ASSOCIATION OF SYSTEMIC RISK FACTORS WITH THE PROGRESSION OF LASER-TREATED RETINOPATHY OF PREMATURITY TO RETINAL DETACHMENT

Anatomical outcome of laser treatment alone in aggressive retinopathy of prematurity

PURPOSE

The purpose is to study the anatomical outcome of eyes in aggressive retinopathy of prematurity (AROP), treated with laser photocoagulation alone and to evaluate factors affecting outcomes.

METHODS

Records of consecutive babies diagnosed with AROP, undergoing laser photocoagulation treatment in rural tertiary care centers from October 2016 to January 2021 were reviewed retrospectively. Anatomical outcome at 6 months follow-up was grouped as good in eyes with complete regression and poor in those who developed retinal detachment (stage IV a, IV b, and V). Both groups were compared with respect to the period of gestation, birth weight (BW), age at screening, age at treatment, zone of disease, presence of retinal fibrovascular proliferation (FVP), tunica vasculosa lentis, preretinal bleed, need for supplement laser, and associated systemic risk factors.

RESULTS

Of the total of 2468 babies screened, 124 (5.02%) were diagnosed with severe retinopathy of prematurity (ROP), of which 54 (43.5%) lasered AROP babies were analyzed. Mean BW and gestation period of the AROP cohort were 1.43 kg and 31.1 weeks, respectively. Eighty-six eyes (79.6%) had good outcomes with laser photocoagulation alone. Posterior location of disease, presence of FVP, neonatal sepsis, shock, and late screening for ROP were found to be factors associated with poor outcomes.

CONCLUSION

Adequate and timely treatment with laser photocoagulation in AROP can achieve good treatment outcomes in a significant proportion of babies. Although a combined approach using laser, anti-vascular endothelial growth factor and early vitrectomy is better, laser remains a viable treatment option in AROP, especially with limited resources and high risk of loss to follow-up.

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.

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

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

Systemic Factors Associated with a Thinner Choroid in Preterm Infants

Purpose

To identify systemic health factors associated with a thinner choroid, which has been hypothesized as a cause of poor visual outcomes in low–birth weight infants.

Design

The prospective, observational Study of Eye Imaging in Preterm Infants (BabySTEPS) enrolled infants recommended for retinopathy of prematurity screening based on the American Association of Pediatrics guidelines.

Participants

Infants who underwent imaging with investigational handheld OCT at 36 ± 1 weeks’ postmenstrual age (PMA) as part of BabySTEPS.

Methods

Average choroidal thickness was measured across the central subfoveal 1 mm. We concurrently collected maternal and infant clinical health data. Univariate and multivariate linear regression analyses were performed to evaluate factors associated with choroidal thickness. The left and right eyes showed similar thicknesses, so their average was used for analysis.

Main Outcomes Measures

Association between infant health factors and subfoveal choroidal thickness.

Results

Subfoveal choroidal thickness was measurable in 82 of 85 infants and 94% of eyes. Mean choroidal thickness was 231 ± 78 μm. In the univariate analysis, a thinner choroid was associated with decreased growth velocity (P < 0.001), lower birth weight (P < 0.001), smaller head circumference (P < 0.001), younger gestational age (P = 0.01), the presence of patent ductus arteriosus (P = 0.05), sepsis or necrotizing enterocolitis (P = 0.03), bronchopulmonary dysplasia (P = 0.03), pulmonary interstitial emphysema (P = 0.002), more days on oxygen support (P < 0.001), and being on oxygen support at 36 weeks (P < 0.001) and at the time of imaging (P < 0.001). In the multivariate analysis, growth velocity (P = 0.002) and oxygen support at the time of OCT imaging (P = 0.004) remained associated with a thinner choroid.

Conclusions

A thinner choroid is associated independently with growth velocity and receiving oxygen support at 36 ± 1 weeks PMA. This suggests that choroidal development in preterm infants may be related to growth rate in the first weeks of life and the prolonged use of supplemental oxygen. Longitudinal studies are needed to assess differences in choroidal thickness before 36 weeks PMA and to assess their impact on visual outcomes.

