Reduction in screening for retinopathy of prematurity through risk factor adjusted inclusion criteria

Early-Onset Sepsis as an Early Predictor for Retinopathy of Prematurity: A Meta-analysis

OBJECTIVE

 Neonatal sepsis has been established as a risk factor for retinopathy of prematurity (ROP) but previous meta-analyses have predominately focused on late-onset sepsis (LOS). This meta-analysis aims to explore the association between early-onset sepsis (EOS) and the risk of ROP.

STUDY DESIGN

 Observational studies reporting (unadjusted) data on proven EOS in neonates with ROP were included. PubMed, Embase, and Cochrane Library were searched. Proven EOS was defined as a positive blood or cerebrospinal fluid culture. Effect sizes were calculated by using logistic random-effects models and meta-regression analyses. Primary outcomes were any stage ROP and severe ROP (≥stage 3, type I, aggressive [posterior] ROP, plus disease or requiring treatment). Potential confounders explored were gestational age at birth, birth weight, small for gestational age, maternal steroid use, necrotizing enterocolitis, LOS, and mechanical ventilation duration.

RESULTS

 Seventeen studies reporting the incidence of proven EOS in neonates with ROP were included. Proven EOS showed no significant association with any stage ROP (odds ratio [OR] = 1.90; 95% confidence interval [CI]: 0.96-3.79, p = 0.067) but heterogeneity between studies was significantly high. Neonates with proven EOS had an increased risk for severe ROP (OR = 2.21; 95% CI: 1.68-2.90), and no significant confounders influencing this effect size were found in the meta-regression analysis.

CONCLUSION

 Neonates with proven EOS are at increased risk of severe ROP. Neonatologists need to be aware that EOS is an early predictor of ROP and should adapt their policy and treatment decisions where possible to reduce ROP.

KEY POINTS

· This meta-analysis reveals a 2.2-fold increased risk of severe ROP in neonates with proven EOS.. · Future studies should distinguish between EOS and LOS when investigating risk factors of ROP.. · Treatment decisions should be adapted where possible in neonates with EOS before ROP screening begins..

The incidence and risk factors of retinopathy of prematurity in South Korea: A nationwide cohort study

Retinopathy of prematurity (ROP) is a major treatable cause of childhood blindness. Thus, epidemiological investigations are necessary for detecting and preventing ROP. Determining risk factors for ROP are also essential to improve screening methods. Therefore, we aimed to investigate the incidence and risk factors of ROP in Korea. The National Health Insurance Service (NHIS) covers almost all Koreans. Furthermore, the National Health Screening Program for Infants and Children (NHSPIC) is a government-run, health-screening program for children aged < 6 years. We used the NHIS-Infants and Children's Health Screening cohort database to evaluate the incidence of preterm infants and ROP. The database contains data on 84,005 participants, drawn from 5% of the NHSPIC survey on participants born annually during 2008 to 2012. Sociodemographic factors and systemic diseases were assessed as potential risk factors for ROP. We identified 2615 premature infants (3.11%); 846 of them had ROP (cumulative incidence: 32.4%). Although preterm births increased annually in 2008 to 2012, the ROP incidence in preterm infants did not increase by the birth year. Twenty patients (2.4%) with ROP underwent laser photocoagulation or surgery. Extremely low birth weight was a high risk factor (odds ratio [OR] = 49.86, P < .001). Moreover, chorioamnionitis (OR = 2.77, P = .028), respiratory distress syndrome (OR = 4.09, P < .001), apnea (OR = 1.59, P = .008), anemia (OR = 2.41, P < .001), and intraventricular hemorrhage (OR = 2.34, P < .001) were found to be risk factors for ROP. In conclusion, the incidence of premature babies increased between 2008 and 2012. However, the overall incidence of ROP among premature infants remained unchanged by birth year. Our findings revealed the roles of birth weight, respiratory conditions, anemia, and intraventricular hemorrhage in ROP.

Histological Chorioamnionitis and Funisitis as New Risk Factors for Retinopathy of Prematurity: A Meta-analysis

OBJECTIVE

 The role of placental inflammation in neonatal morbidities is underestimated due to lack of placental examination. This meta-analysis aims to assess the association between histological chorioamnionitis (HCA) with and without funisitis (FUN) and risk of retinopathy of prematurity (ROP).

STUDY DESIGN

 Forty-five studies reporting (unadjusted) data on HCA without FUN and HCA with FUN in neonates with ROP were included. Primary outcomes were any stage ROP and severe ROP. Potential confounders explored were gestational age (GA) at birth, birthweight, maternal steroid use, necrotizing enterocolitis, sepsis (suspected/proven) and mechanical ventilation duration.

RESULTS

 Neonates with HCA had increased risk for any stage ROP (odds ratio [OR] 1.8; 95% confidence interval [CI] 1.3-2.4) and severe ROP (OR 1.5; 95% CI 1.2-1.8) compared with neonates without HCA. The rates of any stage ROP (OR 1.8; 95% CI 1.4-2.2) and severe ROP (OR 1.4; 95% CI 1.1-1.6) were higher in neonates with FUN compared with neonates without FUN. Multivariate meta-regression analysis suggests that lower GA increases the effect size between FUN and severe ROP.

CONCLUSION

 This meta-analysis confirms that presence of HCA and FUN are risk factors for any stage ROP and severe ROP. Structured histological placental examination of HCA and FUN may be a tool to further refine the ROP risk profile.

KEY POINTS

· This systematic review confirms that HCA is a risk factor for ROP.. · This meta-analysis reveals that FUN results in an even higher risk for developing ROP.. · Placental examination of HCA/FUN may be a tool to further refine the ROP risk profile..

Comparative analysis of risk factors for retinopathy of prematurity in single and multiple birth neonates

AIM

To conduct a comparative analysis of risk factors for retinopathy of prematurity (ROP) in single- and multiple-born neonates.

METHODS

In a retrospective evaluation of 521 premature neonates, encompassing singletons, twins, and triplets born at or before 34 weeks of gestational age with a birthweight of less than 2000 g and who completed the ROP screening program, between 2020 and 2023, in outpatient referral ROP screening clinic affiliated by Shiraz University of Medical Sciences, were included. Neonates with the eligibility criteria were enrolled in the screening program from 28 days old age and followed up to discharge or treatment based on national ROP screening guideline. Data on ROP severity, outcome, treatment modality, and risk factors, including gestational age (GA), birth weight (BW), sex, duration of neonatal intensive care unit (NICU) admission, oxygen supplementation, mechanical ventilation, blood transfusion, method of delivery, and maternal and neonatal comorbidities, were extracted and compared between premature neonates from singleton and multiple births.

