) and young PMA at LSV (P = 0.033; OR, 1.047; 95% CI, 1.012-1.099) were associated significantly with lens opacity requiring lensectomy. However, anti-VEGF therapy was not associated with lens opacity requiring lensectomy.

CONCLUSIONS

Nearly 10% of eyes required lensectomy because of lens opacity after LSV for ROP. The development of lens opacity requiring lensectomy seems to be associated with the use of tamponade and young PMA at LSV.

'Stop-and-Slide' technique for trocar insertion during lens-sparing vitrectomy for retinopathy of prematurity

The modern-day trocar cannula systems meant for adult eyes pose a challenge in infant's eyes with stage 4 retinopathy of prematurity (ROP) undergoing lens-sparing vitrectomy. This is primarily owing to the length of the trocar, globular lens, smaller axial length, and anteriorly displaced retina. We describe an inexpensive modification of the technique of trocar insertion in such cases wherein the trocar is inserted partially till the cannula impinges the sclera and thereon, the cannula slides over the trocar into the vitreous cavity. This obviates the need for complete insertion of the trocar into the vitreous cavity and hence limits the chances of inadvertent injury to the crystalline lens or the anteriorly lifted retina. We have experience in using this technique in 52 eyes of 44 infants over the past 2 years with no episode of iatrogenic lens touch or retinal break during trocar insertion.

Combined Vitrectomy and Anti-VEGF Treatment for Stage 4 Retinopathy of Prematurity With Extensive Neovascular Proliferation

PURPOSE

To study the role of combined vitrectomy and intravitreal anti-vascular endothelial growth factor (VEGF) injection for stage 4 retinopathy of prematurity (ROP) with extensive neovascular proliferation.

METHODS

In a retrospective interventional study at a tertiary eye care center, 15 eyes (9 infants) with advanced stage 4 ROP underwent 25-gauge vitrectomy combined with intravitreal 0.625 mg of bevacizumab (n = 12) or 0.25 mg of ranibizumab (n = 3) injection and were followed up until 65 weeks' postconceptional age (PCA). The perinatal history, tractional retinal detachment (TRD) characteristics (zone, stage, and presence of "plus" disease), treatment details, and anatomical outcomes were reviewed. The main outcome measures were fibrovascular tissue and TRD regression and final macular status.

RESULTS

Mean gestational age and birth weight were 28.5 ± 1.2 weeks and 1,167 ± 185 g, respectively. Thirteen eyes had zone I disease and 2 eyes had zone II disease. Thirteen eyes were stage 4A and 2 eyes were stage 4B ROP. The morphology was aggressive posterior ROP in 10 eyes. The mean PCA at surgery was 37.8 ± 2.3 weeks. Lensectomy was also performed in 2 eyes. Rapid fibrovascular tissue regression was seen in 14 eyes within 2 weeks, followed by TRD regression and macular vascularization, although 2 eyes had macular pucker formation. Persistent vitreous bleeding was present in 1 eye, which needed lavage, and eventually the TRD regressed. Disease reactivation was noted in 1 eye at 5 weeks and was managed with repeat intravitreal anti-VEGF injection.

CONCLUSIONS

Anti-VEGF treatment combined with vitrectomy leads to rapid disease regression in advanced stage 4 ROP with extensive neovascular proliferation. [J Pediatr Ophthalmol Strabismus. 2020;57(1):61-66.].

Surgical outcomes of microincision vitrectomy surgery in eyes with retinal detachment secondary to retinopathy of prematurity in Indian population

Purpose:

To analyze and report outcomes of microincision vitrectomy surgery (MIVS) for Stage 4 and 5 retinopathy of prematurity (ROP).

Methods:

Medical records of 202 eyes of 129 premature children undergoing MIVS for Stage 4/Stage 5 ROP between January 2012 and April 2015 were evaluated. The primary outcome measure was the proportion of eyes with anatomical success (defined as attached retina at the posterior pole at last follow-up). Complications associated with MIVS were noted and analysis of risk factors associated with poor anatomical outcome was also done using logistic regression.