Comparison of Mean Platelet Counts in Preterm Infants with and without Retinopathy of Prematurity

Platelets are a primary source of pro- and anti-angiogenic cytokines. However, the evidence of their role in retinopathy of prematurity (ROP) is controversial. This retrospective study aimed to compare mean weekly platelet counts between infants with and without ROP over the first 6 weeks of life. A total of 93 infants matched by gestational age and birth weight were recruited (31 with ROP, 62 without ROP). Weekly mean platelet counts and other related risk factors were documented. The repeated measure analysis of variance (ANOVA) and the repeated measure analysis of covariance (ANCOVA) were used to compare mean platelet counts over time between the two groups, with and without adjusting for confounders. We found significant differences in the weekly mean platelet counts of infants with and without ROP over the first 6 weeks of life (p = 0.002). These differences disappeared after adjusting for covariates (p = 0.489). Lower mean platelet counts in ROP infants are not directly related to ROP, but rather to the presence of other risk factors for ROP, such as culture-proven sepsis, blood transfusion and bronchopulmonary dysplasia.

Predictors and ocular outcomes of rescue treatment in preterm infants with treated retinopathy of prematurity-a retrospective study

AIM

To determine predictors of rescue treatment among infants treated for retinopathy of prematurity and to evaluate their ocular outcomes at 18-24 months of corrected age.

METHODS

This is a single centre retrospective study of infants who received treatment for type 1 ROP, using laser photocoagulation or anti VEGF agents. Multivariable logistic regression was used to generate a prediction model for rescue treatment of ROP. The primary outcome was an abnormal refractive outcome by 24 months of corrected age, among infants primarily treated with laser therapy.

RESULTS

Two hundred and eight infants (including 416 eyes) who received single (n = 151) or rescue (multiple) treatments (n = 57) were included. Ninety three percent of the infants were primarily treated with laser photocoagulation. Lower gestational age, small for gestational age, early packed red blood cell transfusion (within 2 weeks of postnatal age), and presence of Zone 1 retinopathy predicted the need for rescue treatment in treated infants [area under the receiver operating characteristic curve: 0.81 (0.73-0.89)]. The incidence of abnormal refractive outcome, assessed in a total of 174 infants, was found to be significantly higher in the rescue treatment group (67% versus 21%, adjusted odds ratio: 7.56 (3.3-17.2), P < 0.001). Myopia, very high myopia and use of spectacles was significantly higher in the rescue treatment group (P < 0.001 for each).

CONCLUSIONS

Rescue treatment for ROP was associated with an increased incidence of refractive errors and requirement of spectacles by 2 years of age. Larger prospective multicentre studies are required to confirm the findings from our study.

THROMBOCYTOPENIA AS A RISK FACTOR FOR RETINOPATHY OF PREMATURITY

PURPOSE

To study the association between thrombocytopenia and retinopathy of prematurity (ROP).

METHODS

The case-control study was conducted on preterm newborns with ROP between January 2011 and January 2014, retrospectively. The patients were assigned into two groups: Cases required intervention and controls developed no or Stage I ROP.

RESULTS

Eighty-one premature infants with Type I ROP were enrolled to the study with a mean gestational age of 27.6 ± 2.1 (range: 24-32) weeks and birth weight of 993 ± 292 (range: 560-1,930) g. Mean follow-up time was 38.3 ± 2.7 weeks (min: 32 and max: 46 weeks). Cases were individually matched to a set of controls (1:1 ratio). Thrombocytopenia (<150.000/mm) was seen in 58 (71.6%) of the cases with Type I ROP, whereas only 17 (21%) of the controls had thrombocytopenia (P < 0.001). Logistic regression analysis showed that bronchopulmonary dysplasia and thrombocytopenia were significantly associated with Type I ROP (relative risk [95% confidence interval]: 4.19 [1.47-12] and 6.69 [2.83-15.9], respectively). The thrombocytopenia ratio (P = 0.073), thrombocytopenia 1 week before intervention (P = 0.076) and platelet transfusion ratio (P = 0.062) tended to be higher in Zone I ROP compared with Zone II ROP.

