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

Retinal detachment

Retinal detachment (RD) occurs when the neurosensory retina, the neurovascular tissue responsible for phototransduction, is separated from the underlying retinal pigment epithelium (RPE). Given the importance of the RPE for optimal retinal function, RD invariably leads to decreased vision. There are three main types of RD: rhegmatogenous, tractional and exudative (also termed serous) RD. In rhegmatogenous RD, one or more retinal breaks enable vitreous fluid to enter the subretinal space and separate the neurosensory retina from the RPE. In tractional RD, preretinal, intraretinal or subretinal membranes contract and exert tangential forces and elevate the retina from the underlying RPE. Finally, in exudative RD, an underlying inflammatory condition, vascular abnormality or the presence of a tumour causes exudative fluid to accumulate in the subretinal space, exceeding the osmotic pump function of the RPE. The surgical management of RD usually involves pars plana vitrectomy, scleral buckling or pneumatic retinopexy. The approach taken often depends on patient characteristics as well as on practitioner experience and clinical judgement. Advances in surgical technology and continued innovation have improved outcomes for many patients. However, even if retinal re-attachment is achieved, some patients still experience decreased vision or other visual symptoms, such as metamorphopsia, that diminish their quality of life. Continued research in the areas of neuroprotection and retinal biology as well as continued surgical innovation are necessary to enhance therapeutic options and outcomes for these patients.

Cataract Formation Following Pars Plana Vitrectomy in the Pediatric Population

PURPOSE

To analyze post-vitrectomy cataract formation in the pediatric population to elucidate the number of phakic children requiring cataract surgery following vitreous surgery and the perioperative factors affecting cataract development in these patients.

METHODS

Eyes of pediatric patients that underwent phakic pars plana vitrectomy (PPV) with no prior cataract in a 10-year period were included. Analyses evaluated relationships between patient age and time to cataract surgery, as well as contributing factors for cataract formation. Final visual outcomes were also examined. Outcomes were collected for patient age at first vitrectomy, indication for vitrectomy, use of tamponade agents, history of ocular trauma, cataract status, and time to cataract surgery from first vitrectomy.

RESULTS

Of 44 eyes analyzed, 27 (61%) were noted to have some degree of cataract formation. Of these, 15 (56%; 34% of total eyes) underwent cataract surgery. Use of octafluoropropane (P = .04) or silicone oil (P = .03) positively correlated with the need for cataract surgery in the total study group. Patients requiring cataract surgery had worse endpoint visual acuities than those who did not undergo surgery (P = .02), although this difference becomes less significant in follow-up over 2 years (P = .30). Patients who had cataracts but did not need cataract surgery showed an improvement in visual acuity (P = .04), but this was not demonstrated in patients who did need cataract surgery (P = .90).

CONCLUSIONS

Pediatric eye care providers should be aware of the significant risk of cataract formation following a phakic PPV. [J Pediatr Ophthalmol Strabismus. 2023;60(6):421-426.].

Research hotspots and trends in retinopathy of prematurity from 2003 to 2022: a bibliometric analysis

Background

In order to understand the research hotspots and trends in the field of retinopathy of prematurity (ROP), our study analyzed the relevant publications from 2003 to 2022 by using bibliometric analysis.

Methods

The Citespace 6.2.R3 system was used to analyze the publications collected from the Web of Science Core Collection (WoSCC) database.

Results

In total, 4,957 publications were included in this study. From 2003 to 2022, the number of publications gradually increased and peaked in 2022. The United States was the country with the most publications, while Harvard University was the most productive institution. The top co-cited journal PEDIATRICS is published by the United States. Author analysis showed that Hellström A was the author with the most publications, while Good WV was the top co-cited author. The co-citation analysis of references showed seven major clusters: genetic polymorphism, neurodevelopmental outcome, threshold retinopathy, oxygen-induced retinopathy, low birth weight infant, prematurity diagnosis cluster and artificial intelligence (AI). For the citation burst analysis, there remained seven keywords in their burst phases until 2022, including ranibizumab, validation, trends, type 1 retinopathy, preterm, deep learning and artificial intelligence.