Results:

Mean age of presentation of babies with Stage 4 ROP (2.9 ± 1.75 months) was lower than those with stage 5 disease (5.62 ± 2.55 months) (P < 0.005). One hundred seventeen eyes (56% or 58%) had Stage 5, 38 (19%) had Stage 4a, and 47 (23%) Stage 4b. Ninety-four eyes (47%) had received prior treatment (laser and/or anti-vascular endothelial growth factors [VEGF]). Lens-sparing vitrectomy (LSV) was performed in 58 (29%) eyes while lensectomy with vitrectomy (LV) was performed in 144 (71%) eyes. At a mean follow-up of 32.5 weeks, 102 (50.5%) eyes achieved anatomical success, including 74% eyes in Stage 4a and 4b and 33% in Stage 5. Complications included intraoperative break formation (19%), postoperative vitreous hemorrhage (28%), raised intraocular pressure (12.7%), and cataract progression (2.4%). Factors significantly associated with favorable anatomical outcome were Stage 4 disease (vs. Stage 5) (odds ratio [OR] 5.8; confidence interval [CI] =2.6–13.8, P < 0.005), prior treatment (laser ± anti-VEGF) (OR 2.5; CI 1.4–4.7, P < 0.005) surgery with 25G MIVS (vs. 23G) (OR: 1.7; CI = 0.98–3.00, P = 0.05) and LSV (vs. LV) (OR 7; CI = 3.4–14.6, P < 0.005). Retinal break was significantly associated with poor anatomical outcome (OR 0.21; CI = 0.09–0.5, P < 0.005).

Conclusion:

MIVS along with wide angle viewing systems allow surgeons to effectively manage ROP surgeries while at the same time reducing complication rate in these eyes which have complex pathoanatomy and otherwise grim prognosis.

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.

Parameters affecting postoperative success of surgery for stage 4A/4B ROP

Purpose

To describe the long-term anatomical and functional results of surgery for retinal detachment (RD) associated with stage 4 retinopathy of prematurity (ROP) and patient and surgery-related factors affecting postoperative success.

Design

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

Methods

One hundred and twenty-one eyes of 82 infants (40 female/42 male) who underwent lens-sparing vitrectomy (LSV) or lensectomy with vitrectomy surgery for stage 4A and 4B ROP at Gazi University Department of Ophthalmology between 2011 and 2016 were enrolled in this study. Patient characteristics including gestational age, birth weight, gender, stage of ROP at presentation, preoperative treatment (laser, anti-vascular endothelial growth factor (VEGF) or combined), anatomical and functional outcome and complications were recorded. The effect of birth weight, gestational age, presence of plus disease, preoperative treatment status, surgically induced posterior hyaloid detachment, postoperative vitreous haemorrhage and iatrogenic retinal tear formation on anatomical and functional results was evaluated.

Results

61.2% of the eyes were stage 4A and 38.8% were stage 4B ROP. The mean follow-up was 24.5 months. 18.2% of the eyes had no preoperative treatment. Anatomical success was 86.5% for stage 4A and 68.1% for stage 4B at the first year, 91.7% for stage 4A and 69.4% for stage 4B at the second year, and 95.8% for stage 4A and 57.9% for stage 4B at the third year. Functional success was 85.1% for stage 4A and 65.9% for stage 4B at the first year, 89.6% for stage 4A and 61.1% for stage 4B at the second year, and 87.5% for stage 4A and 57.8% for stage 4B at the third year. The mean visual acuity was 1.12±0.34 logarithm of the minimum angle of resolution (logMAR) for stage 4A and 1.34±0.32 logMAR at the 3-year follow-up duration (p>0.05). There was preoperative plus disease in 59.5% of the eyes. Subsequent retinal surgeries were required in 17.4% of the eyes. Presence of plus disease and absence of preoperative treatment, iatrogenic retinal tear formation and postoperative vitreous haemorrhage were found to have significant negative effects, while surgical induction of posterior hyaloid detachment and sparing the lens intraoperatively affected the anatomical and functional results positively.

Conclusions

Surgery for stage 4 ROP-associated RD resulted in encouraging anatomical and functional outcomes and the results are even better in eyes with preoperative (laser/anti-VEGF) treatment, LSV and surgically induced posterior hyaloid detachment.