CONCLUSION

In our study, there was a significant association between thrombocytopenia and Type I ROP.

Platelet mass index can be a reliable marker in predicting the prognosis of retinopathy of prematurity in very preterm infants

BACKGROUND

Retinopathy of prematurity (ROP) is a proliferative vitreoretinopathy resulting from vascular defect of the retina. The present study evaluates platelets, which are involved in VEGF storage, transport and release, and their functions with regard to the prognosis of the disease. The objective was to suggest a simple minimal invasive method that will facilitate the management of the disease and help clinicians in predicting the prognosis.

METHODS

In this single center, retrospective, case-control study, we included a control group consisting of very preterm newborns (n = 83) at risk of ROP and a laser photocoagulation group including infants (n = 63) who received laser therapy during their follow-up examinations. The employed assessments included platelet counts and platelet mass index (PMI) which provide guidance in understanding platelet activity. In doing so, consideration was given to the first and second phases of ROP. The accuracy of prognostication was assessed with receiver operating characteristic analyses.

RESULTS

The study groups did not differ statistically significantly by platelet count during the first and second phases of ROP (p > 0.05) nor were the PMI measurements statistically significantly different between the study groups during the first phase of the disease (p > 0.05). PMI values of the study groups, however, differed significantly in the second phase of ROP (p < 0.05).

CONCLUSION

The present study found a significant difference between the two groups in PMI measurements which reflect increased VEGF levels during the neovascularization phase, which underlies the disease. This conclusion demonstrated that monitoring the PMI values in newborns at risk of ROP can be considered to be a minimally invasive method that by changing the retinal examination procedure in use today which is rather troublesome for both the physician and the newborn, can provide facilities in monitoring the disease for both the physician and the newborn.

Retinopathy of prematurity: a review of risk factors and their clinical significance

Retinopathy of prematurity (ROP) is a retinal vasoproliferative disease that affects premature infants. Despite improvements in neonatal care and management guidelines, ROP remains a leading cause of childhood blindness worldwide. Current screening guidelines are primarily based on two risk factors: birth weight and gestational age; however, many investigators have suggested other risk factors, including maternal factors, prenatal and perinatal factors, demographics, medical interventions, comorbidities of prematurity, nutrition, and genetic factors. We review the existing literature addressing various possible ROP risk factors. Although there have been contradictory reports, and the risk may vary between different populations, understanding ROP risk factors is essential to develop predictive models, to gain insights into pathophysiology of retinal vascular diseases and diseases of prematurity, and to determine future directions in management of and research in ROP.

Expanded criteria for retinopathy of prematurity screening in moderately preterm infants: Single-center pilot study

BACKGROUND

While developed countries seek to lower the gestational age and birthweight parameters in retinopathy of prematurity (ROP) screening, older, larger infants still develop ROP in other parts of the world. The aim of this study was therefore to define criteria to identify potential ROP developers who are outliers of the common screening range.

METHODS

A retrospective medical record review was performed in 147 inborn moderately preterm infants admitted to the neonatal intensive care unit during the study period. Univariate and logistic regression analysis was carried out.

RESULTS

Forty-two infants developed ROP. Gestational age (31.4 ± 1.1 vs 32.4 ± 1.0 weeks, P = 0.000) and birthweight (1607.7 ± 339.4 vs 1846.4 ± 317.2 g, P = 0.000) were lower in those who developed ROP. Respiratory distress syndrome (P = 0.026) and documented sepsis (P = 0.003) were significant comorbidities on univariate analysis. Inotrope need >72 h starting in the first week of life (P = 0.004; OR, 5.181) and more than three transfusions of packed red blood cells (P = 0.028; OR, 3.891) were also significant, both on univariate and multivariate analysis.