Conclusion

Intravitreal anti-vascular endothelial growth factor therapy and AI-assisted clinical decision-making were two major topics of ROP research, which may still be the research trends in the coming years.

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.

Outcomes of Retinectomy without Lensectomy in Rhegmatogenous Retinal Detachments with Proliferative Vitreoretinopathy

PURPOSE

To report the anatomic and functional outcomes of retinectomy without lensectomy in eyes with rhegmatogenous retinal detachment (RRD) and proliferative vitreoretinopathy (PVR).

DESIGN

Retrospective, noncomparative, and interventional case series.

SUBJECTS

One hundred twelve eyes of 112 patients with RRD complicated by PVR who underwent retinectomy without lensectomy.

METHODS

Retrospective review of patients treated with vitrectomy and retinectomy without lensectomy from January 1, 2015, to January 1, 2020.

MAIN OUTCOME MEASURES

The primary outcome was the final attachment rate and single surgery anatomic success (SSAS) at 3 and 6 months after retinectomy. Secondary outcomes included predictors of final visual acuity (VA), the mean number of subsequent operations required for complete retinal reattachment, cataract surgery, and the number of eyes that ultimately had successful silicone oil removal.

RESULTS

Complete final retinal reattachment was achieved in 111 of 112 (99.1%) patients, with a mean (standard deviation [SD]) follow-up of 29 (14) months (range, 8-62 months) after retinectomy. The SSAS was achieved in 84 of 112 (75%) patients at 3 months and 73 of 112 (65.2%) patients at 6 months. The final VA improved or stabilized in 76 of 112 (67.9%) eyes. Silicone oil removal was performed in 72 of 112 patients (64.3%) at a mean (SD) of 6.6 (3.3) months, and cataract surgery was performed on 101 (90.2%) eyes before the last follow-up visit.

CONCLUSIONS

Retinectomy without lensectomy to repair RRDs complicated by PVR showed acceptable anatomic and functional results. This study suggests that removing the lens when there is no significant cataract may not be necessary in these cases to obtain reasonable outcomes.

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.

Management of Type 2 Retinopathy of Prematurity or Less in Infants Aged 45 Weeks Postmenstrual Age or Older

BACKGROUND AND OBJECTIVE

This study aimed to identify the degree of concordance between fluorescein angiograms (FA) and fundus photographs (FP) in assessing the severity and potential need for treatment in infants 45 weeks or older postmenstrual age (PMA) with type 2 or less retinopathy of prematurity (ROP).

PATIENTS AND METHODS

An observational retrospective case series performed at Associated Retinal Consultants, William Beaumont Hospital in Royal Oak, Michigan. All infants born between 2006 and 2016 with stage 1 to 3 ROP that did not meet type 1 ROP criteria (type 2 or less) who received ablative laser therapy during or after age 45 weeks PMA. Pretreatment FP and FA images were randomized and sent to nine expert retina specialist graders to assess severity and inter-grader variability.

RESULTS

A total of 10 babies (19 eyes) were enrolled in this study, and 53 FAs and 27 FPs of these 19 eyes were selected to be interpreted by the nine graders. The number of eyes deemed to be abnormal and warranted for treatment was higher with FA, whereas more eyes were deemed "normal" with FP.

CONCLUSION

Although still controversial, knowledge of these findings may encourage retina specialists to closely examine infants with mild ROP older than age 45 weeks PMA and consider ablative laser therapy under certain conditions (even if not meeting type 1 Early Treatment for ROP criteria). [Ophthalmic Surg Lasers Imaging Retina. 2021;52:636-641.].

Assessment and management of retinopathy of prematurity in the era of anti-vascular endothelial growth factor (VEGF)

