Pathophysiology, screening and treatment of ROP: A multi-disciplinary perspective

Postnatal weight gain and retinopathy of prematurity in preterm infants: a population-based retrospective cohort study

OBJECTIVE

Infants who meet the screening guidelines for retinopathy of prematurity (ROP) based on birth weight and gestational age undergo serial ophthalmological examinations for its detection and treatment. However, <10% of patients require treatment, and less than half develop ROP. Poor postnatal weight gain has been reported to be a strong indicator of ROP development; however, the information regarding this is unclear. Therefore, this study aimed to determine the relationship between postnatal weight gain and ROP development in preterm infants.

METHODS

The data of 675 preterm infants with gestational age ≤32 weeks, who were hospitalized in our neonatal intensive care unit, were obtained retrospectively from file records. The infants' demographic characteristics, clinical findings, and weekly weight gain (g/kg/day) during the first 8 weeks were recorded. The univariate was used to examine the risk factors for ROP followed by multivariate regression.

RESULTS

The incidence of ROP in the infants included in the study was 41% (n = 278) and 13.3% (n = 37) of them required treatment. In the infants of the group that developed ROP, the mean birth weight and gestational age were significantly lower than those in the group that did not develop ROP (973 ± 288 and 1301 ± 349 g, p = 0.001 and 28.48 ± 1.95 and 30.08 ± 1.60 weeks, p = 0.001, respectively). As the gestational week and birth weight decreased, ROP development and the risk of ROP-requiring treatment increased. In the infants of the group that developed ROP, the mean weight gain in the postnatal third week was detected as significantly lower compared to those in the group that did not develop ROP (13.9 ± 8.2 and 15.4 ± 6.8 g, p = 0.034). On multiple logistic regression analysis, birth weight (<750 g) (odds ratio [OR], 8.67; 95% confidence interval [CI], 3.99-18.82, p = 0.001), blood transfusion (OR, 2.39; 95% CI, 1.34-4.24, p = 0.003), necrotizing enterocolitis (OR, 4.79; 95% CI, 1.05-26.85, p = 0.045), bronchopulmonary dysplasia (OR, 2.03; 95% CI, 1.22-3.36, p = 0.006), antenatal steroid therapy (OR, 1.60; 95% CI, 1.05-2.43, p = 0.028), surfactant administration (OR, 2.06; 95% CI, 1.32-3.2, p = 0.001) were independent risk factors for ROP development.

CONCLUSION

Postnatal weight gain may not be an accurate predictor of ROP development after adjusting for confounding factors. However, the analysis of independent risk factors that influenced the development of ROP revealed a statistically significant effect in cases of low birth weight, blood transfusion, necrotizing enterocolitis, bronchopulmonary dysplasia, and antenatal steroid and surfactant therapies. These findings may help ophthalmologists and neonatologists to pay special attention to this patient group during ROP scanning.

A systematic review of economic evaluation of artificial intelligence-based screening for eye diseases: From possibility to reality

Artificial Intelligence (AI) has become a focus of research in the rapidly evolving field of ophthalmology. Nevertheless, there is a lack of systematic studies on the health economics of AI in this field. We examine studies from the PubMed, Google Scholar, and Web of Science databases that employed quantitative analysis, retrieved up to July 2023. Most of the studies indicate that AI leads to cost savings and improved efficiency in ophthalmology. On the other hand, some studies suggest that using AI in healthcare may raise costs for patients, especially when taking into account factors such as labor costs, infrastructure, and patient adherence. Future research should cover a wider range of ophthalmic diseases beyond common eye conditions. Moreover, conducting extensive health economic research, designed to collect data relevant to its own context, is imperative.

Image Analysis-Based Machine Learning for the Diagnosis of Retinopathy of Prematurity: A Meta-analysis and Systematic Review

TOPIC

To evaluate the performance of machine learning (ML) in the diagnosis of retinopathy of prematurity (ROP) and to assess whether it can be an effective automated diagnostic tool for clinical applications.

CLINICAL RELEVANCE

Early detection of ROP is crucial for preventing tractional retinal detachment and blindness in preterm infants, which has significant clinical relevance.

METHODS

Web of Science, PubMed, Embase, IEEE Xplore, and Cochrane Library were searched for published studies on image-based ML for diagnosis of ROP or classification of clinical subtypes from inception to October 1, 2022. The quality assessment tool for artificial intelligence-centered diagnostic test accuracy studies was used to determine the risk of bias (RoB) of the included original studies. A bivariate mixed effects model was used for quantitative analysis of the data, and the Deek's test was used for calculating publication bias. Quality of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation.

RESULTS

Twenty-two studies were included in the systematic review; 4 studies had high or unclear RoB. In the area of indicator test items, only 2 studies had high or unclear RoB because they did not establish predefined thresholds. In the area of reference standards, 3 studies had high or unclear RoB. Regarding applicability, only 1 study was considered to have high or unclear applicability in terms of patient selection. The sensitivity and specificity of image-based ML for the diagnosis of ROP were 93% (95% confidence interval [CI]: 0.90-0.94) and 95% (95% CI: 0.94-0.97), respectively. The area under the receiver operating characteristic curve (AUC) was 0.98 (95% CI: 0.97-0.99). For the classification of clinical subtypes of ROP, the sensitivity and specificity were 93% (95% CI: 0.89-0.96) and 93% (95% CI: 0.89-0.95), respectively, and the AUC was 0.97 (95% CI: 0.96-0.98). The classification results were highly similar to those of clinical experts (Spearman's R = 0.879).

CONCLUSIONS

Machine learning algorithms are no less accurate than human experts and hold considerable potential as automated diagnostic tools for ROP. However, given the quality and high heterogeneity of the available evidence, these algorithms should be considered as supplementary tools to assist clinicians in diagnosing ROP.

FINANCIAL DISCLOSURE(S)

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

Tetrahedral framework nucleic acids-based delivery of MicroRNA-22 inhibits pathological neovascularization and vaso-obliteration by regulating the Wnt pathway

The objective of this study was to investigate the effects and molecular mechanisms of tetrahedral framework nucleic acids-microRNA22 (tFNAs-miR22) on inhibiting pathological retinal neovascularization (RNV) and restoring physiological retinal vessels. A novel DNA nanocomplex (tFNAs-miR22) was synthesised by modifying microRNA-22 (miR22) through attachment onto tetrahedral frame nucleic acids (tFNAs), which possess diverse biological functions. Cell proliferation, wound healing, and tube formation were employed for in vitro assays to investigate the angiogenic function of cells. Oxygen-induced retinopathy (OIR) model was utilised to examine the effects of reducing pathological neovascularization (RNV) and inhibiting vascular occlusion in vivo. In vitro, tFNAs-miR22 demonstrated the ability to penetrate endothelial cells and effectively suppress cell proliferation, tube formation, and migration in a hypoxic environment. In vivo, tFNAs-miR22 exhibited promising results in reducing RNV and promoting the restoration of normal retinal blood vessels in OIR model through modulation of the Wnt pathway. This study provided a theoretical basis for the further understanding of RNV, and highlighted the innovative and potential of tFNAs-miR22 as a therapeutic option for ischemic retinal diseases.

Molecular hydrogen promotes retinal vascular regeneration and attenuates neovascularization and neuroglial dysfunction in oxygen-induced retinopathy mice

BACKGROUND

Retinopathy of Prematurity (ROP) is a proliferative retinal vascular disease occurring in the retina of premature infants and is the main cause of childhood blindness. Nowadays anti-VEGF and retinal photocoagulation are mainstream treatments for ROP, but they develop a variety of complications. Hydrogen (H2) is widely considered as a useful neuroprotective and antioxidative therapeutic method for hypoxic-ischemic disease without toxic effects. However, whether H2 provides physiological angiogenesis promotion, neovascularization suppression and glial protection in the progression of ROP is largely unknown.This study aims to investigate the effects of H2 on retinal angiogenesis, neovascularization and neuroglial dysfunction in the retinas of oxygen-induced retinopathy (OIR) mice.

METHODS

In this study, mice that were seven days old and either wild-type (WT) or Nrf2-deficient (Nrf2-/-) were exposed to 75% oxygen for 5 days and then returned to normal air conditions. Different stages of hydrogen gas (H2) inhalation were administered. Vascular obliteration, neovascularization, and blood vessel leakage were analyzed and compared. To count the number of neovascularization endothelial nuclei, routine HE staining of retinal sections was conducted. Immunohistochemistry was performed using DyLight 594 labeled GSL I-isolectin B4 (IB4), as well as primary antibodies against proliferating cell nuclear antigen (PCNA), glial fibrillary acidic protein (GFAP), and Iba-1. Western blots were used to measure the expression of NF-E2-related factor 2 (Nrf2), vascular endothelial growth factor (VEGF), Notch1, Dll4, and HIF-1α. Additionally, the expression of target genes such as NQO1, HO-1, Notch1, Hey1, Hey2, and Dll4 was measured. Human umbilical vein endothelial cells (HUVECs) treated with H2 under hypoxia were used as an in vitro model. RT-PCR was used to evaluate the mRNA expression of Nrf2, Notch/Dll4, and the target genes. The expression of reactive oxygen species (ROS) was observed using immunofluorescence staining.

RESULTS

Our results indicate that 3-4% H2 does not disturb retinal physiological angiogenesis, but ameliorates vaso-obliteration and neovascularization in OIR mice. Moreover, H2 prevents the decreased density and reverses the morphologic and functional changes in retinal astrocytes caused by oxygen-induced injury. In addition, H2 inhalation reduces microglial activation, especially in the area of neovascularization in OIR mice. H2 plays a protective role in vascular regeneration by promoting Nrf2 activation and suppressing the Dll4-induced Notch signaling pathway in vivo. Also, H2 promotes the proliferation of HUVECs under hypoxia by negatively regulating the Dll4/Notch pathway and reducing ROS levels through Nrf2 pathway aligning with our findings in vivo.Moreover, the retinal oxygen-sensing mechanisms (HIF-1α/VEGF) are also involved in hydrogen-mediated retinal revascularization and neovascularization suppression.

