Incidence and risk factors of retinopathy of prematurity in three neonatal intensive care units in Palestine

Hyperbilirubinemia and retinopathy of prematurity: a retrospective cohort study

Retinopathy of prematurity (ROP) is a vasoproliferative retinal disease in preterm infants. Oxidative stress plays a key role in the pathogenesis of ROP. Due to its antioxidant effects, bilirubin has been proposed to be protective against ROP. This study explored the association between hyperbilirubinemia and ROP. We analyzed a 10-year cohort from a neonatal intensive care unit in Milan, Italy, including 1606 infants born under 32 weeks and/or < 1500 g. Data from 1606 infants meeting specific inclusion criteria were reviewed. Eighty infants were excluded due to lack of data, 1526 were deemed eligible for analysis, and 1269 had hyperbilirubinemia requiring phototherapy. There was a higher incidence of ROP among infants with hyperbilirubinemia (13.8%) versus those without (7.8%, p<0.01). Infants with any ROP, non-severe or severe ROP, were exposed to hyperbilirubinemia for a significantly higher number of days compared with those without ROP. Each additional day of exposure increases the risk of developing any ROP by 5%, non-severe ROP by 4%, and severe ROP by 6%. However, this correlation was not observed in infants with gestational age less than 27 weeks and/or body weight less than 1000 g.    Conclusion: Our data show that hyperbilirubinemia requiring phototherapy is associated with an increased risk of developing ROP. However, severe hyperbilirubinemia and ROP share many of their risk factors. Therefore, rather than being a risk factor itself, hyperbilirubinemia may be a surrogate for other risk factors for ROP.    Clinical Trial Registration: NCT05806684. What is Known: • The development of retinopathy of prematurity (ROP) is influenced by several critical risk factors, including low gestational age, low birth weight, supplemental oxygen use, and increased oxidative stress. • In vitro, unconjugated bilirubin is an effective scavenger of harmful oxygen species and a reducing agent, highlighting its potential protective role against oxidative stress. What is New: • Hyperbilirubinemia requiring phototherapy was associated with an increased risk of developing ROP, but this association was not observed in the most vulnerable population of extremely preterm infants. • Every additional day of phototherapy for hyperbilirubinemia increases the risk of ROP by 5% for any ROP, 4% for non-severe ROP, and 6% for severe ROP.

Knowledge, Attitudes, and Practices Toward Retinopathy of Prematurity Among Neonatal Intensive Care Nurses: A Cross-sectional Study

It is important to study the awareness of retinopathy of prematurity (ROP) among neonatal care nurses in hospitals. Unfortunately, there is a lack of studies conducted among nurses on this subject in Palestine. Thus, this study purposed to assess the knowledge, attitudes, and practices toward ROP among neonatal intensive care nurses in Palestine. A cross-sectional was used to conduct this study. A convenience sampling method was utilized to recruit 289 neonate intensive care nurses working in private and governmental hospitals. The findings showed that around 48.0% of the nurses had low knowledge about preventing ROP. Most of the nurses (78%) reported a neutral attitude toward preventing ROP. Moreover, overall nurses' practices regarding ROP were fair (57.1%). There was a difference in practices regarding ROP according to the health sector (P < .05), in which the private sector had better practices compared to the governmental sector. Additionally, there was a significant difference in knowledge regarding ROP according to educational level (P < .05). Also, a significant difference was found in knowledge and practices regarding ROP according to nurses' experience. Attitudes and practices were the main significant predictors of knowledge (B = 0.153, P < .05; B = 0.172, P < .05, respectively). Knowledge and practices were the main predictors of attitudes (B = 0.126, P < .05; B = 469, P < .001), respectively. Knowledge, attitudes, and experience in neonate intensive care nurses were the main significant predictors of practices (B = 0.135, P < .05; B = 0.449, P < .001; B = 0.224, P < .05, respectively). It is necessary to develop an educational program and competency-based training programs for neonate intensive care nurses about ROP and implement preventive strategies.

Image harmonization and deep learning automated classification of plus disease in retinopathy of prematurity

Purpose

Retinopathy of prematurity (ROP) is a retinal vascular disease affecting premature infants that can culminate in blindness within days if not monitored and treated. A disease stage for scrutiny and administration of treatment within ROP is "plus disease" characterized by increased tortuosity and dilation of posterior retinal blood vessels. The monitoring of ROP occurs via routine imaging, typically using expensive instruments ($50 to $140 K) that are unavailable in low-resource settings at the point of care.