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.

SURGICAL MANAGEMENT OF TRACTIONAL RETINOSCHISIS ASSOCIATED WITH VITREOUS HEMORRHAGE IN RETINOPATHY OF PREMATURITY

PURPOSE

The tractional retinoschisis is a poorly understood, rare, and likely underappreciated entity in retinopathy of prematurity. The purpose of this article is to describe clinical findings and surgical management of tractional retinoschisis in retinopathy of prematurity, masquerading as Stage 4 retinopathy of prematurity retinal detachment.

METHODS

A retrospective review of a single case with literature review and case discussion.

RESULTS

In this report, we describe a child with retinopathy of prematurity and tractional schisis, who initially presented with vitreous hemorrhage and was effectively managed by vitrectomy and inner wall retinectomy. At 5 months after vitrectomy, the child demonstrated complete collapse of the retinoschisis with intact posterior pole and brisk light perception.

CONCLUSION

Vitrectomy with or without inner wall retinectomy is effective in the management of tractional retinoschisis.

Pharmacologic Vitreolysis in Vascular Diseases of the Retina

Vascular diseases of the retina such as diabetic retinopathy and vascular occlusions account for a large proportion of visual morbidity and blindness worldwide. The role of vitreous in the pathogenesis of these conditions has been increasingly recognized. Despite advances in the surgical technique of pars plana vitrectomy, the use of intravitreal agents for the lysis of vitreous has received attention, guided largely by promising results from the trials involving patients with non-vascular retinal diseases such as vitreomacular traction. The purpose of this review is to provide a comprehensive summary of the present knowledge on pathophysiologic basis of pharmacologic vitreolysis and its efficacy in vascular diseases of the retina. A review of completed and ongoing clinical trials will be presented, along with insights into future directions of this therapy.

Efficacy of intravitreal injection of anti-vascular endothelial growth factor agents for stage 4 retinopathy of prematurity

PURPOSE

To investigate the efficacy of intravitreal injection of anti-vascular endothelial growth factor agents for Stage 4 retinopathy of prematurity.

METHODS

Retrospective case series study. The medical records of patients receiving intravitreal injection of anti-vascular endothelial growth factor agents for Stage 4 retinopathy of prematurity from January 2007 to May 2012 in Taipei Veterans General Hospital were reviewed.

RESULTS

A total of 13 eyes of 7 patients (3 boys and 4 girls) with Stage 4 retinopathy of prematurity were included. The mean gestational age and birth weight were 27.6 ± 2.6 weeks (range, 24.5-30.5 weeks) and 893.1 ± 293.2 g (range, 550-1422 g), respectively. The mean age at the time of injection was 38.2 ± 1.9 weeks (range, 36.0-41.5 weeks) postmenstrual age, and the mean follow-up period was 37.8 ± 19.5 months (range, 11.0-67.5 months). The active neovascularization regressed rapidly, and the anatomical outcomes were favorable in all patients. One eye developed recurrent retinal hemorrhage with localized retinal detachment 21 weeks after initial treatment, which resolved after a second injection. There were no ocular or systemic complications in these patients.

CONCLUSION

Intravitreal injection of anti-vascular endothelial growth factor agents may be effective as monotherapy or as supplement to failed laser treatment for patients with Stage 4 retinopathy of prematurity without additional surgical intervention. Further randomized controlled trials are necessary to compare the clinical efficacy and safety with other conventional interventions.

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.

External subretinal drainage, bevacizumab, and scleral buckling for complete exudative retinal detachment after photocoagulation in retinopathy of prematurity

BACKGROUND

Total serous retinal detachment after laser photocoagulation for retinopathy of prematurity is an infrequent type of retinal detachment in preterm babies.

PURPOSE

To describe the successful outcome for treatment by scleral drainage, bevacizumab, and scleral buckling for complete serous exudative retinal detachment in a patient with retinopathy of prematurity.