CONCLUSIONS

Collectively, our results indicate that H2 could be a promising therapeutic agent for POR treatment and that its beneficial effect in human ROP might involve the activation of the Nrf2-Notch axis as well as HIF-1α/VEGF pathways.

RDLR: A Robust Deep Learning-Based Image Registration Method for Pediatric Retinal Images

Retinal diseases stand as a primary cause of childhood blindness. Analyzing the progression of these diseases requires close attention to lesion morphology and spatial information. Standard image registration methods fail to accurately reconstruct pediatric fundus images containing significant distortion and blurring. To address this challenge, we proposed a robust deep learning-based image registration method (RDLR). The method consisted of two modules: registration module (RM) and panoramic view module (PVM). RM effectively integrated global and local feature information and learned prior information related to the orientation of images. PVM was capable of reconstructing spatial information in panoramic images. Furthermore, as the registration model was trained on over 280,000 pediatric fundus images, we introduced a registration annotation automatic generation process coupled with a quality control module to ensure the reliability of training data. We compared the performance of RDLR to the other methods, including conventional registration pipeline (CRP), voxel morph (WM), generalizable image matcher (GIM), and self-supervised techniques (SS). RDLR achieved significantly higher registration accuracy (average Dice score of 0.948) than the other methods (ranging from 0.491 to 0.802). The resulting panoramic retinal maps reconstructed by RDLR also demonstrated substantially higher fidelity (average Dice score of 0.960) compared to the other methods (ranging from 0.720 to 0.783). Overall, the proposed method addressed key challenges in pediatric retinal imaging, providing an effective solution to enhance disease diagnosis. Our source code is available at https://github.com/wuwusky/RobustDeepLeraningRegistration .

Icariin alleviates oxygen-induced retinopathy by targeting microglia hexokinase 2

Retinopathy of prematurity (ROP) is a retinal disease-causing retinal neovascularization that can lead to blindness. Oxygen-induced retinopathy (OIR) is a widely used ROP animal model. Icariin (ICA) has anti-oxidative and anti-inflammation properties; however, whether ICA has a regulatory effect on OIR remains unclear. In this study, ICA alleviated pathological neovascularization, microglial activation and blood-retina barrier (BRB) damage in vivo. Further results indicated that endothelial cell tube formation, migration and proliferation were restored by ICA treatment in vitro. Proteomic microarrays and molecular mimicry revealed that ICA can directly bind to hexokinase 2 (HK2) and decrease HK2 protein expression in vivo and in vitro. In addition, ICA inhibited the AKT/mTOR/HIF1α pathway activation. The effects of ICA on pathological neovascularization, microglial activation and BRB damage disappeared after HK2 overexpression in vivo. Similarly, the endothelial cell function was revised after HK2 overexpression. HK2 overexpression reversed ICA-induced AKT/mTOR/HIF1α pathway inhibition in vivo and in vitro. Therefore, ICA prevented pathological angiogenesis in OIR in an HK2-dependent manner, implicating ICA as a potential therapeutic agent for ROP.

Panretinal handheld OCT angiography for pediatric retinal imaging

Comprehensive visualization of retina morphology is essential in the diagnosis and management of retinal diseases in pediatric populations. Conventional imaging techniques often face challenges in effectively capturing the peripheral retina, primarily due to the limitations in current optical designs, which lack the necessary field of view to characterize the far periphery. To address this gap, our study introduces a novel ultra-widefield optical coherence tomography angiography (OCTA) system. This system, specifically tailored for pediatric applications, incorporates an ultrahigh-speed 800 kHz swept-source laser. The system's innovative design achieves a 140° field of view while maintaining excellent optical performance. Over the last 15 months, we have conducted 379 eye examinations on 96 babies using this system. It demonstrates marked efficacy in the diagnosis of retinopathy of prematurity, providing detailed and comprehensive peripheral retinal angiography. The capabilities of the ultra-widefield handheld OCTA system in enhancing the clarity and thoroughness of retina vascularization assessments have significantly improved the precision of diagnoses and the customization of treatment strategies. Our findings underscore the system's potential to advance pediatric ophthalmology and broaden the scope of retinal imaging.

Exposure to persistent hemodynamically significant patent ductus arteriosus is associated with retinopathy of prematurity

BACKGROUND

Hemodynamically significant patent ductus arteriosus (hsPDA) shunt may predispose infants to retinopathy of prematurity (ROP) because of its higher preductal cardiac output and blood oxygen content, which may augment ocular oxygen delivery.

METHODS

A retrospective cohort study of preterm infants, born at <27 weeks' gestation and admitted at <24h postnatal age to a large quaternary referral was conducted. The primary composite outcome was death at <32 weeks or moderate-to-severe ROP (≥stage 2 or requiring treatment) in either eye. Secondary outcomes included ROP requiring treatment, and any ROP. Univariate analysis of patient characteristics and outcomes was performed as well as logistic regression. A receiver operating characteristics curve was generated for the outcome of ROP ≥stage 2 or requiring treatment.

RESULTS

A total of 91 patients were screened, of whom 86 (54 hsPDA, 32 controls) were eligible for inclusion. hsPDA patients were younger and lighter at birth and had a higher burden of hyperglycemia and respiratory illness. The rates of the composite outcome (death <32 weeks or moderate-to-severe ROP) and of any ROP were more frequent in the hsPDA group. hsPDA shunt exposure was independently associated with development of any ROP among survivors to assessment (P = 0.006). PDA cumulative exposure score of 78 (clinical equivalent = 7 days high-volume shunt exposure) predicts moderate-to-severe ROP with 80% sensitivity and 78% specificity.

CONCLUSIONS

Among infants <27 weeks, hsPDA shunt is associated with increased risks of a composite outcome of death or moderate-to-severe ROP, as well as ROP of any stage. Shunt modulation as a strategy to reduce ROP represents a biologically plausible avenue for investigation.

4D label-free proteomics analysis of oxygen-induced retinopathy with or without anti-VEGF treatment

Oxygen-induced retinopathy (OIR) animal model is widely used for retinopathy of prematurity (ROP) researches. The purpose of this study was to identify proteins and related pathways of OIR with or without anti-vascular endothelial growth factor (VEGF) treatment, for use as biomarkers in diagnosing and treating ROP. Nine samples were subjected to proteomic analysis. Retina specimens were collected from 3 OIR mice, 3 OIR mice with anti-VEGF treatment and 3 normal mice (control group). Liquid chromatography-tandem mass spectrometry analysis was performed using the 4D label-free technique. Statistically significant differentially expressed proteins, gene ontology (GO) terms, Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway representations, InterPro (IPR) and protein interactions were analyzed. In total, 4585 unique proteins were identified as differentially expressed proteins (DEPs). Enrichment analysis of the GO and KEGG indicated functional clusters related to peptide biosynthetic and metabolic process, cellular macromolecule biosynthetic process and nucleic acid binding in OIR group. For anti-VEGF treatment group, DEPs were clustered in DNA replication, PI3K/Akt signaling pathway and Jak/STAT signaling pathway. Proteomic profiling is useful for the exploration of molecular mechanisms of OIR and mechanisms of anti-VEGF treatment. These findings may be useful for identification of novel biomarkers for ROP pathogenesis and treatment.

Ocular blood flow in preterm neonates

Retinopathy of prematurity (ROP) is a disorder affecting low birthweight, preterm neonates. In the preterm eye, the retina is not fully developed and neovascularization may occur at the margin between the developed vascular retina and undeveloped avascular retina. Without timely treatment by laser or intravitreal anti-vascular endothelial growth factor (VEGF) therapy, this can lead to tractional retinal detachment and blindness. Visualization of the retina in regular examinations by indirect ophthalmoscopy is hence the current standard of care, but the exams are stressful and interpretation of images is subjective. The upregulation of VEGF in ROP would suggest an increase in ocular blood flow. In this report, we evaluate the potential of ultrafast plane-wave Doppler ultrasound (PWU) to detect increased flow velocities in the orbital vessels supplying the eye in a gentle exam with objective findings. We imaged both eyes of 50 low-birthweight preterm neonates using 18 MHz PWU. Flow velocity in the central retinal artery (CRA) and vein (CRV), and the short posterior ciliary arteries were determined and values at each ROP Stage compared. We found significantly increased velocities in the CRA and CRV in Stage 3 ROP eyes, where intervention would be considered. We compared multivariate models for identifying Stage 3 eyes comprised solely of clinical factors, solely of Doppler parameters, and clinical plus Doppler parameters. The respective models provided areas under their respective ROC curves of 0.760, 0.812, and 0.904. PWU Doppler represents a gentle, objective means for identifying neonates at risk for ROP that could complement ophthalmoscopy.

Visual impairment burden in retinopathy of prematurity: trends, inequalities, and improvement gaps

Retinopathy of prematurity (ROP) is an important cause of avoidable childhood visual impairment, and the increase in number and survival of premature infants may inflate its burden globally. We aimed to comprehensively assess the trends and inequalities in the burden of ROP-related visual impairment and to identify improvement gaps to facilitate appropriate actions in neonatal care systems. We obtained ROP data from the Global Burden of Disease 2019 study. We employed joinpoint regression analysis to assess the trends of the burden of ROP-related visual impairment, measured by age-standardised prevalence rates, health equity analysis methods to evaluate cross-country burden inequalities, and data envelopment and stochastic frontier analyses to identify improvement gaps based on the development status, i.e., sociodemographic index (SDI). Between 1990 and 2019, the age-standardised prevalence rates of ROP-related visual impairment significantly increased worldwide (average annual percentage change: 0.23 [95% confidence interval, 0.21-0.26] among males and 0.26 [0.25-0.27] among females), primarily in developed regions. Although significant SDI-related cross-country inequalities were identified, these reduced over time (slope index of inequality: -57.74 [-66.22 to -49.25] in 1990 to -29.68 [-38.39 to -20.97] in 2019; health concentration index: -0.11 [-0.13 to -0.09] in 1990 to -0.07 [-0.09 to -0.06] in 2019). Notably, some less-developed countries exhibited superior performance despite limited resources, whereas others with a higher SDI delivered lagging performance.  Conclusion: The global burden of ROP-related visual impairment has steadily increased between 1990 and 2019, with disproportionate burden concentration among less-developed countries, requiring appropriate preventive and intervention measures. What is Known: • Retinopathy of prematurity (ROP) is an important cause of avoidable childhood visual impairment. • The prevalence of ROP is anticipated to increase due to the growing number of extremely premature infants. What is New: • The prevalence of ROP-related visual impairment has increased worldwide, primarily in developed regions, with declining but persisting cross-country inequalities. • The increasing burden of ROP-related visual impairment should be considered as part of global and national health agendas, requiring interventions with proven efficacy.

