Open sky vitrectomy for total retinal detachment in retinopathy of prematurity

A Literary Pediatric Retina Fellowship With Michael T. Trese, MD

Michael T. Trese, MD (1946-2022), a vitreoretinal surgeon, made significant contributions to the field of retina. Although most known for his work in pediatric retina surgery, he was a pioneer in areas such as medical retina, translational research, and telemedicine. This article reviews his major contributions to spread his knowledge more widely to vitreoretinal trainees and specialists. We discuss six areas where Trese made a lasting impact: lens-sparing vitrectomy, familial exudative vitreoretinopathy, congenital X-linked retinoschisis, autologous plasmin enzyme, regenerative medicine, and telemedicine. [Ophthalmic Surg Lasers Imaging Retina 2023;54:701-712.].

Use of an Iris Speculum for Retrolental Membrane Dissection for Stage 5 Prematurity of Retinopathy Complicated With Pupillary Adhesion

PURPOSE

To report a novel use of an iris speculum to assist with membrane dissection and trough separation for stage 5 retinopathy of prematurity-related funnel-shaped tractional retinal detachment complicated with pupillary adhesion.

METHODS

Limbus-based closed vitrectomy and membrane dissection were performed in 10 eyes (9 patients) with stage 5 retinopathy of prematurity-related tractional retinal detachment and pupillary adhesion. After synechiolysis, an iris speculum was positioned to enlarge the pupil for surgical visualization and maintain a neutral iris plane. The retrolental membrane was dissected bimanually and circumferentially along the peripheral trough and then toward the central retina with vertical scissors and end-gripping forceps.

RESULTS

In all 10 eyes, retrolental membranes were entirely removed and troughs were circumferentially unraveled. Follow-up examinations performed 6 to 18 months postoperatively showed reattachment of the retina in 3 eyes with an open-narrow funnel and 6 of 7 eyes with a narrow-narrow funnel. A near-circular pupil without recurrent pupillary adhesion was preserved in all nine eyes showing retinal reattachment.

CONCLUSION

This use of the iris speculum effectively exposes the surgical field for the entire removal of retrolental tissue and interruption of the peripheral trough in stage 5 retinopathy of prematurity-related tractional retinal detachment complicated with pupillary adhesion. The pupil's configuration is well preserved postoperatively.

Structural outcome following surgery for stage 5 retinopathy of prematurity based on the new international classification: ICROP 3

PURPOSE

This study investigated the outcomes of vitrectomy for stage 5 retinopathy of prematurity (ROP) based on the International Classification of Retinopathy of Prematurity 3rd edition (ICROP 3), in which stage 5 ROP is divided into three subgroups.

METHODS

Fifty-four eyes of 34 patients with stage 5 ROP who underwent vitrectomy between 2004 and 2020 were retrospectively analyzed. Data including sex, gestational age and weight at birth, ICROP 3 subcategories, perioperative use of intravitreal bevacizumab injection (IVB) and laser photocoagulation, surgical procedure and complications, final retinal reattachment, and follow-up period were collected.

RESULTS

Complete retinal reattachment was achieved in 16 eyes (88.9%) with stage 5A and 13 eyes (39.4%) with stage 5B (P = 0.0003, Wilcoxon rank-sum test). Three patients with stage 5C were considered inoperable. Postoperative anatomical failure was significantly associated with stage (stage 5B vs. 5A; odds ratio, 17.986; 95% confidence interval, 3.712-148.502; P = 0.0001, multivariate logistic regression analysis). Intraoperative IVB was significantly associated with lower postoperative incidence of vitreous hemorrhage and glaucoma (P = 0.041, chi-square test).

CONCLUSIONS

Staging of preoperative anatomical features based on ICROP 3 is a useful predictor for final anatomical success. Intraoperative IVB might reduce postoperative complication risks.

Surgery for stage 5 retinopathy of prematurity

PURPOSE OF REVIEW

Our understanding of the pathogenesis and surgical management of stage 5 retinopathy of prematurity has come a long way. Despite of new technologies in retinal surgical devices, the dissection of thick membranes is still a challenge. We use a capsulotomy 'plug on tip' 0.05 mm designed for capsular fimosis. This diathermy instrument is used to cut the lens capsule by low power waves transmitted from the tip of an active incising electrode and make incisions in the tissue. We tested this technique with 226 infants of which all 226 eyes retrolental membrane were removed. In 6-46 months follow-up, light perception or better visual function was achieved in 92%.