RESULTS

The analysis of the ROP severity distribution revealed 238 neonates (45.7%) with low-risk (type 2 prethreshold ROP or less severe) ROP and 16 (3.1%) with high-risk (type I prethreshold ROP or more severe) ROP who underwent treatment. According to the comparative analysis of risk factors in neonates with ROP requiring treatment, multiple birth neonates exhibited significantly greater GA (27.50 ± 3.27 vs. 30.00 ± 2.00 vs. 31.14 ± 0.38 weeks, p = 0.032 for singletons, twins and triplets, respectively); greater BW (861.67 ± 274.62 vs. 1233.33 ± 347.75 vs. 1537.14 ± 208.86 g, p = 0.002); and shorter duration of NICU admission (60.17 ± 21.36 vs. 34.00 ± 12.17 vs. 12.00 ± 6.32 days, p = 0.001) and oxygen supplementation (47.33 ± 16.57 vs. 36.00 ± 8.49 vs. 4.60 ± 2.41 days, p = 0.001). There was no significant difference between single-born neonates and multiple-born neonates regarding the prevalence of other risk factors. Multiple-born neonates with no ROP and low risk ROP showed significantly lower GA and BW compared to singletons (p < 0.001).

CONCLUSION

Multiple gestation neonates may develop high-risk ROP requiring treatment at a greater gestational age and birth weight and at a lower duration of oxygen supplementation and NICU admission compared to the single birth neonates. This pattern prompts a reevaluation of screening criteria, suggesting a potential need to consider multiple birth neonates with lower traditional risk factors in screening programs. This pattern should be further evaluated in larger populations of multiple born premature neonates.

Association between fetal growth-restriction and retinopathy of prematurity using a unique identical twin model

BACKGROUND

Research in singletons identified fetal growth restriction (FGR) as a risk factor for retinopathy of prematurity (ROP), but is generally subject to confounding by genetic, obstetric, and maternal factors. We investigated the effect of FGR on ROP in growth-discordant identical twins, thereby controlling for confounding factors.

METHODS

All data of monochorionic (MC) twin pairs with a birth weight discordance ≥20% born in our center between 2010 and 2021 were retrospectively reviewed for the presence of ROP. Potential risk factors for ROP were analyzed. Outcomes were compared between the smaller and larger twin.

RESULTS

We included 88 MC twin pairs with growth discordance. In 34% (30/88), both neonates were at risk of ROP. Prevalence of ROP was higher among the smaller twin compared to the larger twin, 30% (9/30) versus 13% (4/30), respectively (OR 2.8, 95% CI: 1.2-6.6). The smaller twin had a longer duration of mechanical ventilation (8 (1-20) versus 2 (1-4) days) and received their first red blood cell transfusion at an earlier postmenstrual age (29.6 (28.1-31.6) versus 30.4 (29.7-32.6) weeks).

CONCLUSIONS

In this identical twin model, FGR is associated with almost tripled odds of ROP development, suggesting that both unfavorable antenatal growth conditions and adverse neonatal outcomes affect postnatal retinal vascular proliferation.

IMPACT

Fetal growth restriction in growth-discordant identical twins is associated with almost tripled odds of developing retinopathy of prematurity in the smaller twin. Since these twins do not only differ in birth weight but also duration of mechanical ventilation and timing of the first red blood cell transfusion, both unfavorable antenatal growth conditions and adverse neonatal outcomes can affect postnatal retinal vascular proliferation. More attention for preventing retinopathy of prematurity is needed in those with fetal growth restriction who received prolonged duration of mechanical ventilation, oxygen supplementation, or a first red blood cell transfusion <32 weeks postmenstrual age.

Visual impairment due to retinopathy of prematurity and concomitant disabilities in the Netherlands

AIM

Determine incidence of visual impairment due to retinopathy of prematurity (ROP) and concomitant disabilities between 2009 and 2018 in the Netherlands and compare data to four former similar studies. Secondly, monitor if infants were missed for ROP-screening since the adoption of stricter, risk factor guided criteria (2013).

METHODS

Retrospective inventory on anonymous data of infants diagnosed with ROP from Dutch visual impairment-institutes. Data including: best corrected visual acuity, ROP-treatment and concomitant disabilities: bronchopulmonary dysplasia, behavioral abnormalities, epilepsy, hearing deficit, developmental delay, cerebral palsy and cerebral visual impairment. During the study period, lower age limit for neonatal life support (2010) and higher oxygen saturation targets (2014) were implemented.

RESULTS

Records of 53 infants were analyzed. Visual impairment incidence due to ROP was 2.02 per 100.000 live births (2000-2009: 1.84, p = 0.643). Compared to earlier periods (1975-2000), a significant decrease was observed. The incidence of concomitant disabilities remained stable. Mean gestational age (GA) continued to decrease to 26.6 ± 1.9 weeks (2000-2009: 27.4 ± 2.0 weeks, p = 0.047). All patients met the screening inclusion criteria.

CONCLUSION

The incidence of visual impairment due to ROP and concomitant disabilities between 2009 and 2018 has not increased, despite lower GA and higher oxygen saturation targets. None of the infants were missed for ROP screening following introduction of more restricted screening inclusion criteria.

Most Up-to-Date Analysis of Epidemiological Data on the Screening Guidelines and Incidence of Retinopathy of Prematurity in Europe-A Literature Review

INTRODUCTION

Global predictions indicate that the incidence of retinopathy of prematurity (ROP) is increasing, but the lack of current epidemiological data on the occurrence of ROP in Europe prompted the authors to update these data.

METHODS

European studies related to the presence of ROP were analyzed, and the reason for the differences in the percentage of ROP and different screening criteria were checked.

RESULTS

The study presents results from individual and multiple centers. Current ROP incidence data varies from a low of 9.3% in Switzerland to the highest values of 64.1% in Portugal and 39.5% in Norway. The national screening criteria are used in the Netherlands, Germany, Norway, Poland, Portugal, Switzerland, and Sweden. Uniform criteria-Royal College of Paediatrics and Child Health guidelines are used in England and Greece. American Academy of Pediatrics screening guidelines are used in France and Italy.

CONCLUSIONS

The epidemiology of ROP in European countries varies significantly. The increase in the diagnosis and treatment rate of ROP in recent years correlates with the narrowing of diagnostic criteria in newly issued guidelines (which include the WINROP and G-ROP algorithms), a higher number of less developed preterm infants, and a lower percentage of live births.

Increased Risk of Retinopathy of Prematurity in Donors with Twin-to-Twin Transfusion Syndrome: A Cohort Study

INTRODUCTION

The purpose of this study was to evaluate the within-pair difference in retinopathy of prematurity (ROP) between donors and recipients with twin-to-twin transfusion syndrome (TTTS) and to identify risk factors for ROP development.

METHODS

This retrospective cohort study included 147 TTTS twin pairs managed between 2002 and 2022 and eligible for ROP screening. Primary outcomes were any stage ROP and severe ROP. Secondary outcomes were hemoglobin at birth, red blood cell transfusions, mechanical ventilation days, postnatal steroids, and neonatal morbidity. Donor status was defined as having polyhydramnios pre-laser.

RESULTS

Rates of any stage ROP (23% vs. 14%) and severe ROP (8% vs. 3%) were significantly higher in donors compared to recipients. Donors received a higher number of blood transfusions (1 [±1.9] versus 0.7 [±1.5]). Five factors were univariately associated with any stage ROP: donor status (odds ratio [OR] 1.9; 95% CI 1.3-2.9), lower gestational age (GA) at birth (OR 1.7; 95% CI 1.4-2.1), small for GA (OR 2.1; 95% CI 1.3-3.5), mechanical ventilation days (OR 1.1; 95% CI 1.1-1.2), and blood transfusions in phase 1 (OR 2.3; 95% CI 1.2-4.3). Three factors were independently associated with any stage ROP: donor status (OR 1.8; 95% CI 1.1-2.9), lower GA at birth (OR 1.6; 95% CI 1.2-2.1), and mechanical ventilation days (OR 1.1, 95% CI 1.0-1.1). Donor status was univariately associated with severe ROP (OR 2.3, 95% CI 1.1-5.0).