METHODS

A preterm baby with primary pulmonary hypertension under treatment with sildenafil developed a total (retrolental) serous retinal detachment after photocoagulation for threshold retinopathy. The dense subretinal fluid was externally drained using a bent needle with an infusion placed in the anterior chamber. Additional bevacizumab and scleral buckling helped to control the plus disease and subretinal leakage.

RESULTS

Retinal apposition was obtained with the described approach.

CONCLUSION

Total serous retinal detachment is a rare but severe visual complication in retinopathy of prematurity. The described technique may restore the retinae immediately in a visually critical period.

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).

Microplasmin (ocriplasmin) in pediatric vitreoretinal surgery: update and review

PURPOSE

To discuss the potential role of microplasmin (ocriplasmin) as a surgical adjunct to vitrectomy in pediatric vitreoretinopathies.

METHODS

Literature review of the laboratory and clinical evidence to date for the use of both autologous plasmin enzyme as an adjunct to vitrectomy and more recently recombinant microplasmin (ocriplasmin) as monotherapy for focal vitreomacular traction in adults.

RESULTS

Autologous plasmin enzyme is currently being used as a surgical adjunct to vitrectomy, with supporting Levels 2 and 3 published evidence in a range of pediatric vitreoretinopathies including Stage 5 retinopathy of prematurity and congenital X-linked retinoschisis. The availability of autologous plasmin enzyme is limited. In recent Phase 3 clinical trials, intravitreal ocriplasmin versus sham injection resulted in resolution of focal vitreomacular traction in 27% versus 10% (P < 0.001, n = 652).

CONCLUSION

Ocriplasmin may potentially be used as a surgical adjunct to vitrectomy in place of autologous plasmin enzyme. A Phase 2, randomized, placebo-controlled surgical trial is under way to assess this.

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.

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.

Risk factors for recurrent fibrovascular proliferation in aggressive posterior retinopathy of prematurity after early vitreous surgery

PURPOSE

To analyze risk factors for postoperative recurrence of fibrovascular tissue in eyes with aggressive posterior retinopathy of prematurity (AP ROP) treated with early vitreous surgery.

DESIGN

Retrospective, consecutive, observational case series.

METHODS

Thirty-one patients (50 eyes) with AP ROP who underwent early vitreous surgery between March 2005 and April 2008 participated. Eyes with stage 4A or 4B disease in which fibrovascular tissue was not attached to the vitreous base were included; those in which fibrovascular tissue was attached extensively to vitreous base or those without dense photocoagulation to the nonvascularized retina were excluded. Eligible eyes were divided into 2 groups based on postoperative recurrence or no recurrence of fibrovascular tissue. Data on gender, gestational age, birth weight, Apgar score, intubation duration, severe systemic complications, preoperative ROP stage, zone, fibrovascular tissue and vitreous base adhesion, clock hours of fibrovascular tissue, postmenstrual age at the initial application of dense photocoagulation, dense photocoagulation to both vascularized and nonvascularized retina, postmenstrual age at vitrectomy, and intraoperative hemorrhage were collected and analyzed.

RESULTS

Fifty eyes of 31 patients underwent early vitrectomy. Seven (14%) eyes were excluded and 43 eyes (86%) were included. Eight (18%) of 43 eyes had a recurrence of fibrovascular tissue. Both univariate and multivariate analysis indicated application of dense photocoagulation to both the vascularized and nonvascularized retina was a significant factor in the decreased recurrence of fibrovascular tissue (P = .002 and P = .008, respectively).

CONCLUSIONS

Application of preoperative dense photocoagulation to vascularized and nonvascularized retina may be important for lowering the recurrence of fibrovascular tissue in eyes with AP ROP.

Long-Term Follow-Up of Local Relaxing Vitrectomy for Stage 4 Retinopathy of Prematurity

Scleral buckling and lens-sparing vitrectomy are the two preferred methods of treatment for stage 4 retinopathy of prematurity (ROP). Both have some disadvantages, so the authors modified the lens-sparing vitrectomy method to create the local relaxing vitrectomy technique. The core vitreous is not cut as in the lens-sparing vitrectomy, but the organized vitreous is directly dissected with the vitrectomy probe. Two cases of stage 4 ROP were successfully treated using this method. The local relaxing vitrectomy may be a better treatment choice for some cases of stage 4A ROP.