RECENT FINDINGS

Despite of new technologies in retinal surgical devices, the dissection of thick membranes is still a challenge. Sometimes, we need to use tools that were made for another purpose and adapt it to our current techniques.

SUMMARY

Achieving at least a vision of light perception in eyes that were considered untreatable is a good outcome as light perception maintains the circadian circle and helps in the brain development.

VIDEO ABSTRACT

http://links.lww.com/COOP/A47.

Stage 5 retinopathy of prematurity: An update

Retinopathy of prematurity (ROP) is one of the most common causes of preventable blindness in children. In spite of the availability of various treatment options, and favorable results with timely intervention, many infants present to the ophthalmologists in the advanced end stage of the disease due to lack of awareness especially in the developing nations. This blinding or Stage 5 of ROP presents with total retinal detachment and has to be managed surgically. The surgical techniques for Stage 5 ROP are unique and demanding. The successful anatomical results after surgery are only seen in 20%–50% of cases. In spite of a successful anatomical result, the visual outcome may be slow and limited. The use of newer pharmacological adjuncts has shown promising results. Because of heterogeneity of presentation of the disease severity, a genetic predisposition has also been proposed. A concerted effort from the pediatricians, ophthalmologists, and healthcare workers is required to establish effective screening and treatment guidelines to prevent blindness due to ROP. Till then surgical management has to be done. Parents must be educated regarding the limited visual benefits of surgery and the need for prolonged follow-up. This review gives a comprehensive overview of the pathogenesis, clinical aspects, surgical interventions, and their outcomes and future prospects of Stage 5 ROP.

Treatment of retinopathy of prematurity

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

ANATOMICAL AND VISUAL RESULTS OF VITREORETINAL SURGERY FOR STAGE 5 RETINOPATHY OF PREMATURITY

PURPOSE

To provide a historical perspective on outcomes of surgery for infants with stage 5 retinopathy of prematurity (ROP) as performed by a single surgeon over a 24-year period.

DESIGN

Retrospective observational cohort study.

METHODS

SETTING

Clinical practice of the Charles Retina Institute.

PATIENTS

The 601 infants with stage 5 ROP in at least one eye who were referred for surgery between 1977 and 2001. Charts were reviewed for demographic data and postoperative anatomical and visual acuity outcomes in eyes that underwent surgery.

MAIN OUTCOME MEASURES

The postoperative anatomical status of the retina and visual function were assessed after surgery. Anatomical outcome was categorized as success (macula attached), partial success (macula detached), failure (total retinal detachment), or lost eye (opaque cornea, secluded pupil, or phthisis). Visual function was classified as>20/200, 20/200-5/200, hand movement, light perception, or no light perception. Multivariable logistic regression was used to explore relationships between outcomes and baseline characteristics.

RESULTS

Only a minority of eyes had prior cryotherapy (15%) or laser photocoagulation (7%) therapy. The mean follow-up was 44 months for the 956 eyes treated surgically. The 608 eyes with available follow-up data were classified as follows: 28% success, 5% partial success, 55% failure, and 11% lost eye. Visual function of light perception or better was achieved in 74% of the 183 eyes with data on visual acuity. Controlling for other baseline factors, early postpartum age at the time of surgery was a statistically significant predictor of failure/lost eye (OR=2.08, 95% CI 1.09-3.97) and no light perception (OR=5.13, 95% CI 1.45-18.14). Surgery for stage 5 ROP on the fellow eye was also a predictor of failure/lost eye (OR=2.38, 95% CI 1.39-4.08).

CONCLUSIONS

Surgery resulted in anatomical success for approximately one third of infant eyes with stage 5 ROP, and only a minority of eyes (8 of 183) achieved visual acuity better than 5/200. However, some initially successfully attached retinas redetached. Although this study is limited by follow-up and may represent a group of patients with a more vascularly active disease state due to the low proportion of patients with prior peripheral ablation, this cohort of infants provides results against which future interventions may be compared.

Lens-sparing vitrectomy for stage 4 retinopathy of prematurity

PURPOSE

To investigate the anatomic results of lens-sparing vitrectomy for tractional stage 4 retinopathy of prematurity (ROP).

DESIGN

Retrospective, noncomparative consecutive case series.

PARTICIPANTS

Thirty-seven eyes (24 patients) with tractional stage 4 ROP.

INTERVENTION

Lens-sparing vitrectomy.

MAIN OUTCOME MEASURE

Anatomic status of the retina.