CONCLUSION

Any stage ROP and severe ROP are detected twice as frequently in donors compared to recipients. Increased awareness for ROP is needed in donors, especially those with lower GA at birth and longer duration of mechanical ventilation.

Cost reduction in screening for retinopathy of prematurity in the Netherlands by comparing different screening strategies

PURPOSE

Evaluate possibilities to reduce the number of infants screened for retinopathy of prematurity (ROP) and investigate costs and number of infants detected of current and alternative screening strategies in the Netherlands.

METHODS

Prospective population-based study including clinical data from all infants born in 2017 and referred for ROP screening (NEDROP-2 study). Cost and effects of screening strategies were evaluated that differed on the criteria gestational age (GA), birth weight (BW) and presence of one or more specific risk factor(s) (RF): mechanical ventilation, sepsis, necrotizing enterocolitis, postnatal corticoids and/or hypotension treated with inotropic agents. RF obtained from the Dutch perinatal registry (Perined).

RESULTS

Of the possible efficient strategies, the annual costs varied from €137 966 (inclusion of BW < 700, 63 infants eligible for screening, detection of 17/39 treated ROP) to €492 689 (GA < 30 weeks and BW < 1250 grams, together with infants with GA 30-32 and BW 1250-1500 grams with presence of one more RF, 744 infants eligible for screening, all treated infants detected). Total annual costs of the current Dutch guideline that detects all infants that need treatment for ROP amount to €552 143).

CONCLUSION

The current Dutch ROP guideline can be improved by implementing new screening inclusion criteria. The most effective strategy detecting all severe and treated infants, reduces the number of screened infants by 24% compared to the current guideline and the overall annual costs by €59454.

Evaluation of an Artificial Intelligence System for Retinopathy of Prematurity Screening in Nepal and Mongolia

PURPOSE

To evaluate the performance of a deep learning (DL) algorithm for retinopathy of prematurity (ROP) screening in Nepal and Mongolia.

DESIGN

Retrospective analysis of prospectively collected clinical data.

PARTICIPANTS

Clinical information and fundus images were obtained from infants in 2 ROP screening programs in Nepal and Mongolia.

METHODS

Fundus images were obtained using the Forus 3nethra neo (Forus Health) in Nepal and the RetCam Portable (Natus Medical, Inc.) in Mongolia. The overall severity of ROP was determined from the medical record using the International Classification of ROP (ICROP). The presence of plus disease was determined independently in each image using a reference standard diagnosis. The Imaging and Informatics for ROP (i-ROP) DL algorithm was trained on images from the RetCam to classify plus disease and to assign a vascular severity score (VSS) from 1 through 9.

MAIN OUTCOME MEASURES

Area under the receiver operating characteristic curve and area under the precision-recall curve for the presence of plus disease or type 1 ROP and association between VSS and ICROP disease category.

RESULTS

The prevalence of type 1 ROP was found to be higher in Mongolia (14.0%) than in Nepal (2.2%; P < 0.001) in these data sets. In Mongolia (RetCam images), the area under the receiver operating characteristic curve for examination-level plus disease detection was 0.968, and the area under the precision-recall curve was 0.823. In Nepal (Forus images), these values were 0.999 and 0.993, respectively. The ROP VSS was associated with ICROP classification in both datasets (P < 0.001). At the population level, the median VSS was found to be higher in Mongolia (2.7; interquartile range [IQR], 1.3-5.4]) as compared with Nepal (1.9; IQR, 1.2-3.4; P < 0.001).

CONCLUSIONS

These data provide preliminary evidence of the effectiveness of the i-ROP DL algorithm for ROP screening in neonatal populations in Nepal and Mongolia using multiple camera systems and are useful for consideration in future clinical implementation of artificial intelligence-based ROP screening in low- and middle-income countries.

Nine-Year Epidemiological Data on the Incidence of Retinopathy of Prematurity in Poland-A Literature Review for the 2012-2021 Period

BACKGROUND

The epidemiology of retinopathy of premature infants (ROP) in Poland is a topic rarely discussed in the literature. Single publications (Pubmed) concern only specific regions of Poland and date back to 2000-2006, which prompted the authors to update Polish epidemiological data.

METHODS

Data from the 2012-2021 screening tests were analyzed for: diagnosis of ROP, severe ROP and the percentage of ROP undergoing treatment (laser-diode, anti-VEGF, and complications such as retinal detachment). The Polish results were compared with the available data from Europe in the same period.

RESULTS

The analysis of the GOCC data confirmed that the prevalence of ROP in Poland for 2016-2019 was 15.1%; in 2012-2021 (15.6%). Polish epidemiological data shows a lower percentage of ROP diagnosis compared to other European countries (15.6% vs. 23.8% in Portugal, 28.3% in the Netherlands, 25.1% in Genoa, Italy, 38% in Florence, Italy).

CONCLUSIONS

In order to obtain and create an epidemiological database, it is important to undertake activities aimed at a detailed verification of the analyzed parameters and the collection of similar or the same data from all centers in Poland. There is no economic data available on the cost of caring for a child with ROP.

Optimization of retinopathy of prematurity screening in a tertiary neonatal unit in Northern Greece based on 16-year data

OBJECTIVE

The optimal modification of retinopathy of prematurity (ROP) screening policy in our unit, by tightening the applicable screening criteria, without missing treatment-requiring ROP (TR-ROP).

STUDY DESIGN

Retrospective analysis of screened infants with gestational age (GA) < 32 weeks and/or birth weight (BW) < 1501 g as well as cases beyond these thresholds but with comorbidities (April 2004 to April 2020).

RESULT

Of 1560 included infants, 18.4% (n = 288) developed any stage of ROP and 3.1% (n = 49) were treated. TR-ROP occurred at a mean (SD) 36^2/7 (2^5/7) weeks PMA, and not before a minimum of 32^3/7 weeks PMA. No treated infant would have been missed if screening criteria were reduced to GA < 30 weeks and/or BW < 1251 g. This modification would have resulted in 826 (52.9%) fewer infants undergoing screening.

CONCLUSION

Modifying the current screening criteria to GA < 30 weeks and/or BW < 1251 g would have spared over half of the screened infants from unnecessary examinations, without missing TR-ROP.

Nationwide inventory on retinopathy of prematurity screening in the Netherlands

PURPOSE

Provide up-to-date insight in incidence of retinopathy of prematurity (ROP), logistics of screening and treatment in the Netherlands and influence of the new national ROP guideline in which more stringent screening criteria were implemented and the early treatment for ROP criteria (ETROP) were emphasised.

METHODS

Multicentre prospective nationwide study including all preterm infants, born in the Netherlands in 2017, and considered eligible for ROP screening. Anonymised data from ophthalmologists and paediatricians were merged. Outcome data were compared with the first national ROP inventory (NEDROP-1, 2009).