The incidence of retinopathy of prematurity (ROP) continues to rise due to the improved survival of very low birth weight infants in developed countries. This epidemic is also fueled by increased survival of preterm babies with variable use of oxygen and a lack of ROP awareness and screening services in resource-limited regions. Improvements in technology and a basic understanding of the disease pathophysiology have changed the way we screen and manage ROP, educate providers and patients, and improve ROP awareness. Advancements in imaging techniques, expansion of telemedicine services, and the potential for artificial intelligence-assisted ROP screening programs have created opportunities to improve ROP care in areas with a shortage of ophthalmologists trained in ROP. To address the gap in provider knowledge regarding ROP, the Global Education Network for Retinopathy of Prematurity (GEN-ROP) created a web-based tele-education training module that can be used to educate all providers involved in ROP, including non-physician ROP screeners. Over the past 50 years, the treatment of severe ROP has evolved from limited treatment modalities to cryotherapy and laser photocoagulation. More recently, there has been growing evidence to support the use of anti-vascular endothelial growth factor (VEGF) agents for the treatment of severe ROP. However, VEGF is known to be important in organogenesis and microvascular maintenance, and given that intravitreal anti-VEGF treatment can result in systemic VEGF suppression over a period of at least 1-12 weeks, there are concerns regarding adverse effects and long-term ocular and systemic developmental consequences of anti-VEGF therapy. Future research in ophthalmology to address the growing burden of ROP should focus on cost-effective fundus imaging devices, implementation of artificial intelligence platforms, updated treatment algorithms with optimal use of anti-VEGF and careful investigation of its long-term effects, and surgical options in advanced ROP. Addressing these unmet needs will aid the global effort against the ROP epidemic and optimize our understanding and treatment of this blinding disease.

Analysis of the etiologies, treatments and prognoses in children and adolescent vitreous hemorrhage

AIM

To determine the etiologies, treatment modalities and visual outcomes of vitreous hemorrhage (VH; range from birth to 18y).

METHODS

A total of 262 eyes from 210 patients between January 2010 and September 2016 were included. All children underwent an appropriate ocular and systemic examination. Data collected included demographics, clinical manifestations, details of the ocular and systemic examination, management details, final fundus anatomy and visual acuity (VA).

RESULTS

The most common etiologies were non-traumatic VH (64.89%), most of which were due to retinopathy of prematurity (ROP; 37.10%); while traffic accidents, including 16 (21.00%) eyes, was the most common ocular traumas. Surgery, performed in 143 (54.58%) eyes, was the most common management modality. The initial mean baseline visual acuity was 2.77±0.21 logarithm of the minimal angle of resolution (logMAR) in children and adolescent with traumatic VH, which was significantly improved to 2.15±1.31 logMAR (P<0.05).

CONCLUSION

VH in children and adolescent has a complicated and diverse etiology. ROP is the primary cause of non-traumatic VH, which is the most common etiology. Appropriate treatment of traumatic VH is associated with obvious improvement in visual acuity. The initial VA is one of most important predictors of outcome.

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.

Treatment outcomes of zone 1 retinopathy of prematurity: A study from a tertiary eye care center in South India

PURPOSE:

The main purpose is to study the treatment outcomes of zone 1 retinopathy of prematurity (ROP).

MATERIALS AND METHODS:

A retrospective analysis was done of infants diagnosed with zone 1 ROP with any stage with or without plus disease who were treated with either laser photocoagulation and/or intravitreal injection of antivascular endothelial growth factor (anti-VEGF) agents and/or underwent surgery according to their stage at presentation. The retinal outcome at the final visit was analyzed. A favorable outcome was characterized by an attached retina at the posterior pole with regression of ROP (regression of plus disease as well as new vessels) while an unfavorable outcome was detached retina at posterior pole in spite of treatment.

RESULTS:

Seventy-eight eyes of 39 infants presented with zone 1 ROP in various stages with plus disease in 50% cases. About 60 eyes underwent treatment. Forty eyes (66.6%) had an attached retina at the final follow-up. Thirty-three eyes (55%) underwent monotherapy with 14 eyes (23.3%) showing regression of ROP with laser alone. Nineteen (31.6%) eyes were treated only by surgery. Of these, a favorable outcome was seen in four eyes (44.4%) with Stage 4 disease and three eyes (30%) with Stage 5 disease. None of the eyes received anti-VEGF as monotherapy. A combination of two or more modalities was required in the remaining 27 eyes (45%). Six eyes (10%) needed anti-VEGF injections in addition to laser and six eyes needed surgery in addition to laser to achieve a favorable outcome. Six eyes (10%) required surgery in addition to both laser and anti-VEGF therapy, and one eye (1.6%) required surgery in addition to anti-VEGF therapy for a favorable final outcome. Among the eyes undergoing treatment, 66.6% had a favorable outcome with 92.9% of eyes in Stage 3, 59% in Stage 4, and 33% in Stage 5 showing regression of disease and attached retina.