RESULTS

Twenty-five eyes had stage 4A ROP, and 12 eyes had stage 4B ROP. With a median follow-up of 13 months (range, 6-27), 32 of 37 eyes (86%) had complete reattachment of the retina. Among eyes with 4A ROP, 21 of 25 eyes (84%) had complete retinal reattachment. Among eyes with 4B ROP, 11 of 12 eyes (92%) had complete retinal reattachment. At last follow-up, 29 of 37 eyes (78%) were able to fix and follow.

CONCLUSIONS

These results indicate that lens-sparing vitrectomy is effective for achieving retinal reattachment in tractional stage 4 ROP. This article contains additional online-only material available at .

Long-term form identification vision after early, closed, lensectomy-vitrectomy for stage 5 retinopathy of prematurity

PURPOSE

Form identification vision after early, closed, lensectomy-vitrectomy for retinopathy of prematurity (ROP) stage 5 open funnel retinal detachment is reported from a database that included 45 eyes of 27 infants. The focus of this report is the verbal responses at a mean age of 7.0 years for nine nonamblyopic (preferred) eyes of nine preterm infants with minimal developmental delay (good central nervous system function).

METHODS

All 45 eyes underwent initial cryotherapy for threshold ROP to the avascular retina to decrease the angiogenic stimulus (mean postconceptual age = 34.8 weeks) and subsequently underwent multiple cryotherapy sessions to the avascular retina and shunt with scleral buckling to decrease retinal traction (mean postconceptual age = 38.0 weeks). When tractional retinal detachment occurred with an open funnel, each eye underwent an early, closed, lensectomy-vitrectomy (mean postconceptual age = 45.7 weeks). The 34 eyes with a successful anatomic result were fitted with contact lenses as soon as possible after surgery.

RESULTS

The nine nonamblyopic eyes of nine preterm infants with minimal developmental delay had the following visual acuities using Allen figures or Snellen test types: one eye 20/80, one eye 20/200, two eyes 20/400, three eyes 20/800, and two eyes 20/ 1600.

CONCLUSION

These nine eyes support the thesis that form identification vision can be obtained by early vitrectomy for ROP stage 5 open funnel retinal detachments.

Visual acuity of eyes after vitrectomy for retinopathy of prematurity: follow-up at 5 1/2 years. The Cryotherapy for Retinopathy of Prematurity Cooperative Group

PURPOSE

To provide long-term follow-up on the structural status and visual function at 5 1/2 years of age for 128 eyes of 98 infants who participated in the multicenter randomized clinical trial of cryotherapy for retinopathy of prematurity in whom total retinal detachment developed from retinopathy of prematurity (ROP) by the 3-month study examination. Fifty-four patients had lensectomy-vitrectomy procedures in one or both eyes before 1 year of age (n=72 eyes), and 44 patients did not (n=56 eyes).

METHODS

When the children were 5 1/2 years of age, an eye examination was performed and residua of ROP was assessed. Recognition acuity (Early Treatment of Diabetic Retinopathy Study chart) and grating visual acuity (Teller acuity card procedure) assessments were undertaken by testers who were masked to the status of each of the child's eyes.

RESULTS

At least partial retinal attachment was present at 5 1/2 years in 21% compared with 28% at 1 year of age (not significant). All except one of the eyes tested at 5 1/2 years had vision limited to light perception or no light perception, regardless of whether a vitrectomy had been performed. One eye that underwent vitrectomy had minimal pattern vision. The two eyes that were reported previously to have minimal pattern vision at 1 year of age were blind at the longer-term follow-up.

CONCLUSIONS

The poor visual outcome after a lensectomy-vitrectomy procedure for retinal detachment due to ROP demands that emphasis be placed on prevention of retinal detachment in premature infants.

Long-term follow up of visual acuity in eyes with stage 5 retinopathy of prematurity after closed vitrectomy

PURPOSE

This study was done to determine the efficacy of closed vitrectomy on long-term visual acuity of stage 5 retinopathy of prematurity.

METHODS

We studied the visual acuity of eyes that had undergone retinal reattachment by closed vitrectomy for stage 5 retinopathy of prematurity and were followed up for more than three years.

RESULTS

Forty-nine eyes of 31 patients among a total of 71 eyes of 48 consecutive patients were operated on and followed up for more than three years. Retinal reattachment occurred in 29 (59%) of the 49 eyes. Six patients (eight eyes) did not respond to visual acuity testing because of mental retardation or cerebral palsy. Measured visual acuity in the remaining 21 eyes varied from no light perception in one eye, light perception in four eyes, Recognizable hand movement in three eyes, 20/2,000 to 20/200 in seven eyes, 20/200 to 20/25 in five eyes, and 20/25 in one eye. No correlation was seen between visual outcome and factors such as gestational age, birth weight, and configuration of retinal detachment. Markedly better visual acuity was obtained in eyes that underwent initial surgery within four months of birth.