RESULTS

In 2017, 1492 infants were live born with gestational age (GA) <32 weeks (2009: 1662); 1287 infants were eligible for screening (2009: 2033). Ophthalmologists screened 1085 infants, versus 1688 in 2009, corrected with factor 1.114 for the difference in number of live births, a 28.4% (479/1688) decrease in screened infants was seen. Among surviving infants with GA <32 week, ROP was found in 305/1492 babies, 20.4% (2009: 324/1662, 19.5%) of which 49/1492 stage ≥3, 3.3% (2009: 30/1662, 1.8%). In all infants, report on presence or absence of plus disease was provided, according to the ETROP criteria. Treatment was performed in 39 infants. Of infants with ROP stage ≥3, 3/49 (6.1%) progressed to retinal detachment (2009: 6/30, 20.0%).

CONCLUSION

The overall ROP incidence expressed as a percentage, remained stable but the number of infants that developed severe ROP nearly doubled. A near one-third reduction in screened infants shows satisfactory implementation of the new screening criteria. A notable decrease in retinal detachment delineates improved treatment outcome.

Quantification of Early Neonatal Oxygen Exposure as a Risk Factor for Retinopathy of Prematurity Requiring Treatment

Purpose

Retinopathy of prematurity (ROP) is a leading cause of childhood blindness related to oxygen exposure in premature infants. Since oxygen monitoring protocols have reduced the incidence of treatment-requiring ROP (TR-ROP), it remains unclear whether oxygen exposure remains a relevant risk factor for incident TR-ROP and aggressive ROP (A-ROP), a severe, rapidly progressing form of ROP. The purpose of this proof-of-concept study was to use electronic health record (EHR) data to evaluate early oxygen exposure as a predictive variable for developing TR-ROP and A-ROP.

Design

Retrospective cohort study.

Participants

Two hundred forty-four infants screened for ROP at a single academic center.

Methods

For each infant, oxygen saturations and fraction of inspired oxygen (FiO₂) were extracted manually from the EHR until 31 weeks postmenstrual age (PMA). Cumulative minimum, maximum, and mean oxygen saturation and FiO₂ were calculated on a weekly basis. Random forest models were trained with 5-fold cross-validation using gestational age (GA) and cumulative minimum FiO₂ at 30 weeks PMA to identify infants who developed TR-ROP. Secondary receiver operating characteristic (ROC) curve analysis of infants with or without A-ROP was performed without cross-validation because of small numbers.

Main Outcome Measures

For each model, cross-validation performance for incident TR-ROP was assessed using area under the ROC curve (AUC) and area under the precision-recall curve (AUPRC) scores. For A-ROP, we calculated AUC and evaluated sensitivity and specificity at a high-sensitivity operating point.

Results

Of the 244 infants included, 33 developed TR-ROP, of which 5 developed A-ROP. For incident TR-ROP, random forest models trained on GA plus cumulative minimum FiO₂ (AUC = 0.93 ± 0.06; AUPRC = 0.76 ± 0.08) were not significantly better than models trained on GA alone (AUC = 0.92 ± 0.06 [P = 0.59]; AUPRC = 0.74 ± 0.12 [P = 0.32]). Models using oxygen alone showed an AUC of 0.80 ± 0.09. ROC analysis for A-ROP found an AUC of 0.92 (95% confidence interval, 0.87–0.96).

Conclusions

Oxygen exposure can be extracted from the EHR and quantified as a risk factor for incident TR-ROP and A-ROP. Extracting quantifiable clinical features from the EHR may be useful for building risk models for multiple diseases and evaluating the complex relationships among oxygen exposure, ROP, and other sequelae of prematurity.

Retinopathy prematurity: a systematic review and meta-analysis study based on neonatal and maternal risk factors

BACKGROUND

Retinopathy of prematurity is the abnormal development of retinal arteries in preterm neonates less than 32 weeks and weighing 1500 g, and less, which can lead to visual impairment during life and blindness. This study aims to investigate the relationship between some clinical characteristics of neonates and mothers with Retinopathy of prematurity in the world via a systematic review and meta-analysis.

MATERIALS AND METHODS

The present study is a systematic review and meta-analysis on the relationship between maternal and neonatal clinical variables with Retinopathy of prematurity in the world from the beginning of 2000 to the end of 2020. Accordingly, all English articles published on the topic were searched in scientific databases of Web of Science, PubMed, Google Scholar, Science Direct, and Scopus. The articles were searched independently by two researchers. Statistical analysis of data was performed using fixed and random effects model statistical tests in the meta-analysis, Cochran, meta-regression, I² index, Funnel plot, and Begg's by STATA software program, version 14.

RESULT

A total of 191 studies with a sample size of 140,921 persons were including in the meta-analysis. Accordingly, Preterm delivery ≤28 weeks (OR:6.3, 95% CI:4.9-8.1), Birth Weight ≤1000 g (OR:5.8, 95% CI:4.8-6.8), Birth Weight ≤1500 g (OR:4.8, 95% CI:3.8-6.1), PROM (OR:1.2, 95% CI:1.0-1.4), induced fertility (OR:1.9, 95% CI:1.1-3.0) and Chorioamnionitis (OR:1.5, 95% CI:1.0-2.2) There was a statistically significant association with retinopathy.

CONCLUSION

Based on the results of the present meta-analysis, the risk of retinopathy of prematurity in neonates born at 28 weeks and less, LBW (weight 1500 g and less), neonatal hypotension, chorioamnionitis, and induced fertility increases.

[Screening for retinopathy of prematurity-the most important changes in the new German guidelines 2020]

Hintergrund

Durch Verbesserungen in der neonatologischen Versorgung von Frühgeborenen und die Entwicklung neuer Behandlungsmöglichkeiten der Frühgeborenenretinopathie („retinopathy of prematurity“ [ROP]) haben sich die Anforderungen an das ROP-Screening seit der Veröffentlichung der letzten Fassung der deutschen Leitlinie zum ROP-Screening im Jahr 2008 verändert. Auf Grundlage aktueller Studiendaten wurde die Leitlinie in 2020 grundlegend überarbeitet und in einer aktualisierten Fassung veröffentlicht.

Ziel

Dieser Artikel fasst die wichtigsten Änderungen in der neuen Leitlinie zusammen.

Ergebnisse

Die Altersgrenze für einen Screeningeinschluss wurde für Kinder ohne zusätzliche Risikofaktoren auf ein Gestationsalter von unter 31 Wochen gesenkt. Die Mindestdauer für eine Sauerstoffsupplementation, die einen Einschluss in das Screening bei Frühgeborenen erforderlich macht, wurde auf über 5 Tage angehoben. Eine Behandlung bei ROP in Zone II kann nun schon bei jedem Stadium 3 mit Plus-Symptomatik unabhängig von der Anzahl der betroffenen Uhrzeiten erfolgen. Für die Nachkontrollen nach Anti-VEGF („vascular endothelial growth factor“)-Therapie wurden Kriterien zur Frequenz und Dauer definiert. Das verbindliche Dokument für diese und weitere neue Empfehlungen ist die Leitlinie selber.

