Effect of early vitreous surgery for aggressive posterior retinopathy of prematurity detected by fundus fluorescein angiography

Surgical outcomes in aggressive retinopathy of prematurity (AROP)-related retinal detachments

Introduction

Aggressive retinopathy of prematurity (AROP) is a severe and progressive variant of retinopathy of prematurity (ROP) rapidly forming fibrous tissue extending from the disc toward the posterior lens surface progressing to Stage 5 disease without traversing the classical course that includes Stages 1 to 3. Since AROP behaves differently from type 1 ROP, this study was undertaken to evaluate the surgical outcome of AROP-related detachments.

Methods

Retrospective analysis of data from electronic medical records of babies diagnosed with AROP-related detachments who underwent micro-incision vitrectomy surgery (MIVS) was included. The demographic data, details of primary intervention (laser and/or intravitreal bevacizumab), and surgery were noted. In a subset of patients, surgical intervention was planned early at the onset of fibrovascular tissue.

Results

43 eyes of 26 babies with median birth weight 1175 g and median gestational age of 29 weeks were analyzed. 42/43 eyes underwent primary intervention in form of laser and/or anti-VEGF injection before surgery. 41.8%, 25.5%, and 32.5% eyes progressed to stages 4A, 4B, and 5, respectively, requiring surgical intervention. 66% eyes underwent lensectomy and vitrectomy (LV), and 44% eyes underwent lens sparring vitrectomy (LSV). 58% eyes had attached macula. 44% eyes that had a relatively less vascular diseases had better anatomical outcome (P = 0.019). At final follow-up, 53.4% eyes followed or at least had light fixation, and 77.7% eyes undergoing LSV fixated and/or followed light compared to 33% for LV (P = 0.04).

Conclusion

Challenges in AROP include rapid progression to advanced stages of ROP requiring close monitoring and multiple interventions. Surgeries for AROP have a favorable anatomical and functional outcome in 58% and 53%, respectively. Eyes undergoing lens sparing vitrectomy had better visual outcomes.

Aggressive posterior retinopathy of prematurity: a review on current understanding

A review of literature was performed, focused on the etiopathogenesis of aggressive posterior retinopathy of prematurity (APROP), the characteristic and atypical clinical features, management strategies, anatomical and visual outcomes. Characteristically APROP has zone I/posterior zone II involvement with prominent plus disease, featureless junction, large vascular loops, flat extra-retinal fibrovascular proliferation, and a rapidly progressive course. The risk factors for APROP are extreme prematurity (birth weight ≤1000 gram and/or gestational age ≤28 weeks), dysregulated oxygen supplementation, intrauterine growth retardation, sepsis, and thrombocytopenia. The uncommon presentations include small zone I disease, a hybrid disease with additional ridge tissue, and APROP in bigger babies with birth weight greater than 1500 g. Laser photocoagulation role is limited by the resultant visual field loss and high refractive error. Although anti-vascular endothelial growth factor injection allows peripheral retinal vascularization; reactivation of disease, systemic absorption of the drug and long-term safety are the chief concerns. Early vitrectomy is required when tractional retinal detachment develops. The visual outcome depends upon the morphology and vascular development of the macula. With the limited yet emerging new understanding of the pathophysiology, a multifaceted rational and individualized treatment strategy is suggested for APROP. Best practices in neonatal intensive care may prevent the occurrence of APROP. Further studies need to be performed for the prevention and safe, effective management of APROP.

Retinopathy of prematurity treatment: Asian perspectives

Retinopathy of prematurity (ROP) is a vasoproliferative disease of developing retinal vessels that affects premature infants and can lead to severe and irreversible visual loss if left untreated. India and some other Asian countries are in the middle of a 'third ROP epidemic'. Blindness due to ROP is largely preventable if appropriate, adequate and accessible screening programmes are available. Screening of the premature babies is the first step in ROP management. With the increase in use of tele-screening techniques, more premature babies have been brought under the screening network both from urban and rural regions. Laser photocoagulation to the avascular retina using indirect ophthalmoscopy delivery system is the gold standard for ROP treatment and is usually done under topical anaesthesia in the Asian region in contrast to the western world. Use of intravitreal anti-vascular endothelial growth factors (VEGF) although controversial in management of ROP has been found to be effective in various Asian studies as well. ROP surgery in India and other middle-income Asian countries is largely performed only in few tertiary eye care centres. Poor visual prognosis, late presentation with advanced retinal detachments, lack of adequate number of trained paediatric retinal surgeons and paediatric anaesthetists also contribute to this problem. This current paper summarizes the Asian experience of ROP management.

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.].

Posterior zone I retinopathy of prematurity: spectrum of disease and outcome after laser treatment

OBJECTIVE

To report the morphological spectrum and outcome after laser treatment in posterior zone I retinopathy of prematurity.

DESIGN

Retrospective, consecutive, interventional case series.