CONCLUSIONS

Useful vision can be obtained after reattachment of the retina by closed vitrectomy on some patients who have stage 5 retinopathy of prematurity. Better visual acuity may be obtained by earlier surgery.

Retinopathy of prematurity--current diagnosis and management

Despite advances in ophthalmological care of premature infants, retinopathy of prematurity (ROP) remains a still unsolved problem for paediatricians as well as ophthalmologists. A survey of the current literature concerning drug therapy and surgical management as related to the different stages of ROP is given. The classification system for ROP according to the International Committee is presented as well as our screening policy in relation to the literature. The effectiveness in preventing severe cases of ROP and the toxicity of vitamin E supplementation in high-risk premature infants is still disputed and no recommendations can be given. Cryotherapy is recommended in symmetric cases of stage 3 + ROP. Nevertheless, quite a number of eyes still progress to more severe stages of ROP. Scleral buckling procedures and vitrectomy may lead to anatomical success in a few cases of retinal detachment, however, the visual outcome of such an operation is usually very poor despite reattachment of the central retina.

Evaluation of eyes with advanced stages of retinopathy of prematurity using standardized echography

The authors evaluated 36 patients (72 eyes) who had either Stage 4 or Stage 5 retinopathy of prematurity (ROP) with standardized A-scan and B-scan echography. The eyes were evaluated for vitreous opacities, retrolental membranes, and retinal detachments. Stage 5 retinal detachments were present in 94% (68 of 72) of the eyes with 65% (47 of 72) having a wide anterior and narrow posterior configuration. Anterior retinal loops were noted in 36% of the eyes. Subretinal opacities were present in 47% of the eyes. Choroidal thickening and intraocular calcium were noted in 22% and 14% of eyes, respectively. The axial eye length was measured and adjusted for the differences in chronological and gestational age and compared with data from normal eyes. This showed that eyes with ROP were much smaller. The standardized A-scan was helpful in confirming the diagnosis of retinal detachment, evaluating the peripheral retina, and examining the subretinal space. The combination of A-scan and B-scan echography is helpful in predicting anatomic findings in patients with ROP undergoing surgery.

Visual acuity in infants after vitrectomy for severe retinopathy of prematurity

During the course of the Multicenter Trial of Cryotherapy for Retinopathy of Prematurity (CRYO-ROP), 98 infants (129 eyes) from the randomized segment of the trial developed total retinal detachment from retinopathy of prematurity (ROP) before the 1-year examination. The authors report as a case series the results of acuity card assessment of monocular grating acuity at 1 year in 53 infants (71 eyes) postvitrectomy and in 45 infants (58 eyes) who had retinal detachments but who did not undergo retinal reattachment surgery. The decision to undertake and the surgical technique used for a retinal reattachment procedure was not part of the randomized CRYO-ROP trial. Two eyes of one infant had pattern vision at the lowest measurable threshold after vitrectomy. None of the remaining eyes that had undergone vitrectomy and none of the eyes that did not undergo vitrectomy showed evidence of pattern vision. The relatively poor visual outcomes in this case series suggest that efforts are well-spent in attempting to prevent retinal detachment in ROP.

Scleral buckling in stages 4B and 5 retinopathy of prematurity

Twenty-two eyes with traction retinal detachment (RD) secondary to retinopathy of prematurity (ROP) in 21 infants were treated by scleral buckling in combination with external cryotherapy and drainage of subretinal fluid. Anatomic reattachment of the retina was achieved in 13 (59%) of 22 eyes. Of those patients achieving anatomic reattachment with follow-up of 18 months or more, four (40%) of ten had 20/400 or better visual acuity.

Echographic findings in infants with ROP

The authors, before starting the discussion about ultrasound findings in infants with ROP, present a review of the history of ultrasound in this disease. Early A-scan reports are mentioned while the B-scan literature from 1984 to 1988, consisting of seven papers, is reviewed extensively. The most important echo patterns in the various stages of the disease are described along with the most intriguing ones. There is disagreement as to whether it is always possible to show by echography if the retina is in place or not. This is due to the fact that the acoustic properties of the retina seem sometimes to change as time goes by and is quite independent of any technical difficulties which are still very great and the know-how of the examiner.