Schlussfolgerungen

Die Empfehlungen der Leitlinie ermöglichen eine zuverlässige Identifikation von Kindern mit ROP-Risiko für den Einschluss in das Screening und eine rechtzeitige Erkennung fortgeschrittener Krankheitsstadien für die Therapieeinleitung, um so Erblindung durch ROP zu verhindern.

Perinatal events predicting retinopathy of prematurity in extremely pre-term infants

BACKGROUND

Extremely preterm infants are peculiar in regard to their risk of retinopathy of prematurity (ROP). In this study, we aim to study insults that may affect extremely preterm infants, including prenatal, at birth, and postnatal insults and their effect on the development of ROP.

METHODS

This study used the data from Prematurity and Respiratory Outcomes Program (PROP). All included infants with a gestational age of 23 0/7 to 28 6/7 weeks using best obstetrical estimate. We included stressful events and/or modifiable variables that may affect the normal development. We used multiple regression analysis in our statistical analysis.

RESULTS

We included a total of 751 infants in our study. The mean birth weight for the included sample was 915.1 (±232.94) grams. 391 (52.1%) Infants were diagnosed with ROP. We found a significant negative correlation between ROP development and birth weight (p < 0.001), with a correlation coefficient of - 0.374. We found that the need for prophylactic indomethacin (OR 1.67), the occurrence of air leaks (OR: 2.35), ventilator-associated pneumonia (OR: 2.01), isolated bowel perforations (OR: 3.7), blood culture-proven sepsis (OR: 1.5), other infections (OR: 1.44), and receiving ventricular shunt (OR: 2.9) are significantly associated with the development of ROP.

CONCLUSIONS

We believe this study included the largest number of factors studied in the largest sample of extremely premature infants. We recommend a screening program for extremely preterm infants that takes into account a scoring system with higher scores for complicated condition.

Incidence of retinopathy of prematurity in Germany: evaluation of current screening criteria

OBJECTIVE

To evaluate current screening criteria for retinopathy of prematurity (ROP) by investigating the incidence of ROP requiring treatment in infants with gestational age (GA) ≥30 weeks or postmenstrual age (PMA) <32 weeks in Germany.

METHODS

Three patient databases were analysed, that is, the German Quality Assurance Procedure in Neonatology (years 2011-2017; n=52 461 infants screened for ROP, 1505 infants treated for ROP), the German Retina.net ROP Registry (years 2011-2018; n=281 treated infants) and the ROP screening programme of two German university hospitals (years 2012-2016; n=837 screened infants).

RESULTS

In the analysed cohorts, infants with GA ≥30 weeks represented 33.1%-38.5% of the screening populations but only 1.40%-1.42% of the cases requiring ROP treatment. In a cohort of 281 infants treated for ROP, all 4 infants with GA ≥30 weeks had additional risk factors for ROP including prolonged oxygen supplementation and/or significant comorbidities. Five infants (1.8%) were treated at 32 weeks PMA and none at PMA <32 weeks.

CONCLUSIONS

In the investigated cohorts, preterm infants with GA ≥30 weeks carried a very low or no risk for developing treatment-requiring ROP unless additional risk factors were present, and no treatment was performed earlier than 32 weeks PMA. These findings are of relevance for the ongoing re-evaluation of ROP screening criteria.

Increase in treatment of retinopathy of prematurity in the Netherlands from 2010 to 2017

Purpose

Compare patients treated for Retinopathy of Prematurity (ROP) in two consecutive periods.

Methods

Retrospective inventory of anonymized neonatal and ophthalmological data of all patients treated for ROP from 2010 to 2017 in the Netherlands, subdivided in period (P)1: 1‐1‐2010 to 31‐3‐2013 and P2: 1‐4‐2013 to 31‐12‐2016. Treatment characteristics, adherence to early treatment for ROP (ETROP) criteria, outcome of treatment and changes in neonatal parameters and policy of care were compared.

Results

Overall 196 infants were included, 57 infants (113 eyes) in P1 and 139 (275 eyes) in P2, indicating a 2.1‐fold increase in ROP treatment. No differences were found in mean gestational age (GA) (25.9 ± 1.7 versus 26.0 ± 1.7 weeks, p = 0.711), mean birth weight (791 ± 311 versus 764 ± 204 grams, p = 0.967) and other neonatal risk factors for ROP. In P2, the number of premature infants born <25 weeks increased by factor 1.23 and higher oxygen saturation levels were aimed at in most centres. At treatment decision, 59.6% (P1) versus 83.5% (P2) (p = 0.263) infants were classified as Type 1 ROP (ETROP classification). Infants were treated with laser photocoagulation (98 versus 96%) and intravitreal bevacizumab (2 versus 4%). Retreatment was necessary in 10 versus 21 (p = 0.160). Retinal detachment developed in 6 versus 13 infants (p = 0.791) of which 2 versus 6 bilateral (p = 0.599).

Conclusion

In period 2, the number of infants treated according to the ETROP criteria (Type 1) increased, the number of ROP treatments, retinal detachments and retreatments doubled and the absolute number of retinal detachments increased. Neonatal data did not provide a decisive explanation, although changes in neonatal policy were reported.

Translational Research in Retinopathy of Prematurity: From Bedside to Bench and Back Again

Retinopathy of prematurity (ROP), a vascular proliferative disease affecting preterm infants, is a leading cause of childhood blindness. Various studies have investigated the pathogenesis of ROP. Clinical experience indicates that oxygen levels are strongly correlated with ROP development, which led to the development of oxygen-induced retinopathy (OIR) as an animal model of ROP. OIR has been used extensively to investigate the molecular mechanisms underlying ROP and to evaluate the efficacy of new drug candidates. Large clinical trials have demonstrated the efficacy of anti-vascular endothelial growth factor (VEGF) agents to treat ROP, and anti-VEGF therapy is presently becoming the first-line treatment worldwide. Anti-VEGF therapy has advantages over conventional treatments, including being minimally invasive with a low risk of refractive error. However, long-term safety concerns and the risk of late recurrence limit this treatment. There is an unmet medical need for novel ROP therapies, which need to be addressed by safe and minimally invasive therapies. The recent progress in biotechnology has contributed greatly to translational research. In this review, we outline how basic ROP research has evolved with clinical experience and the subsequent emergence of new drugs. We discuss previous and ongoing trials and present the candidate molecules expected to become novel targets.