Effectiveness of Propranolol in Preventing Severe Retinopathy of Prematurity: A Comprehensive Systematic Review and Meta-Analysis

PURPOSE

To learn more about the effectiveness of oral propranolol as a therapeutic alternative for preterm newborns with pre-existing retinopathy of prematurity (ROP) as well as an early prevention method for ROP, one of the most common but avoidable causes of juvenile blindness.

STUDY DESIGN

Meta-analysis of relevant literature.

METHODS

A total of 3464 papers were identified, with 2873 from PubMed, 39 from Scopus, 67 from Medline, and 16 from Embase. After screening, finally, a total of 8 studies were deemed suitable for review. Following the PRISMA guidelines, published literature was systematically assessed up to May 10, 2023. Trials and observational studies were included in which beta blockage was used to prevent severe ROP (defined as stage ≥3 or requiring treatment). A total of 3646 papers were identified, with 2873 from PubMed, 39 from Scopus, 67 from Medline, and 16 from Embase. After screening, a total of 8 studies were deemed suitable for review.

RESULTS

The use of propranolol is linked to a lower risk of disease development in ROP compared to other therapies or control groups, according to the overall risk ratio of 0.59 (95% CI = 0.42, 0.82; P = .002, I2 = 41%). Additionally, the overall risk ratio for plus disease is 0.42 (95% CI = 0.23, 0.78; P = .006, I2 = 0%), for laser photocoagulation is 0.48 (95% CI = 0.31, 0.74; P = .001; I2 = 2%), and for intravitreal injection of VEGF is 0.43 (95% CI = 0.24, 0.74; P = 0.003, I2 = 0%), suggesting that use of propranolol may reduce the likelihood of developing a disease such as plus disease, requiring laser photocoagulation or necessitating intravitreal injection of vascular endothelial growth factor for ROP, respectively. No statistically significant heterogeneity was found in this study (P > .10, I2 = 50%). It can be concluded from this that the results of the chosen studies were sufficiently comparable and consistent.

CONCLUSION

This study showed that oral propranolol given as a preventive treatment in premature newborns successfully prevented severe ROP. Propranolol dosage and timing must now be carefully considered in the context of the study population, as these factors may have a major impact on the observed outcomes and treatment success.

Targeting adenosine A2A receptors for early intervention of retinopathy of prematurity

Retinopathy of prematurity (ROP) continues to pose a significant threat to the vision of numerous children worldwide, primarily owing to the increased survival rates of premature infants. The pathologies of ROP are mainly linked to impaired vascularization as a result of hyperoxia, leading to subsequent neovascularization. Existing treatments, including anti-vascular endothelial growth factor (VEGF) therapies, have thus far been limited to addressing pathological angiogenesis at advanced ROP stages, inevitably leading to adverse side effects. Intervention to promote physiological angiogenesis during the initial stages could hold the potential to prevent ROP. Adenosine A2A receptors (A2AR) have been identified in various ocular cell types, exhibiting distinct densities and functionally intricate connections with oxygen metabolism. In this review, we discuss experimental evidence that strongly underscores the pivotal role of A2AR in ROP. In particular, A2AR blockade may represent an effective treatment strategy, mitigating retinal vascular loss by reversing hyperoxia-mediated cellular proliferation inhibition and curtailing hypoxia-mediated neovascularization in oxygen-induced retinopathy (OIR). These effects stem from the interplay of endothelium, neuronal and glial cells, and novel molecular pathways (notably promoting TGF-β signaling) at the hyperoxia phase. We propose that pharmacological targeting of A2AR signaling may confer an early intervention for ROP with distinct therapeutic benefits and mechanisms than the anti-VEGF therapy.

The incidence of retinopathy of prematurity in neonates in Germany in 2019; a nationwide epidemiological cohort study

Retinopathy of prematurity (ROP) is a leading cause of childhood blindness in preterm infants. The incidence of ROP varies widely across countries, with rates as high as 30% in some regions. This study investigated the incidence, risk factors, treatment, and mortality of ROP patients in Germany. Data were extracted from the German Federal Statistical Office (Destatis) diagnosis-related group (DRG) and Institute for the Remuneration System in Hospitals (InEK) databases. Patients with a secondary diagnosis of ROP (ICD-10 code H35.1) in the first 28 days of life were included. Data were extracted for patients admitted between January 1, 2019 and December 31, 2019. The diagnoses and procedures were determined using the German version of the International Classification of Diseases (ICD-10-GM) and the German procedure coding system (OPS). The codes 5-154.xx, 5-155.xx, 8-020.xx, 5-156.9, 6-003.(c&d), 6-007.(2&8) were utilised to denote different ocular treatments. Patient Clinical Complexity Levels were extracted and used to compare ROP with non-ROP patients. A total of 1326 patients with ROP were identified. The incidence of ROP is estimated to be 17.04 per 10,000 live births. The incidence was highest in infants with birth weights less than 500 g and decreased with increasing birth weight. The most common risk factors for ROP were low birth weight, male sex, and prematurity. Of the infants with ROP, 7.2% required ocular treatment. The most common treatment was intraocular injections, followed by photocoagulation. No surgical treatment was required for any of the infants during the study period. The mortality rate for infants with ROP was 60.33 per 10,000. This is higher than the overall neonatal death rate of 24.2 per 10,000.

CONCLUSIONS

This study found that the incidence of ROP in Germany is similar to that in other developed countries. The study also found that the mortality rate for infants with ROP is higher than the overall neonatal death rate. These findings highlight the importance of early detection and treatment of ROP in preterm infants.

WHAT IS KNOWN

• ROP is a severe eye condition often affecting preterm infants. • Previous data are limited in scope and generalizability.

WHAT IS NEW

• Based on a national database, our study found ROP incidence to be 17.04 per 10,000 new births, higher in males (17.71) than in females (16.34). • 7.2% of ROP cases required ocular treatment, inversely correlated with birth weight. • High rates of multimorbidity such as neonatal jaundice (84.69%), respiratory distress syndrome (80.84%), and apnea (78.88%) were observed.

N6-methyladenosine methylation in ophthalmic diseases: From mechanisms to potential applications

N6-methyladenosine (m6A) modification, as the most common modification method in eukaryotes, is widely involved in numerous physiological and pathological processes, such as embryonic development, malignancy, immune regulation, and premature aging. Under pathological conditions of ocular diseases, changes in m6A modification and its metabolism can be detected in aqueous and vitreous humor. At the same time, an increasing number of studies showed that m6A modification is involved in the normal development of eye structures and the occurrence and progress of many ophthalmic diseases, especially ocular neovascular diseases, such as diabetic retinopathy, age-related macular degeneration, and melanoma. In this review, we summarized the latest progress regarding m6A modification in ophthalmic diseases, changes in m6A modification-related enzymes in various pathological states and their upstream and downstream regulatory networks, provided new prospects for m6A modification in ophthalmic diseases and new ideas for clinical diagnosis and treatment.

CircRNA in ocular neovascular diseases: Fundamental mechanism and clinical potential

Ocular neovascular disease (OND), characterized by the aberrant formation of immature blood vessels, is the leading cause of vision impairment and blindness. It is important to find effective ways to diagnose and treat these diseases. Circular RNA (circRNA) is a group of endogenous non-coding RNA that play a crucial role in regulating different biological processes. Due to their close association with ocular disease and angiogenesis, circRNAs have become a hotspot in OND research. In this review, we intensively investigate the possibility of using circRNAs in the management of ONDs. In general, angiogenesis is divided into five phases. On the basis of these five steps, we describe the potential of using circRNAs by introducing how they regulate angiogenesis. Subsequently, the interactions between circRNAs and ONDs, including pterygium, corneal neovascularization, age-related macular degeneration, diabetic retinopathy, and retinopathy of prematurity, are analyzed in detail. We also introduce the potential use of circRNAs as OND diagnostic biomarkers. Finally, we summarize the prospects of using circRNAs as a potential strategy in OND management. The gaps in recent research are also pointed out with the purpose of promoting the introduction of circRNAs into clinical applications.

Insulin-like growth factor-1 and retinopathy of prematurity: A systemic review and meta-analysis

The prevalence of retinopathy of prematurity (ROP) is rapidly increasing worldwide. Many researchers have explored the relationship between insulin-like growth factor-1 (IGF-1) and ROP; however, the results are controversial. This meta-analysis evaluates the correlation between IGF-1 and ROP systematically. We searched for PubMed, Web of Science, Embase, the Cochrane Central Register of Controlled Trials, Ovid MEDLINE, SinoMed, ClinicalTrials.gov, and 3 Chinese databases up to June 2022. Then, the meta-regression and subgroup analysis were carried out. Twelve articles with 912 neonates were included in this meta-analysis. The results revealed that 4 of 7 covariates account for significant heterogeneity: location, measurement method of IGF-1 levels, collection time of blood sample, and the severity of ROP. The pooled analysis showed that low IGF-1 levels could serve as a risk factor associated with the development and severity of ROP. Serum IGF-1 monitoring in preterm infants after birth will be helpful in the diagnosis and treatment of ROP, and the reference value of IGF-1 should be standardized according to the measurement of IGF-1 and the region, as well as the postmenstrual age of prematurity.