CONCLUSION:

In spite of the aggressive nature of zone 1 ROP, favorable outcome is possible as was seen in 66.6% of our cases. A multipronged approach using a combination of laser, intravitreal anti-VEGF agents with or without surgery may be necessary for the management of these eyes.

Macular hole following successful stage 4B/stage 5 retinopathy of prematurity surgery

To report three eyes surgically managed for stage 4B/stage 5 retinopathy of prematurity (ROP) with successful retinal reattachment resulting in macular hole formation after 2–3 months. One patient was observed, and two patients underwent membrane dissection and silicone oil injection and maintained attached retina at last follow-up. The case series is novel to present internal limiting membrane peeling around macular hole with hole closure in one patient which is hitherto not reported. Two of the three eyes received intravitreal bevacizumab injection for aggressive posterior ROP before surgical intervention.

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.

RETINAL DETACHMENT SURGERY IN A PEDIATRIC POPULATION: Visual and Anatomic Outcomes

PURPOSE

Pediatric retinal detachments (RDs) are unique in etiology, anatomy, and prognosis compared with the adult population. The mechanisms of pediatric RD include tractional (TRD), rhegmatogenous retinal detachment, traumatic, and other types, such as exudative or hemorrhagic. This study examined visual and anatomical outcomes of pediatric RD undergoing surgical repair at a single university referral center.

METHODS

A retrospective consecutive case series of patients clinically diagnosed and undergoing surgery for RD between birth and 15 years of age from 2002 to 2013 at a single academic institution.

RESULTS

A total of 206 patients (231 eyes) were included in this study, of which 25 (12%) had bilateral RD. Of those patients, 67 (29%) had TRD (retinopathy of prematurity, persistent fetal vasculature, or familial exudative vitreoretinopathy), 51 (22%) had rhegmatogenous retinal detachment (myopia, X-linked retinoschisis, or Stickler syndrome), 60 (26%) had traumatic RD, and 53 (23%) were due to other types of RD, such as Coats disease or coloboma. Presenting best-corrected visual acuity better than 20/200 correlated with better final best-corrected visual acuity (P < 0.0001). Anatomical success was strongly correlated with visual acuity outcome (P < 0.00001) and was significantly more likely in rhegmatogenous retinal detachment versus TRD (78% vs. 39%, P < 0.05). The rates of obtaining a final best-corrected visual acuity > 20/200 were poorer in TRD (10%) compared with rhegmatogenous retinal detachment (39%, P < 0.01) or traumatic RD (28%, P < 0.05).

CONCLUSION

Visual and anatomical outcomes varied among categories of RD. Rhegmatogenous retinal detachments were associated with the best outcomes (anatomical success and globe conservation), whereas TRDs generally had poorer visual and anatomical 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.

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.

Advances in understanding and management of retinopathy of prematurity

The understanding, diagnosis, and treatment of retinopathy of prematurity have changed in the 70 years since the original description of retrolental fibroplasia associated with high oxygenation. It is now recognized that retinopathy of prematurity differs in appearance worldwide and as ever smaller and younger premature infants survive. New methods are being evaluated to image the retina, diagnose severe retinopathy of prematurity, and determine windows of time for treatment to save eyes and improve visual and neural outcomes. New treatments to promote physiologic retinal vascular development, vascular repair, and inhibit vasoproliferation by regulating proteins involved in vascular endothelial growth factor, insulin-like growth factor, or erythropoietin signaling. Reducing excessive oxidative/nitrosative stress and understanding progenitor cells and neurovascular and glial vascular interactions are being studied.

Combined vitrectomy and glaucoma drainage device implantation surgical approach for complex pediatric glaucomas

PURPOSE

To evaluate efficacy of combined vitrectomy with posteriorly placed glaucoma drainage device (GDD) in lowering intraocular pressure (IOP) in children.

METHODS

The medical records of children who underwent vitrectomy with posteriorly placed GDD were reviewed retrospectively. Patients with a minimum of 6 months' follow-up were included. The first eye operated on for each patient was analyzed. Success was defined as IOP of 5-20 mm Hg and no additional IOP-lowering surgery or visually devastating complications.