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.

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.

Spontaneous resolution of stage 4B retinopathy of prematurity

An unfavorable outcome occurs in 31% of cases of treated severe threshold retinopathy of prematurity (ROP) and includes a retinal detachment of the posterior pole. Early treatment with laser of high risk prethreshold or type 1 ROP has significantly reduced this complication. However, despite prompt laser treatment, retinal detachments continue to be seen. Treatment of tractional partial retinal detachments involving the posterior pole (stage 4B ROP) is surgical. Successful reattachment of stage 4B ROP with a lens-sparing vitrectomy is high. The authors describe an infant who had spontaneous reattachment after stage 4B ROP.

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.

Surgical management of retinopathy of prematurity

PURPOSE OF REVIEW

The surgical management of retinopathy of prematurity continues to employ a paradigm of peripheral laser followed by vitrectomy for patients who develop retinal detachment. This review addresses significant advances that have been made in our understanding of the indications, timing, techniques, and outcomes of these interventions.

RECENT FINDINGS

The indications for laser are highly dependent on the diagnosis of plus disease. Recognition of plus disease is variable and subjective. Efforts are underway to develop more objective measures of plus using image analysis software. Intravitreal injection of bevacizumab is emerging as an adjunct to laser for aggressive posterior retinopathy of prematurity. Although vitrectomy for retinal detachment is effective in eyes without plus, management of eyes with retinal detachment and persistent plus continues to be a major challenge. Older children with regressed retinopathy of prematurity may suffer from vitreous hemorrhage in the absence of retinal tears, detachments, or active neovascularization.

SUMMARY

Our understanding of the best indications, timing, and techniques for the surgical management of retinopathy of prematurity continues to evolve and outcomes have improved in recent years. Areas that generate significant ongoing interest and investigation include the assessment of plus disease and the use of adjuncts for aggressive posterior retinopathy of prematurity.

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.

Treatment of retinopathy of prematurity

Retinopathy of prematurity is a potentially blinding disorder of premature infants. Retinal ablation of the avascular retina originally described using cryotherapy but now most commonly undertaken with laser photocoagulation, reduces the unfavourable structural outcomes and improves the functional visual acuity outcome. The CRYO-ROP study showed the long-term benefit of treatment of threshold disease compared with no treatment, however even with cryoablation 44.4% of treated eyes had a visual acuity of 6/60 or worse at 10 year follow-up. The ETROP study of earlier treatment for high-risk pre-threshold disease, rather than treatment at threshold, has shown that pre-threshold treatment of type 1 disease produces a significantly improved outcome. Despite treatment some infants develop retinal detachment for which various surgical treatments have been described, although not always with a good functional outcome. Future treatment modalities may include the use of anti-VEGF therapies.

Three-port lens-sparing vitrectomy for aggressive posterior retinopathy of prematurity: early surgery before tractional retinal detachment appearance

PURPOSE

Aggressive posterior retinopathy of prematurity (APROP) may suddenly develop into tractional retinal detachment (TRD), often resulting in poor vision if untreated. The aim of the current study is to examine the anatomic results and complications of lens-sparing vitrectomy (LSV) for stage 3 APROP, before TRD appearance.

METHODS

A retrospective, noncomparative, consecutive case series of 13 eyes of 9 patients (mean gestational age 24.1+/-0.9 weeks [range: 23-25 weeks], mean birthweight of 725.8+/-107.9 grams [range: 598-897 grams]) with stage 3 APROP was carried out. The eyes did not respond to at least one session of retinal laser photocoagulation, showing signs of disease progression. All eyes underwent 20-gauge LSV before retinal detachment appearance.

RESULTS

All eyes underwent 20-gauge three-port LSV and intraoperative additional laser photocoagulation. At the end of the surgery, five eyes were tamponaded with air; in eight eyes, a balanced salt solution was left in the vitreous cavity. After 13.5+/-5.3 months of follow-up (range: 4-22), the retina was completely attached in all eyes, without any signs of progression. The authors did not observe any intraoperative or postoperative complications.