Impact of COVID-19 pandemic on retinopathy of prematurity services in low resource settings

BACKGROUND AND OBJECTIVES

Retinopathy of prematurity is an increasingly important cause of blindness in children in low- and middle-income countries. Timely screening and treatment greatly reduce blindness. This study assessed the impact of the COVID-19 pandemic on ROP services in low- and middle-income countries.

METHODS

An online survey with closed and open-ended questions in Microsoft Teams was sent to 304 ophthalmologists providing screening, treatment and/or vitreoretinal services (January 15 to March 12 2021). Categories were used to report impact on services. 28 participants were purposively selected for interview.

RESULTS

184/201 completed forms from 32 countries were received. Two thirds of participants worked in government facilities and 45.6% were paediatric ophthalmologists. A moderate to severe impact was reported by 13% for screening, 9% for treatment and 16% for vitreoretinal surgery with some variation between government, private and not-for-profit sectors. 22% thought services would take a year to recover. Fifteen ophthalmologists from 12 countries were interviewed. Many reported fewer neonatal admissions, and several reported more ROP blind infants once restrictions lifted. Themes associated with services continuing included limited lockdown, autonomy and flexibility, commitment, advocacy and technology. Themes associated with a negative impact include fear and panic, closure of facilities, COVID infection or quarantining of health workers and parents, lack of transport and exacerbation of poverty.

CONCLUSIONS

The COVID pandemic had a very variable impact on the provision of ROP services. In some countries where the impact was great, more infants may have become blind from ROP. Lessons can be learnt for planning pandemic preparedness.

Potential application of foveal structural measurements in treatment decision for retinopathy of prematurity: an OCT-based study

PURPOSE

To investigate foveal changes in infants with ROP not requiring treatment(nROP) and ROP infants needing treatment (tROP) using a handheld SD-OCT device.

METHOD

We performed horizontal SD-OCT scans through the fovea in 156 eyes of 81 infants diagnosed with ROP. Foveal immaturity indices including the presence of inner retinal layers (IRL), absence of foveal outer nuclear layers widening (ONL) and attenuation of hyperreflective outer segment layers (OS), presence and type of cystoid macular edema (CME), epiretinal membrane (ERM), foveal pit depth (FPD), foveal pit width (FPW) and central foveal thickness (CFT) were calculated. The multivariate logistic regression model was used to predict the need for treatment based on OCT measurements.

RESULTS

The shape of the foveolar pit was not significantly different among tROP and nROP groups (P-value = 0.287, Chi-square test). IRL extrusion was incomplete in both tROP and nROP groups (P-value = 0.0.41, Chi-square test). Nevertheless, the presence of thicker IRL was more frequent in the nROP group in comparison with the tROP group (100% vs.64.8%, P-value = 0.001). CME was observed in 29% of eyes in the tROP group and 40% of eyes in the nROP group; however, this difference was not statistically significant (P-value = 0.32, Chi-square test). ERM was detected in 15 (75%) and 84 (65.6%) eyes in the nROP and tROP groups, respectively (P-value = 0.39, Chi-square test). Multivariate logistic regression analyses showed that the need for treatment was significantly associated with gestational age (GA), CFT and FPD (P-values 0.001 and 0.002 respectively).

CONCLUSIONS

This study demonstrated GA, foveal pit depth and the central foveal thickness could accurately predict the need for treatment with sensitivity, specificity, and diagnostic accuracy of 97%, 65% and 91.7% respectively.

Comprehensive Analysis of the Role of Gene Variants in Matrix Metalloproteinases and Their Tissue Inhibitors in Retinopathy of Prematurity: A Study in the Polish Population

This study was designed to investigate the relationship between variants of matrix metalloproteinases (MMP-1 rs179975, MMP-9 rs17576 and rs17577), their tissue inhibitors (TIMP-1 rs4898, TIMP-2 rs2277698 and rs55743137) and the development of retinopathy of prematurity (ROP) in infants from the Polish population. A cohort of 100 premature infants (47% female) was enrolled, including 50 ROP cases and 50 no-ROP controls. Patients with ROP were divided into those with spontaneous remission and those requiring treatment. A positive association between MMP-1 rs179975 1G deletion allele and ROP was observed in the log-additive model (OR = 5.01; p = 0.048). Furthermore, female neonates were observed to have a negative association between the TIMP-1 rs4898C allele and the occurrence of ROP and ROP requiring treatment (codominant models with respective p-values < 0.05 and 0.043). Two and three loci interactions between MMP-1 rs1799750 and TIMP1rs4989 (p = 0.015), as well as MMP-1 rs1799750, MMP-9 rs17576 and TIMP-1 rs4989 (p = 0.0003) variants influencing the ROP risk were also observed. In conclusion, these findings suggest a potential role of MMPs and TIMPs genetic variations in the development of ROP in the Polish population. Further studies using a larger group of premature infants will be required for validation.

Effect of autologous umbilical cord blood transfusion in the development of retinopathy of prematurity: randomized clinical trial - study protocol

Background

Currently, the treatment of anemia in preterm infants is based on packed red blood cell (RBC) transfusions from adult donors. Oxygen (O2) is mainly transported to the tissues bound to hemoglobin (Hb). In extremely low gestational age neonates (ELGANs), fetal hemoglobin (HbF), which has a higher affinity for O2, represents up to 95% of circulating hemoglobin. During the first month of life, the majority of ELGANs will require an adult-donor RBC transfusion causing HbF levels to rapidly drop. HbA releases 50% more oxygen in peripheral tissues than HbF. Increased release of O2 in the retina is one of the main factors related to the development of retinopathy of prematurity (ROP). Collecting umbilical cord blood and using autologous umbilical cord whole blood (UCB) transfusions would contribute to maintaining physiological HbF concentrations in newborns and avoid oxygen-in-excess derived damage.

Methods

This is a randomized, double-blinded, multicenter clinical trial. ELGANs ≤28 weeks of gestational age will be randomized 1:1 to receive an autologous umbilical cord blood transfusion (intervention arm) or standard transfusion of packed RBC from an adult donor (control arm) to assess ROP development. Assuming a 50% reduction in ROP incidence, 134 patients (67 per group) will be recruited. When blood transfusion is indicated, the Blook Bank will supply UCB or RCB according to the patient's group. The primary endpoint is the incidence of any ROP. Secondary endpoints are assessessment of treatment safety, results of biomarkers related to ROP and its chronology, and urine oxidative stress markers. In addition, the cellular composition of umbilical cord blood and its relationship with prematurity-related pathologies will be analyzed. All patients will be followed-up to 24 months of corrected age to evaluate their neurodevelopment.

Discussion

ROP is a major cause of irreversible blindness in preterm newborns. Transfusions with adult donor blood can lead to complications, including ROP. UCB transfusions offer advantages by maintaining physiological HbF levels and potentially optimizing postnatal development. Moreover, autologous UCB transfusion could reduce risks associated with heterologous blood products, although volume collection remains challenging. UCB contains growth factors and progenitor cells that may impact ROP.

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.

Is There a Relationship Between First-Trimester Aneuploidy Screening Serum Biomarker Values and Nuchal Translucency Measurements and the Development of Retinopathy of Prematurity (ROP) in Premature Infants?

Purpose The purpose of this study is the evaluation of serum biomarker and nuchal translucency (NT) values measured during first-trimester aneuploidy screening in terms of the development of retinopathy of prematurity (ROP) in premature infants and investigation of whether the development of ROP is associated with these parameters. Methods In this retrospective cohort study, 3,750 premature infants who underwent ROP screening from 2016 to 2021 were identified from the hospital medical record system. Among 2,130 premature babies screened for first-trimester aneuploidy, 166 babies whose mothers had single pregnancies were screened by the same method and showed the same clinical course in both eyes were included in the study. The infants were divided into two groups according to the presence of ROP, and those with ROP were further evaluated in two groups according to the presence of proliferation. The groups were compared in terms of the serum values of human chorionic gonadotropin and pregnancy-associated plasma protein A, among aneuploidy screening biomarkers, and NT measurements. Results There was no significant difference in the evaluated serum biomarker values and NT measurements between the ROP and non-ROP groups or between the proliferative ROP, non-proliferative ROP, and non-ROP groups. Conclusion Our results showed that first-trimester aneuploidy screening serum biomarker values and NT measurements were not associated with the development of ROP in premature infants.

Retinopathy of prematurity: from oxygen management to molecular manipulation

INTRODUCTION

Retinopathy of prematurity (ROP) is a vasoproliferative disorder of the premature retina with the potential to progress to extraretinal neovascularisation. This review serves as an introduction to retinopathy of prematurity (ROP), outlining key parts of ROP pathophysiology, diagnosis and treatment. ROP is traditionally diagnosed by indirect ophthalmoscopy and classified using anatomical zones, stages of disease, and the presence or absence of "plus disease" (dilation and tortuosity of the major retinal arterioles and venules). ROP has a bi-phasic pathophysiology: initial hyperoxia causes reduced retinal vascularisation, followed by pathological vaso-proliferation resulting from subsequent hypoxia and driven by vascular endothelial growth factor (VEGF).

ADVANCEMENTS IN MANAGEMENT

This review summarises previous trials to establish optimum oxygen exposure levels in newborns and more recently the development of anti-VEGF agents locally delivered to block pathological neovascularisation, which is technically easier to administer and less destructive than laser treatment.

FUTURE DIRECTIONS

There remains an ongoing concern regarding the potential unwanted systemic effects of intravitreally administered anti-VEGF on the overall development of the premature baby. Ongoing dosing studies may lessen these fears by identifying the minimally effective dose required to block extraretinal neovascularisation.