RESULTS

A total of 20 patients were included, with the following etiologies: primary infantile-onset glaucoma, 5 (25%); traumatic glaucoma, 3 (15%); Peters anomaly, 3 (15%); microphthalmia, 5 (25%); glaucoma following cataract surgery, 2 (10%); microspherophakia, 1 (5%); and retinopathy of prematurity, 1 (5%). Eyes with corneal opacification (8 [40%]) underwent endoscopic vitrectomy (5 [25%]), concurrent penetrating keratoplasty (3 [15%]) and/or keratoprosthesis surgery (1 [5%]). Mean follow-up was 1.9 ± 1.1 years (range, 6.5-49.2 months). Vision remained stable or improved in 17 eyes (85%). Mean IOP decreased from 27.2 ± 10.1 mm Hg to 14.5 ± 6.8 mm Hg (P < 0.0001) at last follow-up or at failure. Kaplan-Meier curves showed 12- and 24-month rate of IOP control of 69% and 62%, respectively. The number of glaucoma medications decreased from a mean of 2.3 ± 1.4 to 1.3 ± 1.2 (P < 0.015) at last follow-up or at failure. Overall success rate was 65%. Complications included hypotony (3 [15%]), vitreous hemorrhage (1 [5%]), and retinal detachment (1 [5%]). Two eyes (10%) required surgery for hypotony; 4 eyes (20%) underwent additional glaucoma surgery.

CONCLUSIONS

Combined surgical approach with vitrectomy and posteriorly placed GDD decreased IOP in complex pediatric glaucomas. Further, endoscope-assisted vitrectomy is useful in cases with corneal opacification. Complication rates of this combined procedure appear to be comparable to traditional anterior chamber approach.

Current screening and treatments in retinopathy of prematurity in the US

Retinopathy of prematurity (ROP) is a complex disease characterized by an aberrant developmental retinal angiogenesis in preterm infants and can carry significant visual morbidity, including retinal detachment and blindness. Though large scale, randomized clinical trials have improved our understanding of the pathophysiology and progression of the disease, the management of ROP remains a challenge for ophthalmologists. This review addresses the up-to-date screening approach, diagnosis, and treatment guidelines for ROP in the US.

Human Milk Feeding as a Protective Factor for Retinopathy of Prematurity: A Meta-analysis

CONTEXT

Studies have suggested that human milk feeding decreases the incidence of retinopathy of prematurity (ROP); however, conflicting results have been reported.

OBJECTIVE

The aim of this meta-analysis was to pool currently available data on incidence of ROP in infants fed human milk versus formula.

DATA SOURCES

Medline, PubMed, and EBSCO were searched for articles published through February 2015.

STUDY SELECTION

Longitudinal studies comparing the incidence of ROP in infants who were fed human milk and formula were selected. Studies involving donor milk were not included.

DATA EXTRACTION

Two independent reviewers conducted the searches and extracted data. Meta-analysis used odds ratios (ORs), and subgroup analyses were performed.

RESULTS

Five studies with 2208 preterm infants were included. Searches including various proportions of human milk versus formula, any-stage ROP, and severe ROP were defined to pool data for analyses. For any-stage ROP, the ORs (95% confidence intervals [CIs]) were as follows: exclusive human milk versus any formula, 0.29 (0.12 to 0.72); mainly human milk versus mainly formula, 0.51 (0.26 to 1.03); any human milk versus exclusive formula, 0.54 (0.15 to 1.96); and exclusive human milk versus exclusive formula, 0.25 (0.13 to 0.49). For severe ROP, they were 0.11 (0.04 to 0.30), 0.16 (0.06 to 0.43), 0.42 (0.08 to 2.18), and 0.10 (0.04 to 0.29), respectively.

LIMITATIONS

Prospective randomized studies being impossible because of ethical issues, we chose observational studies for analysis. A few studies involving subgroup analyses presented high heterogeneity.

CONCLUSIONS

Based on current limited evidence, in very preterm newborns, human milk feeding potentially plays a protective role in preventing any-stage ROP and severe ROP.