METHODS

Review of charts and RetCam images of preterm infants with posterior zone I retinopathy of prematurity (defined as area within a circle, the radius of which extends from the center of the optic disc to the center of the macula) treated with confluent laser at a tertiary care referral institute between January 2006 and December 2015. Data was analyzed and tabulated using frequency and descriptive statistics to describe the demography, morphology, and outcome after laser treatment.

RESULTS

Fifty-six eyes (28 infants) with a mean gestational age of 28.65 ± 2.18 weeks and birth weight of 1153.04 ± 251.51 g were analyzed. Forty-two (75%) eyes had persistent tunica vasculosa lentis and 25 (44.6%) had preretinal hemorrhages. All eyes had circumferential ROP and a poorly developed foveal vasculature. Four distinct morphological patterns were encountered: I - typical aggressive posterior retinopathy was seen in 36 (64.3%) eyes; II - atypical aggressive posterior retinopathy (14 eyes; 25%) had raised fibrovascular proliferation always on the nasal retina close to the optic disc; III - hybrid retinopathy of prematurity (4 eyes; 8.7%) had a mat-like fibrous proliferation on vascularized posterior retina; and IV - threshold retinopathy of prematurity seen in 2 (4.4%) eyes. An unfavourable outcome was seen in 44 (78.6%) eyes.

CONCLUSIONS

Retinopathy of prematurity in posterior zone I presents with atypical morphology and poor outcomes despite confluent laser photocoagulation.

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.

Bedside Diode Laser Photocoagulation Under Remifentanil Analgesia for Retinopathy of Prematurity: Early Structural Outcomes

Objectives:

To evaluate one-year structural outcomes of bedside diode laser photocoagulation with remifentanil analgesia for retinopathy of prematurity (ROP) and discuss clinical and demographic characteristics of infants and other possible risk factors that may affect the outcome.

Materials and Methods:

The medical records of premature infants who were treated with bedside transpupillary diode laser photocoagulation under remifentanil analgesia for ROP were evaluated for clinical and demographic characteristics, accompanying systemic risk factors, laser parameters, complications of treatment, retreatment rate and one-year structural outcomes.

Results:

One-hundred and ninety-five eyes of 99 infants (59 males, 40 females) were recruited for the study. The mean gestational age and birth weight were 27.4±2.3 weeks (23-34) and 1003.3±297.8 g (570-2250), respectively. Laser therapy was performed for high-risk prethreshold ROP in 66.2% of eyes, aggressive posterior ROP (APROP) in 15.4% and threshold ROP in 18.4%. The mean number of laser spots was 1510.4±842.1 per laser session. No adverse effects of laser photocoagulation were observed except small lens opacities in two eyes and corneal opacity in one eye. Retreatment was needed in only three eyes, and vitreoretinal surgery was needed in six eyes of six patients despite laser treatment. Anatomic outcome was favorable in 189 eyes (96.9%) at the end of a 1-year follow-up. Presence of dilated and tortuous iris vessels (p=0.002) and tunica vasculosa lentis (p=0.009) along with type of ROP (APROP and stage 4a ROP at initial presentation) (p=0.001) were associated with poor anatomical outcome.

Conclusion:

Accurate and timely bedside transpupillary diode-laser photocoagulation under remifentanil analgesia is an effective and safe treatment modality for ROP, and may prevent vision-threatening retinal detachment and reduce the need for vitreoretinal surgery.

Type 1 Retinopathy of Prematurity and Its Laser Treatment of Large Preterm Infants in East China

Purpose

To describe Type 1 retinopathy of prematurity (ROP) and its laser treatment outcomes in premature infants with birth weight > 1250 g in Eastern China.

Methods

A retrospective review of 3175 ROP records was conducted at Shanghai Eye & ENT Hospital of Fudan University. The records were collected at the ROP clinic from 2006 to 2014, including their demographic and medical information such as gestational age, birth weight, supplemental oxygen therapy, systemic complications, ROP stage, location, presence of plus disease. All infants were examined by RetCam fundus camera. Those with Type 1 ROP were also examined by indirect ophthalmoscope before undergoing transpupillary laser treatment.

Results

A total of 12 infants (24 eyes) with Type 1 ROP and birth weight > 1250 g were enrolled. All infants enrolled had plus disease and ROP in zone II retina. Specifically, 16 eyes (67%) had stage 2 ROP. 8 eyes (33%) had stage 3 ROP. ROP regressed in 23 eyes (96%) following laser treatment. Partial retinal detachment developed in one eye (4%). No severe involution sequelaes or laser-related complications were recorded. Mean follow-up was 30±6 weeks.

Conclusion

Type 1 ROP may occur in large premature infants who have undergone supplemental oxygen therapy. This Type 1 ROP is mainly located in zone II retina. Laser treatment is a safe and effective intervention for these infants.