Increased risk of retinopathy of prematurity since increased O2 saturation targets: A multi-centre study

BACKGROUND/AIMS

Retinopathy of prematurity (ROP) is a leading cause of visual impairment in premature neonates. The BOOST II, SUPPORT and COT trials recommended increasing O2 saturation targets for pre-term neonates to reduce mortality; however, this is a risk factor for ROP. We aimed to determine whether these targets increased prevalence of ROP among pre-term neonates and higher risk groups.

METHODS

Retrospective cohort study conducted using data from the Australian and New Zealand Neonatal Network. 17 298 neonate cohort born 2012-2018 at <32 weeks' GA and/or <1500 g BW was analysed. Adjusted odds ratios (aORs) were calculated for post-2015 risk of: any ROP; ROP ≥ Stage 2; and treated ROP. Sub-analysis stratified at <28 GA, < 26 weeks' GA, <1500 g BW and <1000 g BW was performed.

RESULTS

Risk of any ROP increased in the post-2015 group (aOR = 1.23, 95% confidence interval (CI) = 1.14-1.32), <28 weeks' GA (aOR = 1.31, 95% CI = 1.17-1.46), <26 weeks (aOR = 1.57, 95% CI = 1.28-1.91), <1500 g (aOR = 1.24, 95% CI = 1.14-1.34) and <1000 g (aOR = 1.34, 95% CI = 1.20-1.50). ROP ≥ Stage 2 increased at <28 weeks (aOR = 1.30, 95% CI = 1.16-1.46), <26 weeks (aOR = 1.57, 95% CI = 1.28-1.91), <1500 g (aOR = 1.18, 95% CI = 1.08-1.30), and <1000 g (aOR = 1.26, 95% CI = 1.13-1.42).

CONCLUSION

O2 therapy guidelines since 2015 have resulted in decreased mortality but increased risk of ROP. Individualised NICU adjustments of ROP screening/follow-up methods are necessary to address the clinical burden.

SYVN1 Promotes STAT3 Protein Ubiquitination and Exerts Antiangiogenesis Effects in Retinopathy of Prematurity Development

PURPOSE

SYVN1, a gene involved in endoplasmic reticulum-associated degradation, has been found to exert a protective effect by inhibiting inflammation in retinopathy. This study aimed to clarify whether SYVN1 is involved in the pathogenesis of retinopathy of prematurity (ROP) and its potential as a candidate for target therapy.

METHODS

Human retinal microvascular endothelial cells (hRMECs) and a mouse model of oxygen-induced retinopathy (OIR) were used to reveal the retinopathy development-associated protein expression and molecular mechanism. An adenovirus overexpressing SYVN1 or vehicle control was injected intravitreally at postnatal day 12 (P12), and the neovascular lesions were evaluated in retinal flatmounts with immunofluorescence staining, and hematoxylin and eosin staining at P17. Visual function was assessed by using electroretinogram (ERG).

RESULTS

Endogenous SYVN1 expression dramatically decreased in hRMECs under hypoxia and in ROP mouse retinas. SYVN1 regulated the signal transducer and activator of transcription 3 (STAT3)/vascular endothelial growth factor (VEGF) axis. SYVN1 overexpression promoted ubiquitination and degradation of STAT3, decreased the levels of phospho-STAT3, secretion of VEGF, and formation of neovascularization in hRMECs, which could be rescued by STAT3 activator treatment. In addition, SYVN1 overexpression prevented neovascularization and extended physiologic retinal vascular development in the retinal tissues of OIR mice without affecting retinal function.

CONCLUSIONS

SYVN1 has a protective effect against OIR, and the molecular mechanisms are partly through SYVN1-mediated ubiquitination of STAT3 and the subsequent downregulation of VEGF. These findings strongly support our assumption that SYVN1 confers ROP resistance and may be a potentially novel pharmaceutical target against proliferative retinopathy.

Tear-based MMP-9 detection: A rapid antigen test for ocular inflammatory disorders using vanadium disulfide nanowires assisted chemi-resistive biosensor

A sensitive, non-invasive, and biomarker detection in tear fluids for inflammation in potentially blinding eye diseases could be of great significance as a rapid diagnostic tool for quick clinical decisions. In this work, we propose a tear-based MMP-9 antigen testing platform using hydrothermally synthesized vanadium disulfide nanowires. Also, various factors contributing to baseline drifts of the chemiresistive sensor including nanowire coverage on the interdigitated microelectrode of the sensor, sensor response duration, and effect of MMP-9 protein in different matrix solutions were identified. The drifts on the sensor baseline due to nanowire coverage on the sensor were corrected using substrate thermal treatment providing a more uniform distribution of nanowires on the electrode which brought the baseline drift to 18% (coefficient of variations, CV = 18%). This biosensor exhibited sub-femto level limits of detection (LODs) of 0.1344 fg/mL (0.4933 fmoL/l) and 0.2746 fg/mL (1.008 fmoL/l) in 10 mM phosphate buffer saline (PBS) and artificial tear solution, respectively. For a practical tear MMP-9 detection, the proposed biosensor response was validated with multiplex ELISA using tear samples from five healthy controls which showed excellent precision. This label-free and non-invasive platform can serve as an efficient diagnostic tool for the early detection and monitoring of various ocular inflammatory diseases.

Tetrahedral framework nucleic acids inhibit pathological neovascularization and vaso-obliteration in ischaemic retinopathy via PI3K/AKT/mTOR signalling pathway

This study aimed to explore the effect and the molecular mechanism of tetrahedral framework nucleic acids (tFNAs), a novel self-assembled nanomaterial with excellent biocompatibility and superior endocytosis ability, in inhibition of pathological retinal neovascularization (RNV) and more importantly, in amelioration of vaso-obliteration (VO) in ischaemic retinopathy. tFNAs were synthesized from four single-stranded DNAs (ssDNAs). Cell proliferation, wound healing and tube formation assays were performed to explore cellular angiogenic functions in vitro. The effects of tFNAs on reducing angiogenesis and inhibiting VO were explored by oxygen-induced retinopathy (OIR) model in vivo. In vitro, tFNAs were capable to enter endothelial cells (ECs), inhibit cell proliferation, tube formation and migration under hypoxic conditions. In vivo, tFNAs successfully reduce RNV and inhibit VO in OIR model via the PI3K/AKT/mTOR/S6K pathway, while vascular endothelial growth factor fusion protein, Aflibercept, could reduce RNV but not inhibit VO. This study provides a theoretical basis for the further understanding of RNV and suggests that tFNAs might be a novel promising candidate for the treatment of blind-causing RNV.

Associations of VEGF Polymorphisms With Retinopathy of Prematurity

Purpose

This study investigated the associations between vascular endothelial growth factor (VEGF) polymorphisms and retinopathy of prematurity (ROP) risk.

Methods

Infants born prematurely at any time from 2009 to 2018 were included. Five single-nucleotide polymorphisms (SNPs) of VEGF were analyzed using real-time PCR in all infants. Multivariate logistic regression was applied to model the associations between VEGF polymorphisms and ROP susceptibility, severity, and premature clinicopathologic characteristics.

Results

A total of 334 patients were included and categorized into three groups: those without ROP, those with mild ROP (i.e., ROP not requiring treatment), and those with severe ROP (i.e., ROP for whom treatment was indicated). Among the female patients with ROP, those with VEGF rs3025035 CT (3.231-fold; 95% confidence interval [CI], 1.238-8.431) and a combination of CT and TT genotypes (2.643-fold; 95% CI, 1.056-6.619) exhibited significantly higher risks of severe ROP compared with those with wild-type genotypes. Female ROP infants with VEGF rs3025010 C (TC + CC) alleles had a lower risk of ROP stage ≥3 (odds ratio [OR] = 0.406; 95% CI, 0.165-0.999) than those with TT homozygotes. ROP patients with the VEGF rs10434 A allele (GA + AA) exhibited higher risks of necrotizing enterocolitis (OR = 2.750; 95% CI, 1.119-6.759) and lower risk of bronchopulmonary dysplasia (OR = 0.390; 95% CI, 0.173-0.877) than those with GG homozygotes did.

Conclusions

VEGF polymorphisms affect ROP risks differently in male and female infants. In female infants, VEGF rs3025035 with T alleles may predict ROP severity, and VEGF rs3025010 with C alleles may protect against severe ROP.

YY1 lactylation in microglia promotes angiogenesis through transcription activation-mediated upregulation of FGF2

BACKGROUND

Ocular neovascularization is a leading cause of blindness. Retinal microglia have been implicated in hypoxia-induced angiogenesis and vasculopathy, but the underlying mechanisms are not entirely clear. Lactylation is a novel lactate-derived posttranslational modification that plays key roles in multiple cellular processes. Since hypoxia in ischemic retinopathy is a precipitating factor for retinal neovascularization, lactylation is very likely to be involved in this process. The present study aimed to explore the role of lactylation in retinal neovascularization and identify new therapeutic targets for retinal neovascular diseases.

RESULTS

Microglial depletion by the colony-stimulating factor 1 receptor (CSF1R) inhibitor PLX3397 suppresses retinal neovascularization in oxygen-induced retinopathy. Hypoxia increased lactylation in microglia and accelerates FGF2 expression, promoting retinal neovascularization. We identify 77 sites of 67 proteins with increased lactylation in the context of increased lactate under hypoxia. Our results show that the nonhistone protein Yin Yang-1 (YY1), a transcription factor, is lactylated at lysine 183 (K183), which is regulated by p300. Hyperlactylated YY1 directly enhances FGF2 transcription and promotes angiogenesis. YY1 mutation at K183 eliminates these effects. Overexpression of p300 increases YY1 lactylation and enhances angiogenesis in vitro and administration of the p300 inhibitor A485 greatly suppresses vascularization in vivo and in vitro.

CONCLUSIONS

Our results suggest that YY1 lactylation in microglia plays an important role in retinal neovascularization by upregulating FGF2 expression. Targeting the lactate/p300/YY1 lactylation/FGF2 axis may provide new therapeutic targets for proliferative retinopathies.