CONCLUSIONS

In moderately preterm infants, status should be evaluated in order to effectively select candidates for ROP screening without missing potential ROP developers.

Structural, visual and refractive outcomes of intravitreal aflibercept injection in high-risk prethreshold type 1 retinopathy of prematurity

PURPOSE

To study the structural, visual and refractive outcomes of intravitreal injection of aflibercept monotherapy in patients with high-risk prethreshold type 1 retinopathy of prematurity (ROP).

DESIGN

Prospective nonrandomized interventional case series study.

PATIENTS AND METHODS

1 mg/0.025 ml intravitreal aflibercept was administered for patients with high-risk prethreshold type 1 ROP. The primary outcomes studied were unfavorable structural outcome, unfavorable visual outcome and unfavorable refractive outcome. The secondary outcomes were absence of recurrence, ocular and systemic adverse events.

RESULTS

Twenty-six eyes were enrolled in the study; all had completed 1 year of follow-up. The mean birth weight was 991 ± 266 g (range: 875-1,105 g); the mean gestational age at birth was 26.33 ± 2.1 weeks (range: 24-30 weeks); 9 eyes were graded as ROP with stage 2+, zone I retinopathy, 14 eyes had stage 3+ disease in zone II and 3 eyes were diagnosed with stage 3 disease in zone I. Twenty-five eyes (96.2%) showed a favorable structural and 21 (80.1%) a favorable visual outcome, and the median refractive error after 1 year was 0.75 dpt (range: -9.5 to +4).

CONCLUSIONS

Intravitreal injection of aflibercept monotherapy is an easy, safe and effective alternative modality of therapy for high-risk prethreshold type 1 ROP. A further multicenter study with a longer duration of follow-up is required.

The utility of serial plasma sE-selectin measurements in the prediction of retinopathy of prematurity in premature infants

BACKGROUND

sE-selectin has recently been suggested as a surrogate marker for prediction of ROP development.

AIMS

The possible role of serial plasma sE-selectin measurements in early prediction and diagnosis of ROP was evaluated.

STUDY DESIGN

Prospective observational study

SUBJECTS

Forty six preterm infants aged <34weeks of gestation and weighing <1500 g were enrolled. Of these, 26 constituted the ROP group and 20 constituted the no-ROP group. sE-selectin levels were measured serially in blood samples on the 1st day and on 14th and 28th postnatal days.

OUTCOME MEASURES

The primary outcome measure was to evaluate the role of sE-selectin concentrations in prediction of ROP.

RESULTS

The mean gestational age and birth weight were significantly lower in the ROP group. The mean sE-selectin concentrations in ROP group were significantly greater than those in no-ROP group at each time point (1st, 14th and 28th days of postnatal life). A receiver operating characteristic (ROC) analysis showed that at a plasma concentration of ≥86ng/mL on the 1st postnatal day, sE-selectin had a sensitivity of 100% and a specificity of 94.1% with a positive predictive value of 96.3% and a negative predictive value of 100%. Plasma sE-selectin concentrations were significantly greater in infants who developed ROP in three different time points.

CONCLUSIONS

This study shows for the first time that measurement of plasma sE-selectin concentrations as early as the first day of life might help identify preterm infants at risk of ROP.

Oral propranolol for retinopathy of prematurity: risks, safety concerns, and perspectives

OBJECTIVE

To evaluate safety and efficacy of oral propranolol administration in preterm newborns affected by an early phase of retinopathy of prematurity (ROP).

STUDY DESIGN

Fifty-two preterm newborns with Stage 2 ROP were randomized to receive oral propranolol (0.25 or 0.5 mg/kg/6 hours) added to standard treatment or standard treatment alone. To evaluate safety of the treatment, hemodynamic and respiratory variables were continuously monitored, and blood samples were collected weekly to check for renal, liver, and metabolic balance. To evaluate efficacy of the treatment, the progression of the disease (number of laser treatments, number of bevacizumab treatments, and incidence of retinal detachment) was evaluated by serial ophthalmologic examinations, and plasma soluble E-selectin levels were measured weekly.