A Good Way to Reduce Screening for Retinopathy of Prematurity: Development of the ROP Model in a China Preterm Population

Importance: Retinopathy of prematurity (ROP) is a preventable cause of blindness in children. Without treatment, more than 45% of eyes may suffer permanent vision loss. Current ROP screening guidelines, which include a range of birth weights (BWs) and gestational ages (GAs), may require screening many low-risk preemies who might develop severe ROP. Method: All high-risk infants in the neonatal intensive care unit (NICU) of the First Affiliated Hospital of Zhengzhou University from 2017 to 2021 were included in this retrospective cohort study. Each of the 27 candidate risk factors was evaluated in univariate analysis and adjusted for known risk factors (i.e., GA and BW). The significant results were analyzed in a backward selection multivariate logistic regression model. Receiver operating characteristic (ROC) curves and a nomogram were drawn. Results: The study included 2,040 infants who underwent ROP screening. The weight gain rate [OR, 2.65; 95% confidence interval (CI), 1.49-1.21 ≤ 12 g/d vs. > 18 g/d; P = 0.001], blood transfusion (OR, 2.03; 95% CI, 1.14-3.64; P = 0.017), invasive mechanical ventilation (OR, 1.74; 95% CI, 1.15-2.66; P = 0.009) and N-terminal segment of pro-B-type natriuretic peptide (NT-proBNP) ≥ 25,000 ng/L (OR, 1.51; 95% CI, 1.00-2.28; P = 0.048) were four new statistically independent risk factors in addition to GA and BW. The area under the curve (AUC) of the final multivariate model was 0.90 (95% CI, 0.88-0.92; P < 0.001). Conclusions and Relevance: These findings add to our understanding of ROP screening because they include all eligible infants rather than only high-risk infants, as in previous studies. Under the control of BW and GA, low weight gain rate, increased number of blood transfusion, invasive mechanical ventilation and NT-proBNP ≥ 25,000 ng/L were "new" statistically independent risk factors for ROP. The ROP risk can be calculated manually or represented by a nomogram for clinical use.

Risk Factors for Retinopathy of Prematurity in the Netherlands: A Comparison of Two Cohorts

INTRODUCTION

Retinopathy of prematurity (ROP) remains an important cause for preventable blindness. Aside from gestational age (GA) and birth weight, risk factor assessment can be important for determination of infants at risk of (severe) ROP.

METHODS

Prospective, multivariable risk-analysis study (NEDROP-2) was conducted, including all infants born in 2017 in the Netherlands considered eligible for ROP screening by pediatricians. Ophthalmologists provided data of screened infants, which were combined with risk factors from the national perinatal database (Perined). Clinical data and potential risk factors were compared to the first national ROP inventory (NEDROP-1, 2009). During the second period, more strict risk factor-based screening inclusion criteria were applied.

RESULTS

Of 1,287 eligible infants, 933 (72.5%) were screened for ROP and matched with the Perined data. Any ROP was found in 264 infants (28.3% of screened population, 2009: 21.9%) and severe ROP (sROP) (stage ≥3) in 41 infants (4.4%, 2009: 2.1%). The risk for any ROP is decreased with a higher GA (odds ratio [OR] 0.59 and 95% confidence interval [CI] 0.54-0.66) and increased for small for GA (SGA) (1.73, 1.11-2.62), mechanical ventilation >7 days (2.13, 1.35-3.37) and postnatal corticosteroids (2.57, 1.44-4.66). For sROP, significant factors were GA (OR 0.37 and CI 0.27-0.50), SGA (OR 5.65 and CI 2.17-14.92), postnatal corticosteroids (OR 3.81 and CI 1.72-8.40), and perforated necrotizing enterocolitis (OR 7.55 and CI 2.29-24.48).

CONCLUSION

In the Netherlands, sROP was diagnosed more frequently since 2009. No new risk factors for ROP were determined in the present study, apart from those already included in the current screening guideline.

Risk of development of treated retinopathy of prematurity in very low birth weight infants

OBJECTIVE

Quantify the risk of treatment for retinopathy of prematurity (ROP) among infants meeting current U.S. screening guidelines.

STUDY DESIGN

Among infants ≤1500 g birth weight or ≤30 weeks gestation screened for ROP from 2006-2015, we developed a risk prediction model to identify infants treated for ROP. We applied our model to a separate infant cohort discharged in 2016.

RESULT

Seventy-five thousand eight hundred and twenty one infants met inclusion criteria; 2306 (3%) were treated for ROP. Infants with several risk factor combinations (no ventilator support or oxygen on postnatal day 28, no history of necrotizing enterocolitis, and no intraventricular hemorrhage) were at low risk of ROP. Applied to 6127 infants discharged in 2016, our model had 97.9% sensitivity, 63.3% specificity, positive predictive value of 4.0%, and negative predictive value of 99.9%.

CONCLUSION

Large numbers of infants at low risk of developing ROP are required to undergo screening. Refining current ROP guidelines may reduce unnecessary examinations.

New modifications of Swedish ROP guidelines based on 10-year data from the SWEDROP register

BACKGROUND/AIMS

During the last decade, improved neonatal care has resulted in increased survival of the most immature infants and improved health of more mature infants. We hypothesise that this has affected incidence and treatment of retinopathy of prematurity (ROP), enabling guidelines for screening to be modified.

METHODS

In Sweden, all infants with gestational age (GA) at birth ≤30 weeks are screened for ROP. Results are registered in a web-based register, Swedish National ROP Register, with a coverage rate of 97%. Incidence of ROP and frequency of treatment, aspects on natural course of ROP and number of examinations, are calculated in relation to GA at birth in infants born during 2008-2017.

RESULTS

Of 7249 infants, 31.9% (2310) had ROP and 6.1% (440) were treated. No infant with GA 30 weeks was treated. Incidence of ROP remained similar, but frequency of treatment increased (p=0.023). Over time, GA and birth weight were reduced in infants with ROP and with treated ROP. In the most immature infants, postmenstrual age was lower and postnatal age was higher when any ROP and stage 3 ROP were first detected (p<0.001). At treatment, postmenstrual but not postnatal age of the infant was associated with GA (p<0.001). During the 10-year period, 46 038 examinations were performed.

CONCLUSION

Modification of Swedish guidelines is proposed, including only infants with a GA of <30 weeks and postponing the first examination with 1 week in infants with GA 26-29 weeks. This would spare many infants from stressful examinations and reduce eye examinations with at least 20%.

Postnatal weight gain and retinopathy of prematurity

Infants meeting retinopathy of prematurity (ROP) screening guidelines based on birth weight and gestational age undergo serial examinations by ophthalmologists for detection and treatment. However, less than 10% require treatment, and less than half develop ROP. Slow postnatal weight gain is highly predictive of ROP, and investigators have incorporated weight gain measures to develop more specific criteria for ROP screening. Such clinical prediction model use involves a large development study, validation studies specific to the target populations, and ongoing impact surveillance, with adjustment as necessary. Of the many weight gain inclusive prediction models intended to improve the precision of ROP screening, the Postnatal Growth and ROP (G-ROP) modified screening criteria were developed using the largest dataset and may provide the most robust model for clinical use. A recently completed G-ROP validation study will evaluate the generalizability of these modified criteria prior to clinical use.

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.

Validation of the Colorado Retinopathy of Prematurity Screening Model

Importance

The Colorado Retinopathy of Prematurity (CO-ROP) model uses birth weight, gestational age, and weight gain at the first month of life (WG-28) to predict risk of severe retinopathy of prematurity (ROP). In previous validation studies, the model performed very well, predicting virtually all cases of severe ROP and potentially reducing the number of infants who need ROP examinations, warranting validation in a larger, more diverse population.

Objective

To validate the performance of the CO-ROP model in a large multicenter cohort.

Design, Setting, Participants

This study is a secondary analysis of data from the Postnatal Growth and Retinopathy of Prematurity (G-ROP) Study, a retrospective multicenter cohort study conducted in 29 hospitals in the United States and Canada between January 2006 and June 2012 of 6351 premature infants who received ROP examinations.