Triciribine attenuates pathological neovascularization and vascular permeability in a mouse model of proliferative retinopathy

Proliferative retinopathies are the leading cause of irreversible blindness in all ages, and there is a critical need to identify novel therapies. We investigated the impact of triciribine (TCBN), a tricyclic nucleoside analog and a weak Akt inhibitor, on retinal neurovascular injury, vascular permeability, and inflammation in oxygen-induced retinopathy (OIR). Post-natal day 7 (P7) mouse pups were subjected to OIR, and treated (i.p.) with TCBN or vehicle from P14-P16 and compared with age-matched, normoxic, vehicle or TCBN-treated controls. P17 retinas were processed for flat mounts, immunostaining, Western blotting, and qRT-PCR studies. Fluorescein angiography, electroretinography, and spectral domain optical coherence tomography were performed on days P21, P26, and P30, respectively. TCBN treatment significantly reduced pathological neovascularization, vaso-obliteration, and inflammation marked by reduced TNFα, IL6, MCP-1, Iba1, and F4/80 (macrophage/microglia markers) expression compared to the vehicle-treated OIR mouse retinas. Pathological expression of VEGF (vascular endothelial growth factor), and claudin-5 compromised the blood-retinal barrier integrity in the OIR retinas correlating with increased vascular permeability and neovascular tuft formation, which were blunted by TCBN treatment. Of note, there were no changes in the retinal architecture or retinal cell function in response to TCBN in the normoxia or OIR mice. We conclude that TCBN protects against pathological neovascularization, restores blood-retinal barrier homeostasis, and reduces retinal inflammation without adversely affecting the retinal structure and neuronal function in a mouse model of OIR. Our data suggest that TCBN may provide a novel therapeutic option for proliferative retinopathy.

Potential role of eNOS and EDN-1 gene polymorphisms in the development and progression of retinopathy of prematurity

The aim of this study was to investigate the association between selected polymorphisms of nitric oxide synthetase (eNOS) and endothelin-1 (EDN-1) with the occurrence and progression of retinopathy of prematurity (ROP). A prospective study was conducted on 90 preterm infants (44 female), comparing 39 cases with ROP and 51 controls without ROP. Patients who developed ROP were further divided into two subgroups-those with spontaneous regression of the disease and those with ROP requiring treatment. We found that preterm infants with TT genotype eNOS 894G > T had a 12.8-fold higher risk of developing ROP requiring treatment (p = 0.02). Our results showed that allele T of eNOS894G > T polymorphism was significantly more prevalent in ROP patients requiring treatment (p = 0.029). We also investigated preterm infants with TC genotype eNOS - 786 T > C and found an 8.8-fold higher risk developing of ROP requiring treatment (p = 0.021). Our results didn't show any association between EDN-1 5665G > T polymorphism and ROP development. The eNOS polymorphisms appears to influence incidence of ROP requiring treatment in preterm infants. Future research on single nucleotide polymorphisms may provide important information about the pathogenetic mechanisms underlying the development of ROP.

Role of Anti-Vascular Endothelial Growth Factor (Anti-VEGF) in the Treatment of Retinopathy of Prematurity: A Narrative Review in the Context of Middle-Income Countries

The rise in preterm births and higher survival rates of premature infants have led to a global increase in retinopathy of prematurity (ROP), a vasoproliferative retinal disorder common in premature infants. ROP is one of the leading causes of childhood blindness. Clinical manifestation of ROP ranges from mild abnormal retinal neovascularization to bilateral retinal detachment and vision loss. The incidence of ROP is higher in middle income countries, including India, which has the highest number of global preterm births. Low birth weight and low gestational age are the primary risk factors for ROP; however, anemia, cardiac defects, blood transfusion, apnea, sepsis, respiratory distress syndrome, high exposure to oxygen and poor postnatal weight gain may also contribute to its development. India has stringent ROP screening guidelines revised in 2018, and screening of infants with either birth weight <2000 grams or gestational age <34 weeks is mandated. With an improved understanding of the pathogenesis of ROP in the past decades and advances in clinical research, treatment for ROP has evolved from cryotherapy to laser retinal ablation. Most recently, anti-vascular endothelial growth factor (anti-VEGF) drugs have emerged as a favorable treatment option for zone-I and II ROP. This article reviews the current approaches for ROP treatment in India with a particular focus on anti-VEGF drugs. The article also integrates the understanding of safety and risk-benefit evaluation of the current approaches in ROP management. The review concluded that there is a need to increase the ROP screening not only for preterm and low birth weight but also for optimal gestational age infants with healthy birth weight. Anti-VEGF therapies have shown improved efficacy, although studies are required to establish the long-term safety.

Systemic Cytokines in Retinopathy of Prematurity

Retinopathy of prematurity (ROP), a vasoproliferative vitreoretinal disorder, is the leading cause of childhood blindness worldwide. Although angiogenic pathways have been the main focus, cytokine-mediated inflammation is also involved in ROP etiology. Herein, we illustrate the characteristics and actions of all cytokines involved in ROP pathogenesis. The two-phase (vaso-obliteration followed by vasoproliferation) theory outlines the evaluation of cytokines in a time-dependent manner. Levels of cytokines may even differ between the blood and the vitreous. Data from animal models of oxygen-induced retinopathy are also valuable. Although conventional cryotherapy and laser photocoagulation are well established and anti-vascular endothelial growth factor agents are available, less destructive novel therapeutics that can precisely target the signaling pathways are required. Linking the cytokines involved in ROP to other maternal and neonatal diseases and conditions provides insights into the management of ROP. Suppressing disordered retinal angiogenesis via the modulation of hypoxia-inducible factor, supplementation of insulin-like growth factor (IGF)-1/IGF-binding protein 3 complex, erythropoietin, and its derivatives, polyunsaturated fatty acids, and inhibition of secretogranin III have attracted the attention of researchers. Recently, gut microbiota modulation, non-coding RNAs, and gene therapies have shown promise in regulating ROP. These emerging therapeutics can be used to treat preterm infants with ROP.

Persistent Vascular Anomalies in Retinopathy of Prematurity Children: Ultra-Widefield Fluorescein Angiography Findings until School Age

Purpose

To investigate vascular abnormalities, including persistent avascular retina (PAR), in a large cohort of patients with regressed or treated retinopathy of prematurity (ROP) through long-term follow-up until school age.

Design

Retrospective large cohort study.

Participants

We included pediatric patients (< 18 years old) with a history of nontreated or treated ROP (treated with either photocoagulation or intravitreal injection [IVI]) and regularly followed up until 2020.

Methods

Upon enrollment, we categorized patients into 4 groups: prematurity, regressed ROP, and IVI and laser treatment ROP groups. All patients had undergone visual acuity examinations, OCT, and ultrawide-field fluorescein angiography.

Main Outcome Measures

Percentage of eyes with PAR (greater than or equal to the area of 2 disc diameters from the ora serrata to vascular termini) and with vascular abnormalities in the peripheral and posterior retina.

Results

In total, we included 187 eyes of 95 patients. The prevalence of PAR was 0%, 33.33%, and 31.65% in eyes in the prematurity, regressed ROP, and IVI treatment groups, respectively (P < 0.0001). There was no significant difference in the percentage of PAR eyes when comparing regressed ROP group (33.33%) with the IVI treatment group (31.65%). At least 1 type of vascular abnormality was noted until school age in all (100%) treated ROP eyes. Although multivariate analysis found a significant association between IVI treatment and PAR (odds ratio: 10.28, 95% confidence interval: 3.29-32.14) until the school age of 6 to 8 years old, there were no stage 3 eyes in the spontaneously regressed group, suggesting that stage 3 ROP in the IVI group could also drive the association.

Conclusions

Approximately one-third of ROP eyes with spontaneous regression or IVI treatment still exhibit PAR when the child reaches school age. Several distinct vascular anomalies at the vascular-avascular juncture and within the vascularized retina can persist in these children. The clinical significance of these anomalies and the decision whether to treat them warrant further investigation to optimize their outcomes.

Financial Disclosures

The authors have no proprietary or commercial interest in any materials discussed in this article.

Late Vitreoretinal Complications of Regressed Retinopathy of Prematurity: Retinal Break, Vitreous Hemorrhage, and Retinal Detachment

PURPOSE

To investigate late vitreoretinal complications and visual outcomes in patients with regressed retinopathy of prematurity (ROP) with or without prior treatment.

DESIGN

International, multicenter, noncomparative retrospective case series.

PARTICIPANTS

We analyzed 264 eyes of 238 patients from 13 centers worldwide who developed vitreoretinal complications (retinal detachment [RD], vitreous hemorrhage [VH], or retinal break) ≥ 2 years after resolution of acute ROP.

METHODS

Each participant was assigned to 1 of 3 groups (the RD, VH, and retinal break groups) according to their primary diagnosis. The average age at presentation, visual acuities, refractive error, axial length, gestational age, birth weight, acute ROP classification, prior treatments for acute ROP, postoperative visual acuity (VA), and concomitant eye conditions in the 3 groups were documented and compared.

MAIN OUTCOME MEASURES

Clinical features and visual outcomes of late vitreoretinal complications in patients with regressed ROP.

RESULTS

A total of 264 eyes of 238 patients were included. The prior acute ROP status was comparable among the 3 groups, except that the VH group had a higher proportion of patients with type 1 ROP (P = 0.03) and prior treatment (P < 0.001) than the other groups. The average age at presentation was earlier in the RD (20.3 ± 15.5 years) and VH (21.4 ± 18.9 years) groups than in the retinal break group (31.9 ± 18.2 years; P < 0.001). The retinal break group had the best presenting best-corrected VA, followed by the RD and VH groups (P < 0.001). Surgical intervention improved VA in both the RD and VH groups (both P < 0.05). The overall trend of VA was the most favorable in the retinal break group, followed by that in the VH and RD groups. Cicatricial changes in the fellow retina were observed in > 90% of patients with unilateral involvement.