RESULTS

Newborns treated with propranolol showed less progression to Stage 3 (risk ratio 0.52; 95% CI 0.47-0.58, relative reduction of risk 48%) or Stage 3 plus (relative risk 0.42 95% CI 0.31-0.58, relative reduction of risk 58%). The infants required fewer laser treatments and less need for rescue treatment with intravitreal bevacizumab (relative risk 0.48; 95% CI 0.29-0.79, relative reduction of risk 52 %), a 100% relative reduction of risk for progression to Stage 4. They also had significantly lower plasma soluble E-selectin levels. However, 5 of the 26 newborns treated with propranolol had serious adverse effects (hypotension, bradycardia), in conjunction with episodes of sepsis, anesthesia induction, or tracheal stimulation.

CONCLUSION

This pilot study suggests that the administration of oral propranolol is effective in counteracting the progression of ROP but that safety is a concern.

Patent ductus arteriosus and indomethacin treatment as independent risk factors for plus disease in retinopathy of prematurity

PURPOSE

To examine whether clinically significant patent ductus arteriosus (PDA) or indomethacin treatment are associated with plus disease or retinopathy of prematurity (ROP) requiring treatment.

METHODS

Retrospective, cross-sectional study. Charts were reviewed for gestational age, birth weight, birth head circumference, birth length, maternal characteristics, gender, bronchopulmonary dysplasia, neurologic comorbidities, PDA and its treatments, gastrointestinal comorbidities, blood transfusions, and sepsis. Main outcome measures were increased rates of plus disease or ROP requiring treatment.

RESULTS

A total of 450 premature infants screened for ROP in a mid-sized, urban neonatal intensive care unit were included. On univariate analysis, gestational age, birth weight, birth head circumference, birth length, bronchopulmonary dysplasia, neurologic comorbidities, PDA and its treatments, gastrointestinal comorbidities, and sepsis were significantly correlated to plus disease and ROP requiring treatment. PDA was significantly associated with bronchopulmonary dysplasia, neurologic comorbidities, sepsis, and blood transfusions (P < .0001). With type 3 multivariate analysis, only gestational age and bronchopulmonary dysplasia were independent risk factors for ROP.

CONCLUSION

PDA and indomethacin were associated with plus disease and ROP requiring treatment on univariate analysis but this was not significant after adjusting for other risk factors. PDA was also strongly related to bronchopulmonary dysplasia and blood transfusions, which may explain its effect on ROP.

Structural and functional results of indirect diode laser treatment for retinopathy of prematurity from 1999 to 2003 in Kuwait

Purpose

The purpose was to report the structural, visual, and refractive outcomes of infants treated for retinopathy of prematurity (ROP) with laser and to identify the risk factors for unfavorable outcomes.

Materials and methods

The charts of infants with severe ROP treated by diode laser in a tertiary center during the period April 1999 to November 2003 were reviewed. Treated infants were followed up for fundus examination, visual acuity assessment, and cycloplegic refraction. Data regarding ocular risk factors, like zones of ROP and the extent of extraretinal proliferations, and data regarding various systemic risk factors were collected. A minimum follow up of 6 months was needed for inclusion in the study of structural outcome. A minimum follow up of 24 months was needed for the study of visual and refractive outcomes. The outcomes measured were: rate of unfavorable structural outcome, unfavorable visual outcome (visual acuity < 20/40), and high myopia (myopia ≥ 5 diopters). The ocular and systemic risk factors were studied for their significance in the development of unfavorable outcomes.

Results

Two hundred seventy eyes of 148 infants were treated for severe ROP, out of which 20 eyes (7.4%) had unfavorable structural outcome. Visual data were available for 149 eyes of 81 infants, of which 70 eyes (47%) had unfavorable visual outcome. Refractive data were available for 131 eyes of 72 infants, and high myopia was present in 23 (17.6%) eyes. Zone I disease was the significant risk factor for unfavorable structural (P < 0.0001), unfavorable visual outcome (P = 0.03), and for high myopia (P < 0.0001). Lower post-conceptional age at treatment was significant for unfavorable structural outcome (P = 0.03) and high myopia (P < 0.0001). Presence of sepsis (P = 0.029) and extraretinal proliferation ≥ 6 hours were significant for unfavorable structural outcome (P = 0.002).