Elk3 deficiency causes transient impairment in post-natal retinal vascular development and formation of tortuous arteries in adult murine retinae

Serum Response Factor (SRF) fulfills essential roles in post-natal retinal angiogenesis and adult neovascularization. These functions have been attributed to the recruitment by SRF of the cofactors Myocardin-Related Transcription Factors MRTF-A and -B, but not the Ternary Complex Factors (TCFs) Elk1 and Elk4. The role of the third TCF, Elk3, remained unknown. We generated a new Elk3 knockout mouse line and showed that Elk3 had specific, non-redundant functions in the retinal vasculature. In Elk3(−/−) mice, post-natal retinal angiogenesis was transiently delayed until P8, after which it proceeded normally. Interestingly, tortuous arteries developed in Elk3(−/−) mice from the age of four weeks, and persisted into late adulthood. Tortuous vessels have been observed in human pathologies, e.g. in ROP and FEVR. These human disorders were linked to altered activities of vascular endothelial growth factor (VEGF) in the affected eyes. However, in Elk3(−/−) mice, we did not observe any changes in VEGF or several other potential confounding factors, including mural cell coverage and blood pressure. Instead, concurrent with the post-natal transient delay of radial outgrowth and the formation of adult tortuous arteries, Elk3-dependent effects on the expression of Angiopoietin/Tie-signalling components were observed. Moreover, in vitro microvessel sprouting and microtube formation from P10 and adult aortic ring explants were reduced. Collectively, these results indicate that Elk3 has distinct roles in maintaining retinal artery integrity. The Elk3 knockout mouse is presented as a new animal model to study retinal artery tortuousity in mice and human patients.

Prevalence and outcomes of laser treatment of aggressive posterior retinopathy of prematurity

BACKGROUND

To describe outcomes in a cohort of extremely premature infants treated for aggressive posterior retinopathy of prematurity by diode laser panretinal photocoagulation.

DESIGN

Retrospective study.

PARTICIPANTS

Fifteen eyes in eight infants.

METHODS

A review was carried out on infants between 23 and 25.6 weeks gestational age admitted to The Royal Brisbane and Women's Hospital neonatal intensive care unit between 1992 and 2009.

MAIN OUTCOME MEASURES

Success of treatment, visual and refractive outcomes.

RESULTS

Five hundred fifty-four infants were admitted to neonatal intensive care unit, 373 survived till screening, and 304 had retinopathy of prematurity. Sixty-six infants required treatment, and eight of these had aggressive posterior retinopathy of prematurity (2.5% of all infants with retinopathy of prematurity). Mean gestational age was 24.2 weeks, mean birthweight was 634 g, and treatment occurred at mean 34.1 weeks post-menstrual age. The mean total number of burns per eye was 2967. Five of 15 treated eyes required retreatment. Two patients subsequently died of unrelated causes. Regression occurred in 9 of 11 remaining eyes; one eye progressed to stage 4b and another to stage 5 retinopathy of prematurity. Vitrectomy was performed in two eyes. Five eyes had 6/12 vision, one had 3/60, and three had no perception of light. Of the remaining two eyes, one had good fixation and the other had poor fixation.

CONCLUSIONS

Despite good structural outcomes, visual outcomes for conventional laser treatment of aggressive posterior retinopathy of prematurity are poor.

Aggressive posterior retinopathy of prematurity: risk factors for retinal detachment despite confluent laser photocoagulation

PURPOSE

To analyze risk factors for retinal detachment in eyes with aggressive posterior retinopathy of prematurity (ROP) treated with confluent laser photocoagulation.

DESIGN

Retrospective, consecutive, interventional case series.

METHODS

Infants undergoing laser treatment for aggressive posterior ROP from January 2006 through June 2010 participated. Eyes with retinal detachment (stage 4A, 4B, and 5) at presentation and those lost to follow-up after treatments were excluded. We defined 2 groups based on outcome after confluent laser photocoagulation: retinal detachment or favorable outcome. Two groups were compared for various factors, which included birth weight, gestational age, postconceptional age at laser treatment, zone of disease, preretinal hemorrhage, pre-existing fibrovascular proliferation, tunica vasculosa lentis, laser spots used for primary treatment, need for repeat laser treatment, and new-onset fibrovascular proliferation after laser treatment. Data were analyzed using univariate and multivariate logistic regression analysis.

RESULTS

One hundred nineteen eyes of 61 infants underwent laser treatment for aggressive posterior ROP. Ten (8.4%) eyes were excluded and 109 eyes (91.6%) were included. Nineteen (17.4%) of 109 eyes progressed to retinal detachment after laser treatment. On univariate analysis, multiple factors were associated with retinal detachment. Of these, all eyes with posterior zone 1 disease and all eyes demonstrating extensive fibrovascular proliferation (> 3 clock hours) after laser treatment progressed to retinal detachment. On multivariate logistic regression analysis, the most significant predictors of retinal detachment were gestational age of less than 29.5 weeks (P = .006), hemorrhages (P = .003), need for repeat laser treatment (P = .006), and new-onset limited fibrovascular traction (< 3 clock hours) after laser treatment (P = .042).

CONCLUSIONS

A gestational age of less than 29.5 weeks, posterior zone 1 disease, and preretinal hemorrhages before laser treatment are the most significant risk factors for retinal detachment in aggressive posterior ROP. Of the events occurring after laser treatment, new-onset fibrovascular traction is associated significantly with development of retinal detachment.

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.