CONCLUSIONS

Surgical approach to stage 3 APROP refractory to laser photocoagulation could be effective and safe in order to avoid the progression of the disease.

Current understanding and management of retinopathy of prematurity

PURPOSE OF REVIEW

Retinopathy of prematurity is the leading cause of childhood blindness in industrialized countries and is the fifth leading cause of bilateral childhood blindness worldwide. There have been new insights into understanding the factors involved in the pathogenesis of retinopathy of prematurity and related retinal detachment. This review outlines the current recommendations for initiation, frequency, and duration of screening examinations and describes the infants at the highest risk for developing complications from retinopathy of prematurity. The rationale and timing of treatment are also discussed.

RECENT FINDINGS

Infants who undergo early screening and treatment for retinopathy of prematurity have improved long-term functional and structural outcomes compared with those who receive conventional screening and treatment. Patients undergoing surgical repair of retinopathy of prematurity-related detachments (stage 4A, 4B and 5) can have favorable anatomical and functional outcomes. The increased survival of lower birth weight infants has increased the prevalence of aggressive, posterior retinopathy of prematurity that may be unresponsive to conventional treatment.

SUMMARY

While full understanding of the mechanisms that underlie the formation of retinopathy of prematurity and related detachments is not complete, progress has been made in identifying risk factors, screening of high-risk patients, and optimizing the timing of surgical interventions to improve structural and functional outcomes.

Anatomic success of lens-sparing vitrectomy with and without scleral buckle for stage 4 retinopathy of prematurity

PURPOSE

To compare the anatomic outcomes of lens-sparing vitrectomy (LSV) with those of combined LSV and scleral buckle (SB) in surgical repair of retinopathy of prematurity (ROP) stage 4 retinal detachment.

DESIGN

Retrospective, interventional, consecutive case series.

METHODS

Twenty-one eyes of 15 patients with stage 4 ROP detachment were enrolled. All patients were selected from consecutive patients with stage 4 ROP detachment treated with LSV alone or combined LSV and SB. Patient characteristics, including gestational age, birth weight, gender, corrected gestational age at time of surgery, surgical procedure, anatomic outcome, ability to fix and follow, and progression of cataract or glaucoma were recorded.

RESULTS

Twelve of 21 eyes underwent the combined procedure (LSV with SB), and the remaining nine eyes underwent LSV alone. Eighteen (86%) of 21 eyes achieved retinal reattachment overall, with seven (87%) of eight stage 4B detachments repaired in one surgery. Eleven (85%) of 13 stage 4A detachments were repaired in one surgery. Of the patients in whom treatment failed, two were in the LSV with SB group (2/12; 16%) and one was in the LSV alone group (1/9; 11%).

CONCLUSIONS

The data suggest that SB adds little to the success or failure of LSV and therefore is an unnecessary adjunct to LSV for stage 4 ROP.

Costenbader Lecture. The factor of time in retinopathy of prematurity

PURPOSE

To analyze and discuss the relationship between the factor of time and our understanding of retinopathy of prematurity (ROP).

METHODS

The author calls upon 30 years of experience in clinical investigations of ROP to critically synthesize selected literature on ROP, with attention to the broad theme of time. Future opportunities for clinical research are also considered.

RESULTS

Although retinopathy of prematurity (ROP) ultimately is self-limited in its course, it is highly variable in its severity and outcome. Both the CRYO-ROP and the ETROP studies paid close attention to the chronology of ROP events; however, they approached the question of when to randomize eyes for treatment not simply according to a time definition, but rather according to disease severity characteristics. Still, results of both these studies can be reviewed from a time perspective, and indeed the pace of progression was one of the risk variables considered for ETROP randomization. The optimal schedule under which to perform eye examinations for active ROP is changing, as our understanding of this disease continues to improve.

DISCUSSION

The factor of time is interwoven throughout the clinical course of ROP. Randomized clinical trials have proven to be an extremely efficient scientific method of comparing alternative treatment strategies. In looking toward the future, further randomized clinical trials are needed to investigate rational clinical management of cases in which retinal ablative therapy fails to arrest ROP's progression.