Main Outcomes and Measures

Sensitivity and specificity for severe (early treatment of ROP [ETROP] type 1 or 2) ROP, and reduction in infants receiving examinations. The CO-ROP model was applied to the infants in the G-ROP data set with all 3 data points (infants would have received examinations if they met all 3 criteria: birth weight, <1501 g; gestational age, <30 weeks; and WG-28, <650 g). Infants missing WG-28 information were included in a secondary analysis in which WG-28 was considered fewer than 650 g.

Results

Of 7438 infants in the G-ROP study, 3575 (48.1%) were girls, and maternal race/ethnicity was 2310 (31.1%) African American, 3615 (48.6%) white, 233 (3.1%) Asian, 40 (0.52%) American Indian/Alaskan Native, and 93 (1.3%) Pacific Islander. In the study cohort, 747 infants (11.8%) had type 1 or 2 ROP, 2068 (32.6%) had lower-grade ROP, and 3536 (55.6%) had no ROP. The CO-ROP model had a sensitivity of 96.9% (95% CI, 95.4%-97.9%) and a specificity of 40.9% (95% CI, 39.3%-42.5%). It missed 23 (3.1%) infants who developed severe ROP. The CO-ROP model would have reduced the number of infants who received examinations by 26.1% (95% CI, 25.0%-27.2%).

Conclusions and Relevance

The CO-ROP model demonstrated high but not 100% sensitivity for severe ROP and missed infants who might require treatment in this large validation cohort. The model requires all 3 criteria to be met to signal a need for examinations, but some infants with a birth weight or gestational age above the thresholds developed severe ROP. Most of these infants who were not detected by the CO-ROP model had obvious deviation in expected weight trajectories or nonphysiologic weight gain. These findings suggest that the CO-ROP model needs to be revised before considering implementation into clinical practice.

N-terminal B-type natriuretic peptide urinary concentrations and retinopathy of prematurity

BackgroundTo validate the findings of a single-center pilot study showing elevated urinary N-terminal B-type natriuretic peptide (NTproBNP) concentrations in preterm infants subsequently developing severe retinopathy of prematurity (ROP) in a multicenter setting across eight European and Middle East countries.MethodsProspective observational study in 967 preterm infants <30 weeks' gestational age assessing the capacity of urinary NTproBNP on days of life (DOLs) 14 and 28 to predict ROP requiring treatment.ResultsUrinary NTproBNP concentrations were markedly elevated in infants who developed ROP requiring treatment (n=94) compared with survivors without ROP treatment (n=837), at both time points (median (interquartile range) DOL14: 8,950 (1,925-23,783) vs. 3,083 (1,193-17,393) vs. 816 (290-3,078) pg/ml, P<0.001) and DOL28 (2,203 (611-4,063) vs. 1,671 (254-11,340) vs. 408 (162-1,126) pg/ml, P<0.001). C-statistic of NTproBNP for treated ROP or death was 0.731 (95% confidence interval 0.654-0.774) for DOL14 and 0.683 (0.622-0.745) for DOL28 (P<0.001). Threshold scores were calculated, potentially enabling around 20% of infants with low NTproBNP scores never to be screened with ophthalmoscopy.ConclusionThere is a strong association between early urinary NTproBNP and subsequent ROP development, which can be used to further refine subgroups of patients with high or low risk of severe ROP.

Can a Risk Factor Based Approach Safely Reduce Screening for Retinopathy of Prematurity?

Objective. Current American retinopathy of prematurity (ROP) screening guidelines is imprecise for infants ≥ 30 weeks with birth weights between 1500 and 2000 g. Our objective was to evaluate a risk factor based approach for screening premature infants at low risk for severe ROP. Study Design. We performed a 13-year review from Intermountain Health Care (IHC) data. All neonates born at ≤32 weeks were reviewed to determine ROP screening and/or development of severe ROP. Severe ROP was defined by stage ≥ 3 or need for laser therapy. Regression analysis was used to identify significant risk factors for severe ROP. Results. We identified 4607 neonates ≤ 32 weeks gestation. Following exclusion for death, with no retinal exam or incomplete data, 2791 (61%) were included in the study. Overall, severe ROP occurred in 260 (9.3%), but only 11/1601 ≥ 29 weeks (0.7%). All infants with severe ROP ≥ 29 weeks had at least 2 identified ROP risk factors. Implementation of this risk based screening strategy to the IHC population over the timeline of this study would have eliminated screening in 21% (343/1601) of the screened population. Conclusions. Limiting ROP screening for infants ≥ 29 and ≤ 32 weeks to only those with clinical risk factors could significantly reduce screening exams while identifying all infants with severe ROP.

Risk Score for Predicting Treatment-Requiring Retinopathy of Prematurity (ROP) in the Telemedicine Approaches to Evaluating Acute-Phase ROP Study

PURPOSE

To develop a risk score for predicting treatment-requiring retinopathy of prematurity (TR-ROP) in the Telemedicine Approaches to Evaluating Acute-Phase Retinopathy of Prematurity (e-ROP) study.

DESIGN

Second analyses of an observational cohort study.

PARTICIPANTS

Infants with birth weight (BW) <1251 g who had ≥1 imaging session by 34 weeks of postmenstrual age (PMA) and ≥1 subsequent retinopathy of prematurity (ROP) examination for determining TR-ROP by study-certified ophthalmologists.

METHODS

Nonphysician trained readers evaluated wide-field retinal image sets for characteristics of ROP, pre-plus/plus disease, and retinal hemorrhage. Risk score points for predicting TR-ROP were derived from the regression coefficients of significant predictors in a multivariate logistic regression model.

MAIN OUTCOME MEASURES

TR-ROP.

RESULTS

Eighty-five of 771 infants (11.0%) developed TR-ROP. In a multivariate model, significant predictors for TR-ROP were gestational age (GA) (odds ratio [OR], 5.7; 95% confidence interval [CI], 1.7-18.9 for ≤25 vs. ≥28 weeks), need for respiratory support (OR, 7.0; 95% CI, 1.3-37.1 for high-frequency oscillatory ventilation vs. no respiratory support), slow weight gain (OR, 2.4; 95% CI, 1.2-4.6 for weight gain ≤12 g/day vs. >15 g/day), and image findings at the first image session including number of quadrants with pre-plus (OR, 3.8; 95% CI, 1.5-9.7 for 4 pre-plus quadrants vs. no pre-plus), stage and zone of ROP (OR, 4.7; 95% CI, 2.1-11.8 for stage 1-2 zone I, OR, 5.9; 95% CI, 2.1-16.6 for stage 3 zone I vs. no ROP), and presence of blot hemorrhage (OR, 3.1; 95% CI, 1.4-6.7). Image findings predicted TR-ROP better than GA (area under receiver operating characteristic curve [AUC] = 0.82 vs. 0.75, P = 0.03). The risk of TR-ROP steadily increased with higher risk score and predicted TR-ROP well (AUC = 0.88; 95% CI, 0.85-0.92). Risk score ≥3 points for predicting TR-ROP had a sensitivity of 98.8%, specificity of 40.1%, and positive and negative predictive values of 17.0% and 99.6%, respectively.