CONCLUSIONS

Infants with acute ROP remain at a high risk of vision-threatening complications throughout childhood and adulthood. Continual follow-up of patients with ROP is important. When severe complications, such as RD or VH, are detected, timely surgical intervention is necessary to ensure favorable visual outcomes in these patients.

Disruption of CD73-Derived and Equilibrative Nucleoside Transporter 1-Mediated Adenosine Signaling Exacerbates Oxygen-Induced Retinopathy

Retinopathy of prematurity (ROP) is characterized by pathologic angiogenesis in retina, and remains a leading cause of blindness in children. Although enhanced extracellular adenosine is markedly increased in response to retinal hypoxia, adenosine acting at the A1 and A2A receptors has the opposite effect on pathologic angiogenesis. Herein, the oxygen-induced retinopathy (OIR) model of ROP was used to demonstrate that pharmacologic and genetic inactivation of CD73 (the key 5'-ectonucleotidase for extracellular generation of adenosine) did not affect normal retinal vasculature development but exacerbated intravitreal neovascularization at postnatal day (P) 17 and delayed revascularization at P21 of OIR. This exacerbated damage to retinal vessels by CD73 inactivation was associated with increased cellular apoptosis and microglial activation but decreased astrocyte function at P17 of OIR. Furthermore, pharmacologic blockade of equilibrative nucleoside transporter 1/2 (ENT1/2; bidirectional transport for controlling the balance of intracellular and extracellular adenosine) by 6-nitrobenzylthioinosine aggravated pathologic angiogenesis at P17 of OIR. Pharmacologic blockade of ENT1/2 and genetic inactivation of CD73 also aggravated avascular areas at the hyperoxia phase (P12) of OIR. Thus, disruption of CD73-derived extracellular adenosine or ENT1/2-mediated transport of adenosine flux across membrane aggravated the damage to retinal vessels. These findings support the role of adenosine as an endogenous protective regulator that limits oxygen-induced retinopathy. Thus, enhancing extracellular adenosine signaling represents a novel neuroprotection strategy for ROP by targeting CD73 and ENT1/2 activities.

Development of myopia in laser-treated ROP infants: prematurity or laser photocoagulation?

PURPOSE

To investigate the relationship between the development of corrected 1-year-old refraction values and risk factors in preterm infants who underwent laser photocoagulation (LPC) therapy for retinopathy of prematurity (ROP).

METHODS

The ophthalmic examination findings of preterm neonates who had developed Type I ROP and received LPC therapy were evaluated retrospectively. The association between spherical equivalent (SE) values and clinical findings were analyzed by using multivariable linear regression analysis.

RESULTS

The study included 157 eyes of 80 neonates with a mean birth week of 27.1 ± 2.2 weeks (23 to 32 weeks) and a mean birth weight of 995 ± 273 g (565 to 1760 g). The treatments were administered on an average of 36.8 ± 2.7 (32 to 45 weeks) postmenstrual age. LPC treatment was applied bilaterally to 77 of the 80 neonates included in the study, and unilaterally to 3 of them. The mean ± standard deviation of the SE value was 0.31 ± 1.89 diopters (D) (- 8.00 to 4.63 D) according to the results of the 1-year corrected age refraction examination. In univariate analysis, no significant association between GA, BW, and ROP zone and SE value, while the number of laser spots (ß =  - 0.27 ± 0.00 D, p = 0.00) and stage 3 ROP (ß =  - 0.29 ± 0.37 D, p = 0.00) were significantly associated with the SE value. In multivariable linear regression analysis, a significant association between number of laser spot, stage 3 ROP and SE value (ß =  - 0.25 ± 0.00 D, p = 0.01 for number of laser spot, ß =  - 0.28 ± 0.36 D, p = 0.00 for stage 3 ROP).

CONCLUSION

In conclusion, this study supports that stage of ROP and the number of laser spots count applied in photocoagulation treatment for ROP is significantly correlated with degree of myopia (p < 0.05).

Incidence and risk factors for retinopathy of prematurity in premature, extremely low birth weight and extremely low gestational age infants

BACKGROUND

The aim of the study was to determine the incidence and risk factors of retinopathy of prematurity (ROP) in premature, extremely low birth weight (BW, ELBW) and extremely low gestational age (GA, ELGA) infants.

METHODS

The medical records of preterm infants who were screened for ROP between January 2012 and December 2020 were retrospectively reviewed. Only one eye of each infant with higher grade ROP was included in the study. BW; GA; medical characteristics; the presence, severity, and need for treatment of ROP were recorded. Infants were divided into groups according to BW (≤1000 g, 1001-1750 g, > 1750 g) and GA (≤25w, 26-28w, 29-31w, 32-34w, ≥35w) and data were analyzed.

RESULTS

Data of 2186 infants were evaluated. The overall incidences of any stage ROP and ROP requiring treatment were 43.5 and 8.0%, respectively. These rates were 81.1 and 23.9% in ELBW (≤1000 g) infants and were 92.9 and 64.3% in ELGA (≤25w) infants, respectively. The rates of ROP, the median duration of oxygen therapy and systemic diseases increased significantly as BW and GA decreased. The median duration of oxygen therapy and the rates of sepsis, pulmonary dysplasia (BPD), and intraventricular hemorrhage (IVH) were statistically higher in infants with ROP compared to those without ROP (p < 0.001). Multivariate regression analysis demonstrated that low BW and GA; prolonged duration of oxygen therapy; presence of PDA and necrotizing enterocolitis (NEC) were important risk factors for ROP.

CONCLUSIONS

ELBW and ELGA infants develop higher rates of ROP and severe ROP. Prolonged duration of oxygen therapy, the presence of concomitant neonatal sepsis, BPD, IVH, PDA, and NEC further increases the risk of ROP.

CD146 as a promising therapeutic target for retinal and choroidal neovascularization diseases

Blood vessel dysfunction causes several retinal diseases, including diabetic retinopathy, familial exudative vitreoretinopathy, macular degeneration and choroidal neovascularization in pathological myopia. Vascular endothelial growth factor (VEGF)-neutralizing proteins provide benefits in most of those diseases, yet unsolved haemorrhage and frequent intraocular injections still bothered patients. Here, we identified endothelial CD146 as a new target for retinal diseases. CD146 expression was activated in two ocular pathological angiogenesis models, a laser-induced choroid neovascularization model and an oxygen-induced retinopathy model. The absence of CD146 impaired hypoxia-induced cell migration and angiogenesis both in cell lines and animal model. Preventive or therapeutic treatment with anti-CD146 antibody AA98 significantly inhibited hypoxia-induced aberrant retinal angiogenesis in two retinal disease models. Mechanistically, under hypoxia condition, CD146 was involved in the activation of NFκB, Erk and Akt signalling pathways, which are partially independent of VEGF. Consistently, anti-CD146 therapy combined with anti-VEGF therapy showed enhanced impairment effect of hypoxia-induced angiogenesis in vitro and in vivo. Given the critical role of abnormal angiogenesis in retinal and choroidal diseases, our results provide novel insights into combinatorial therapy for neovascular fundus diseases.

A Novel Hypoxia-inducible Factor 1α Inhibitor KC7F2 Attenuates Oxygen-induced Retinal Neovascularization

Purpose

KC7F2 is a novel molecule compound that can inhibit the translation of hypoxia-inducible factor 1α (HIF1α). It has been reported to exhibit potential antiangiogenic effect. We hypothesized that KC7F2 could inhibit oxygen-induced retinal neovascularization (RNV). The purpose of this study was to investigate this assumption.

Methods

Oxygen-induced retinopathy (OIR) models in C57BL/6J mice and Sprague-Dawley rats were used for in vivo study. After intraperitoneal injections of KC7F2, RNV was detected by immunofluorescence and hematoxylin and eosin staining. Retinal inflammation was explored by immunofluorescence. EdU incorporation assay, cell counting kit-8 assay, scratch test, transwell assay, and Matrigel assay were used to evaluate the effect of KC7F2 on the proliferation, migration and tube formation of human umbilical vein endothelial cells (HUVEC) induced by vascular endothelial growth factor (VEGF) in vitro. Protein expression was examined by Western blot.

Results

KC7F2 treatment (10 mg/kg/d) in OIR mice significantly attenuated pathological neovascularization and decreased the number of preretinal neovascular cell nuclei, without changing the avascular area, which showed the same trends in OIR rats. Consistently, after the KC7F2 intervention (10 µM), cell proliferation was inhibited in VEGF-induced HUVEC, which was in agreement with the trend observed in the retinas of OIR mice. Meanwhile, KC7F2 suppressed VEGF-induced HUVEC migration and tube formation, and decreased the density of leukocytes and microglia colocalizing neovascular areas in the retinas. Moreover, the HIF1α–VEGF pathway activated in retinas of OIR mice and hypoxia-induced HUVEC, was suppressed by KC7F2 treatment.

Conclusions

The current study revealed that KC7F2 was able to inhibit RNV effectively via HIF1α–VEGF pathway, suggesting that it might be an effective drug for RNV treatment.

Evaluation of the prematurity retinopathy and other eye changes in the newborn

Objective

To assess the prevalence of ophthalmologic manifestations in newborns in a maternity hospital in the city of São Paulo, SP, and the main risk factors related with the development of retinopathy of prematurity.

Methods

A retrospective, longitudinal study with patients born from 2015 to 2017 who required ophthalmological evaluation. The research variables were obtained by analysis of the newborn medical charts.