Conclusion

ROP in zone I was the most significant risk factor for all the unfavorable outcomes. Laser-treated ROP infants need long term follow up.

Analysis of risk factors for progression to treatment-requiring ROP in a single neonatal intensive care unit: is the exposure time relevant?

OBJECTIVE

Retinopathy of prematurity (ROP) is a multifactorial disease whose pathogenesis is organized in two phases. We hypothesized that postnatal risk factors may differently exert their effect in a phase dependent way.

METHODS

Data obtained from medical records of 93 very low birth weight neonates with stage ≥ 3 ROP were analyzed. Perinatal ROP risk factors were compared between infants with stage 3 ROP not requiring surgery and infants with treatment-requiring ROP with relation to newborn's lifetime exposure.

RESULTS

In the first two weeks and in the whole first month of life length of oxygen administration was an independent risk factor for treatment-requiring ROP. In the first month of life also sepsis was identified as independent risk factor for surgical ROP. Sepsis and Candida pneumonia in the time frame from birth to ROP diagnosis and prolonged mechanical ventilation from diagnosis to prethreshold ROP were associated to treatment-requiring ROP. Blood transfusions are the only risk factor for treatment-requiring ROP identified in all the periods analyzed.

CONCLUSION

Risk factors for ROP play their role since birth. Beside scrupulous oxygen-administration monitoring and prevention of infections, blood transfusions are of primary importance in the development of treatment-requiring ROP.

Risk factors for severe retinopathy of prematurity in preterm low birth weight neonates

OBJECTIVE

To evaluate the risk factors predisposing to severe retinopathy of prematurity (ROP) in a level III neonatal unit. This retrospective study was conducted in a tertiary care neonatal and ophthalmic center.

METHODS

The authors retrospectively analyzed data of preterm infants who were born from January 2003 through December 2008 and were screened for ROP. Data were collected from prospectively filled ROP screening forms. All the neonates with gestation ≤ 32 wks or birth weight ≤ 1500 g were screened. In addition, infants with birth weight of 1501-1800 g or gestation of 33-34 wks were also screened in the presence of additional risk factors like need for oxygen or mechanical ventilation. Primary outcome was severe ROP defined as treatable ROP as per type I ETROP guidelines (after year 2005) or threshold disease (before 2005).

RESULTS

A total of 704 neonates were screened during the study period, of whom 84 (11.9%) and 33 (4.7%) infants developed any ROP and severe ROP, respectively. The mean birth weight and gestation of infants with severe ROP were 1113 ± 438 g and 29 ± 3 wks, respectively. The following risk factors were found to be significant for severe ROP on univariate analysis: gestation ≤ 30 wks, birth weight < 1000 g, respiratory distress syndrome, use of surfactant, apnea, hypotension, patent ductus arteriosus (PDA), sepsis, necrotizing enterocolitis, pneumonia, meningitis, intraventricular hemorrhage, packed cell transfusion, and use of oxygen, continuous positive airway pressure and positive pressure ventilation. On multivariate analysis by stepwise logistic regression, respiratory distress syndrome (adjusted OR: 8.1 (95% CI 2.6-25.1); p < 0.001), PDA requiring medical or surgical management (adjusted OR: 3.2 (95% CI 1.1-8.9); p = 0.03), and meningitis (adjusted OR: 6.7 (95% CI 1.9-23.0); p = 0.002) were found to be independently associated with severe ROP. All infants with severe ROP had regression of the disease after laser therapy.

CONCLUSIONS

Respiratory distress syndrome, PDA requiring medical or surgical management and meningitis were found to be associated with severe ROP. Outcomes were good after laser therapy with all followed-up infants having regression of the disease.