CONCLUSIONS

Image characteristics at 34 PMA weeks or earlier independently predict TR-ROP. If externally validated in other infants, risk score, calculated from image findings, GA, weight gain, and respiratory support, enables early identification of infants in need of increased surveillance for TR-ROP.

Aggressive Posterior Retinopathy of Prematurity Is Associated with Multiple Infectious Episodes and Thrombocytopenia

BACKGROUND

The most severe form of rapidly progressing retinopathy of prematurity (ROP) is termed aggressive posterior ROP (APROP). APROP frequently causes severe visual impairment in affected preterm infants despite timely and appropriate laser treatment.

OBJECTIVES

We investigated the postnatal characteristics associated with APROP development in a national Swedish cohort.

METHODS

This retrospective, 1:1 matched case-control study included all infants that developed APROP in zone 1 (n = 9) between 2008 and 2012. Control infants, matched for gestational age and birth weight, developed ROP no worse than stage 2 (n = 9). We retrieved data from medical records on infant birth characteristics, postnatal morbidities, and blood analyses from birth to the first ROP treatment. Infectious episodes included sepsis, C-reactive protein ≥10 mg/l, and other clinical signs of infection that required antibiotic treatment. A platelet count <100 × 109/l was considered to be thrombocytopenia.

RESULTS

All APROP cases postnatally developed at least two infectious episodes, one in the first month and one around the time of ROP diagnosis. All APROP cases exhibited thrombocytopenia in the first month, and 6/9 exhibited thrombocytopenia around the time of ROP diagnosis. Compared to the controls, APROP cases more frequently developed necrotizing enterocolitis (8/9 vs. 1/9; p < 0.01) and sepsis (9/9 vs. 3/9; p < 0.01), and they had significantly lower median platelet counts (90 × 109/l, range 4-459, vs. 158 × 109/l, range 20-500; p < 0.001).

CONCLUSION

Multiple infectious episodes and thrombocytopenia, particularly around the time of ROP diagnosis, were associated with APROP development.

Clinical Models and Algorithms for the Prediction of Retinopathy of Prematurity: A Report by the American Academy of Ophthalmology

OBJECTIVE

To assess the accuracy with which available retinopathy of prematurity (ROP) predictive models detect clinically significant ROP and to what extent and at what risk these models allow for the reduction of screening examinations for ROP.

METHODS

A literature search of the PubMed and Cochrane Library databases was conducted last on May 1, 2015, and yielded 305 citations. After screening the abstracts of all 305 citations and reviewing the full text of 30 potentially eligible articles, the panel members determined that 22 met the inclusion criteria. One article included 2 studies, for a total of 23 studies reviewed. The panel extracted information about study design, study population, the screening algorithm tested, interventions, outcomes, and study quality. The methodologist divided the studies into 2 categories-model development and model validation-and assigned a level of evidence rating to each study. One study was rated level I evidence, 3 studies were rated level II evidence, and 19 studies were rated level III evidence.

RESULTS

In some cohorts, some models would have allowed reductions in the number of infants screened for ROP without failing to identify infants requiring treatment. However, the small sample size and limited generalizability of the ROP predictive models included in this review preclude their widespread use to make all-or-none decisions about whether to screen individual infants for ROP. As an alternative, some studies proposed approaches to apply the models to reduce the number of examinations performed in low-risk infants.

CONCLUSIONS

Additional research is needed to optimize ROP predictive model development, validation, and application before such models can be used widely to reduce the burdensome number of ROP screening examinations.

Cost and effects of risk factor guided screening strategies for retinopathy of prematurity for different treatment strategies

PURPOSE

To investigate the cost and effects of risk factor guided screening strategies for retinopathy of prematurity.

METHODS

Clinical data from the Netherlands Retinopathy of Prematurity study (NEDROP study) that included all infants screened for ROP and born in 2009 were used to assess the cost and effects of several screening strategies for ROP using different criteria: (1) gestational age (GA), (2) birthweight (BW), (3) combined GA-BW and (4) combined GA-BW and presence of risk factors. Two treatment strategies were evaluated: the infants actually treated in the NEDROP study (n = 17) and all infants detected with severe ROP (n = 29).

RESULTS

The most efficient screening strategy to include all infants treated for both treatment strategies is to screen all infants with a GA of 30 weeks or less and a BW of 1250 g or lower together with infants with a GA of 30-32 weeks and a BW of 1250-1500 g with at least one risk factor. The marginal cost ranged from €43 848 to € 226 914 per additional infant with improved vision.

CONCLUSION

The current Dutch guideline may be improved: the same effectiveness can be obtained for lower costs. Releasing the precondition that no infants with severe ROP might be missed will lead to lower costs, but this will also lead to a lower number of infants with improved visual acuity. The costs of detecting all infants with severe ROP seem acceptable for society when the QALY gain and savings from a societal perspective resulting from improved vision are taken into account.

Incidence and severity of retinopathy of prematurity in Turkey

BACKGROUND

The purpose of this study was to estimate the current incidence of retinopathy of prematurity (ROP) and the need for treatment in preterm infants in Turkey.

METHODS

The study included preterm infants who had been screened for ROP between 2011 and 2013 in 49 neonatal intensive care units. Infants with birth weight (BW) ≤1500 g or ≤32 weeks' gestational age and those with BW >1500 g or >32 weeks' GA with an unstable clinical course were included. The incidence of any ROP or severe ROP and treatment modalities were determined.

RESULTS

The study population included 15 745 preterm infants: 11 803 (75%) with GA ≤32 weeks, and 3942 (25%) with GA >32 weeks. Overall, 30% were found to have any stage of ROP, and 5% had severe ROP. Severe ROP was diagnosed in 8.2% of infants with BW ≤1500 g and 0.6% of infants with BW >1500 g. Of all infants diagnosed with ROP, 16.5% needed laser photocoagulation, and 20 patients born at >32 weeks' GA required this treatment modality. Vitroretinal surgery was performed in 28 infants with severe ROP: 23 with GA ≤28 weeks and 5 with GA 29-32 weeks.

CONCLUSIONS

The findings of our study have the important implication that more mature babies are at risk of severe ROP requiring treatment. An effective programme for detecting and treating ROP should be established in Turkey.

TRIAL REGISTRATION NUMBER

orcid.org/0000-0002-1329-2167.

Retinopathy of prematurity risk prediction for infants with birth weight less than 1251 grams

OBJECTIVE

To predict retinopathy of prematurity (ROP) exam findings among infants with birth weight <1251 g from 32-40 weeks postmenstrual age (PMA).

STUDY DESIGN

Secondary analysis of 3714 eye exams from 1239 infants.

RESULTS

The likelihood of developing type 1 ROP by 40 weeks PMA varied by gestational age (GA) (P < .001), from 33% for ≤25 weeks, 10% for 26 or 27 weeks, 4% for 28 or 29 weeks, and none for ≥30 weeks. By 40 weeks PMA, 51% with GA ≤27 weeks still needed subsequent exams. Previous exam findings, GA, and PMA were predictive of the development of type 1 ROP (area under the curve, 0.78) or mature retina (area under the curve, 0.85).

CONCLUSIONS

This analysis provides the opportunity for development of an ROP approach to estimate resource needs in the neonatal intensive care unit and to facilitate communication with families when planning discharge or transfer.