Results

A total of 773 patients were studied. The sample consisted of 288 examinations performed by indication of gestational age ≤32 weeks: 118 (42.4%) in 2015, 105 (42.2%) in 2016, 65 (26.4%) cases in 2017. There were 329 evaluations indicated due to birth weight: 113 (40.6%) in 2015, 108 (43.4%) in 2016, and 108 (43.9%) in 2017. The prevalence of associated risk factors was 97 (34.9%) cases in 2015, 96 (38.6%) in 2016, and 54 (22%) in 2017, followed by mechanical ventilation with 82 (29.5%) cases in 2015, 64 (25.7%) in 2016 and 41 (16.7%) in 2017, and continuous positive airway pressure with 59 (21.2%) cases in 2015, 72 (28.9%) in 2016, and 46 (18.7%) in 2017. For the other indications, the evaluations performed due to congenital syphilis were the majority in the 3-year period of the study, with 55 (19.8%) newborns in 2015, 54 (21.7%) in 2016, and 59 (24.0%) in 2017. The most prevalent ophthalmologic diagnosis was retinopathy of prematurity, with 79 (35.3%) cases in 2015, 64 (32.2%) in 2016, and 41 (24.1%) in 2017.

Conclusion

Most neonates born in the organization do not present risk factors for ophthalmological manifestations. Retinopathy of prematurity was the disease with greater strength of association found in our study. For the other indications, the evaluations performed due to congenital syphilis prevail in the 3- year period of the study.

Surgical Antimicrobial Prophylaxis in Patients of Neonatal and Pediatric Age Subjected to Eye Surgery: A RAND/UCLA Appropriateness Method Consensus Study

Ocular surgery encompasses a wide range of procedures, including surgery of the tear ducts, eyelid, cornea and conjunctiva, lens, ocular muscle, and vitreoretinal and iris surgery. Operations are also performed for the removal of tumors, repairs of ocular trauma and, finally, corneal transplantation. Antibiotic prophylaxis for the prevention of surgical site infections (SSIs) in ocular surgery is a complex field in which shared lines of action are absent. In light of the scarcity of shared evidence in the use of ocular antimicrobial prophylaxis for the pediatric population, this consensus document aims to provide clinicians with a series of recommendations on antimicrobial prophylaxis for patients of neonatal and pediatric age undergoing eye surgery. The following scenarios are considered: (1) intraocular surgery; (2) extraocular surgery; (3) ocular trauma; (4) ocular neoplasm; (5) ocular surface transplantations; (6) corneal grafts. This work has been made possible by the multidisciplinary contribution of experts belonging to the most important Italian scientific societies and represents, in our opinion, the most complete and up-to-date collection of recommendations regarding clinical actions in the peri-operative environment in eye surgery. The application of uniform and shared protocols aims to improve surgical practice, through the standardization of procedures, with a consequent reduction of SSIs, also limiting the phenomenon of antimicrobial resistance.

Neurovascular abnormalities in retinopathy of prematurity and emerging therapies

Blood vessels in the developing retina are formed in concert with neural growth, resulting in functional neurovascular network. Disruption of the neurovascular coordination contributes to the pathogenesis of retinopathy of prematurity (ROP), a potentially blinding retinal neovascular disease in preterm infants that currently lacks an approved drug therapy in the USA. Despite vasculopathy as predominant clinical manifestations, an increasing number of studies revealed complex neurovascular interplays among neurons, glial cells and blood vessels during ROP. Coordinated expression of glia-derived vascular endothelial growth factor (VEGF) in spatio-temporal gradients is pivotal to the formation of well-organized vascular plexuses in the healthy retina, whereas uncoordinated VEGF expression triggers pathological angiogenesis with disorganized vascular tufts in ROP. In contrast with VEGF driving both pathological and physiological angiogenesis, neuron-derived angiogenic factor secretogranin III (Scg3) stringently regulates ROP but not healthy retinal vessels in animal models. Anti-VEGF and anti-Scg3 therapies confer similar high efficacies to alleviate ROP in preclinical studies but are distinct in their disease selectivity and safety. This review discusses neurovascular communication among retinal blood vessels, neurons and glial cells during retinal development and ROP pathogenesis and summarizes the current and emerging therapies to address unmet clinical needs for the disease.

Cost-effectiveness of Artificial Intelligence-Based Retinopathy of Prematurity Screening

Importance

Artificial intelligence (AI)-based retinopathy of prematurity (ROP) screening may improve ROP care, but its cost-effectiveness is unknown.

Objective

To evaluate the relative cost-effectiveness of autonomous and assistive AI-based ROP screening compared with telemedicine and ophthalmoscopic screening over a range of estimated probabilities, costs, and outcomes.

Design, Setting, and Participants

A cost-effectiveness analysis of AI ROP screening compared with ophthalmoscopy and telemedicine via economic modeling was conducted. Decision trees created and analyzed modeled outcomes and costs of 4 possible ROP screening strategies: ophthalmoscopy, telemedicine, assistive AI with telemedicine review, and autonomous AI with only positive screen results reviewed. A theoretical cohort of infants requiring ROP screening in the United States each year was analyzed.

Main Outcomes and Measures

Screening and treatment costs were based on Current Procedural Terminology codes and included estimated opportunity costs for physicians. Outcomes were based on the Early Treatment of ROP study, defined as timely treatment, late treatment, or correctly untreated. Incremental cost-effectiveness ratios were calculated at a willingness-to-pay threshold of $100 000. One-way and probabilistic sensitivity analyses were performed comparing AI strategies to telemedicine and ophthalmoscopy to evaluate the cost-effectiveness across a range of assumptions. In a secondary analysis, the modeling was repeated and assumed a higher sensitivity for detection of severe ROP using AI compared with ophthalmoscopy.

Results

This theoretical cohort included 52 000 infants born 30 weeks' gestation or earlier or weighed 1500 g or less at birth. Autonomous AI was as effective and less costly than any other screening strategy. AI-based ROP screening was cost-effective up to $7 for assistive and $34 for autonomous screening compared with telemedicine and $64 and $91 compared with ophthalmoscopy in the primary analysis. In the probabilistic sensitivity analysis, autonomous AI screening was more than 60% likely to be cost-effective at all willingness-to-pay levels vs other modalities. In a second simulated cohort with 99% sensitivity for AI, the number of late treatments for ROP decreased from 265 when ROP screening was performed with ophthalmoscopy to 40 using autonomous AI.

Conclusions and Relevance

AI-based screening for ROP may be more cost-effective than telemedicine and ophthalmoscopy, depending on the added cost of AI and the relative performance of AI vs human examiners detecting severe ROP. As AI-based screening for ROP is commercialized, care must be given to appropriately price the technology to ensure its benefits are fully realized.

Retinopathy of prematurity: a review of epidemiology and current treatment strategies

Retinopathy of prematurity (ROP) is among the most common causes of childhood blindness. Three phases of ROP epidemics have been observed worldwide since ROP was first described in the 1940s. Despite advances in neonatal care, the occurrence of ROP and associated visual impairment has been increasing somewhere on Earth and remains difficult to control. Conventional treatment options for preventing ROP progression include retinal ablation using cryotherapy or laser therapy. With the emergence of anti-vascular endothelial growth factor (anti-VEGF) treatment for ocular diseases, the efficacy and safety of anti-VEGF therapy for ROP have recently been actively discussed. In the advanced stage of ROP with retinal detachment, surgical treatment including scleral buckling or vitrectomy is needed to maintain or induce retinal attachment. At this stage, the visual outcome is usually poor despite successful anatomical retinal attachment. Therefore, preventing ROP progression by timely screening examinations and treatment remains the most important part of ROP management.

Novel Potential Biomarkers for Retinopathy of Prematurity

Retinopathy of prematurity (ROP) is the main risk factor for vision-threatening disease in premature infants with low birth weight. An accumulating number of independent studies have focused on ROP pathogenesis and have demonstrated that laser photocoagulation therapy and/or anti-VEGF treatment are effective. However, early diagnosis of ROP is still critical. At present, the main method of ROP screening is based on binocular indirect ophthalmoscopy. However, the judgment of whether ROP occurs and whether treatment is necessary depends largely on ophthalmologists with a great deal of experience. Therefore, it is essential to develop a simple, accurate and effective diagnostic method. This review describes recent findings on novel biomarkers for the prediction, diagnosis and prognosis of ROP patients. The novel biomarkers were separated into the following categories: metabolites, cytokines and growth factors, non-coding RNAs, iconography, gut microbiota, oxidative stress biomarkers, and others. Biomarkers with high sensitivity and specificity are urgently needed for the clinical applications of ROP. In addition, using non-invasive or minimally invasive methods to obtain samples is also important. Our review provides an overview of potential biomarkers of ROP.

Perinatal risk factors associated with central retinal changes in former preterm children on optical coherence tomography angiography

PURPOSE

To assess the association between perinatal risk factors for retinopathy of prematurity (ROP) and central retinal structures of former preterm children seen on optical coherence tomography angiography (OCTA).

METHODS

This prospective cohort study included 40 children with a history of preterm birth and 33 healthy full-term children. We documented their birth weight, gestational age, other significant risk factors for ROP development and presence of ROP. Imaging was performed using swept-source OCTA, and quantitative evaluation was performed. Analytic parameters included the area of foveal avascular zone (FAZ), foveal depth (FD), central subfoveal retinal thickness (CSFT) and capillary density index (CDI) of the deep and superficial capillary plexus.

RESULTS

Preterm children had significantly smaller FAZ, lower FD and higher CSFT compared to controls (all p < 0.001). Both groups exhibited no differences in total CDI at the superficial (p = 0.969) and deep capillary plexus (p = 0.370). The duration of mechanical ventilation correlated negatively with FAZ and FD but positively with CSFT. The duration of supplemental oxygen treatment correlated negatively with FD. The presence of intraventricular haemorrhage correlated negatively with FAZ and FD but positively with CSFT. Regression analysis found that the duration of mechanical ventilation and the presence of bronchopulmonary dysplasia were associated with lower FD (p = 0.002 and 0.01, respectively) and higher CSFT (p = 0.002 and 0.028, respectively).

CONCLUSION

Central retinal anomalies were identified in former preterm children using OCTA. Macular changes were associated with several risk factors for ROP development.