Outcomes of a protocol-based management for zone 1 retinopathy of prematurity: the Indian Twin Cities ROP Screening Program report number 2

PURPOSE

To report the outcomes of zone 1 aggressive posterior retinopathy of prematurity (ROP) treated with aggressive laser photocoagulation by a protocol-based approach over a 10-year period.

DESIGN

Prospective, interventional case series.

METHODS

SETTING

Tertiary eye institute and neonatal intensive care units in the twin cities of Hyderabad and Secunderabad in South India.

STUDY POPULATION

Babies screened under the Indian Twin Cities Retinopathy of Prematurity Screening (ITCROPS) program between January 1, 1997 and March 31, 2007.

INTERVENTION

Multiple sessions of laser photocoagulation at any sign of plus disease with abnormal shunt vessels with or without neovascularization in zone 1.

OUTCOME MEASURE

Based on the anatomic status of the retina at the final follow-up, the outcome was classified into good (completely regressed with no vitreoretinal changes), fair (regression with vitreoretinal distortion), or poor (progression into partial or total retinal detachment involving macula). Descriptive statistics (mean and range) were used for gestational age at birth, birth weight, and post-conceptional age at first presentation and at the first intervention. Trends in incidence of zone 1 ROP over 1 decade were analyzed. Outcomes were expressed in terms of proportions and 95% confidence interval (CI).

RESULTS

Of the 3654 babies screened, 227 eyes of 115 babies were detected to have zone 1 aggressive disease, defined as zone 1 retinal vessels having abnormal closed-loop shunts, dilation and tortuosity, flat new vessels, or rapid progression. Laser was performed in 169 eyes. Disease regressed with good outcome in 142 eyes (84%) (95% CI, 77.6-89.2) and progressed to poor outcome in 13 eyes (7.69%) (95% CI, 4.1-12.8), while fair outcome was seen in 6 eyes (3.55%) (95% CI, 1.3-7.5). Thus 148 babies (87.5%) (95% CI, 81.6-92.14) had a favorable outcome. The outcomes in 8 treated eyes (4.7%) lost to follow-up were unknown.

CONCLUSIONS

Zone 1 aggressive ROP has a good outcome if the screening is done early; intervention is prompt and adequate, with frequent follow-up until complete regression is achieved.

Effects of maternal and placental inflammation on retinopathy of prematurity

PURPOSE

To identify maternal and placental risk factors for the occurrence and progression of retinopathy of prematurity (ROP).

METHODS

This was a retrospective cohort study. The study cohort consisted of 246 infants with gestational age ≤ 32 weeks, with histologic examinations of their placentas. Medical records of eligible preterm infants were retrospectively reviewed. A regression model was constructed with control for known or potential factors associated with ROP. Occurrences of ROP, severe ROP (≥ stage 3), and clinically significant ROP requiring laser treatment were assessed.

RESULTS

ROP was diagnosed in 82 of 246 infants (33.3%), including 49 with mild ROP and 33 with severe ROP. Laser treatment was performed on 27 infants (11%: 27/246). Multivariate regression analysis indicated clinical chorioamnionitis and elevated maternal WBC count on admission to be associated with ROP occurrence [odds ratio (OR) = 4.370, P = 0.046; and OR = 1.104 per 1,000 cells/mm(3) incremental increase, P = 0.019, respectively], while the use of tocolytics was associated with reduced occurrence of ROP (OR = 0.278, P = 0.006). Elevated maternal WBC count on admission was also independently associated with ROP progression requiring laser treatment (OR = 1.171 per 1,000 cells/mm(3) incremental increase, P = 0.026). However, neither histologic chorioamnionitis nor funisitis was associated with the occurrence or progression of ROP.

CONCLUSIONS

Clinical chorioamnionitis and elevated maternal WBC count, but not histologic chorioamnionitis, were significantly and independently associated with ROP. These findings support the hypothesis that maternal systemic inflammation may play a role in the pathogenesis of ROP.