Approach

As part of the smartphone-ROP program to enable referrals to expert physicians, fundus images are acquired using smartphone cameras and inexpensive lenses. We developed methods for artificial intelligence determination of plus disease, consisting of a preprocessing pipeline to enhance vessels and harmonize images followed by deep learning classification. A deep learning binary classifier (plus disease versus no plus disease) was developed using GoogLeNet.

Results

Vessel contrast was enhanced by 90% after preprocessing as assessed by the contrast improvement index. In an image quality evaluation, preprocessed and original images were evaluated by pediatric ophthalmologists from the US and South America with years of experience diagnosing ROP and plus disease. All participating ophthalmologists agreed or strongly agreed that vessel visibility was improved with preprocessing. Using images from various smartphones, harmonized via preprocessing (e.g., vessel enhancement and size normalization) and augmented in physically reasonable ways (e.g., image rotation), we achieved an area under the ROC curve of 0.9754 for plus disease on a limited dataset.

Conclusions

Promising results indicate the potential for developing algorithms and software to facilitate the usage of cell phone images for staging of plus disease.

Therapeutic effects of herbal medicines in different types of retinopathies: A systematic review

Objective

Retinopathy is an ocular manifestation of systemic diseases such as diabetes and vascular diseases. Herbal drugs have been considered as an effective therapeutic option with minimal side effects for the treatment of retinopathy by reducing the symptoms and improving visual acuity. The purpose of this systematic review was to collect studies on the effectiveness of medicinal plants in the treatment or prevention of retinopathy.

Materials and Methods

A systematic literature search was performed in PubMed, Scopus, Google Scholar, and other databases in April 2021 using "herbal products" and "Retinopathy" with all their equivalent and similar terms. For this purpose, human clinical trials with the English language were included and articles with subject irrelevancy were excluded from further evaluation.

Results

Overall, 30 articles with 2324 patients were studied for possible effects of herbal therapy on retinopathy. From 30 included articles, different herbal products had been evaluated. Out of 30 selected articles, 11 articles were for the treatment of age-related macular degeneration (AMD), 14 articles covered patients with diabetic retinopathy, and the other five studies were for other retinal disorders. The outcomes in majority of the studies include changes in visual acuity (VA), fundus performance, best-corrected visual acuity (BCVA), central macular thickness (CMT), focal electroretinogram (fERG), supplements and adjuvant medications appeared to be more beneficial in patients with AMD and diabetic maculopathy.

Conclusion

Herbal therapy can be considered as a potential candidate in the adjuvant and complementary therapies of retinopathy. However, further studies are required to verify such efficiency.

Latest Trends in Retinopathy of Prematurity: Research on Risk Factors, Diagnostic Methods and Therapies

Retinopathy of prematurity (ROP) is a vasoproliferative disorder with an imminent risk of blindness, in cases where early diagnosis and treatment are not performed. The doctors' constant motivation to give these fragile beings a chance at life with optimal visual acuity has never stopped, since Terry first described this condition. Thus, throughout time, several specific advancements have been made in the management of ROP. Apart from the most known risk factors, this narrative review brings to light the latest research about new potential risk factors, such as: proteinuria, insulin-like growth factor 1 (IGF-1) and blood transfusions. Digital imaging has revolutionized the management of retinal pathologies, and it is more and more used in identifying and staging ROP, particularly in the disadvantaged regions by the means of telescreening. Moreover, optical coherence tomography (OCT) and automated diagnostic tools based on deep learning offer new perspectives on the ROP diagnosis. The new therapeutical trend based on the use of anti-VEGF agents is increasingly used in the treatment of ROP patients, and recent research sustains the theory according to which these agents do not interfere with the neurodevelopment of premature babies.

Potential Role of Bilirubin in Preventing Retinopathy of Prematurity

BACKGROUND

One of the most common problems in preterm neonates is retinopathy of prematurity (ROP). It has been shown antioxidants may be effective in preventing the development and progression of ROP. Considering the antioxidant properties of bilirubin, we decided to investigate the bilirubin level in neonates with ROP and compare it with healthy neonates.

METHODS

This case-control study was performed on VLBW neonates admitted to the NICU of Ghaem Hospital in Mashhad between 2014 and 2020 for a Jaundice evaluation. Complete neonate's characteristics, maternal history and laboratory results were collected in a questionnaire. Then the neonates were examined for ROP by a fellowship of the retina of an ophthalmologist at 32 weeks or four weeks after birth. The highest bilirubin levels during their hospitalization were also recorded.

RESULTS

Of 427 neonates examined, 121 (37.7%) had a normal eye examination, and 266 (62.3%) had ROP. The mean weight, gestational age and bilirubin were 1455.8 ± 431.4 grams, 31.6 ± 2.3 weeks and 8.8 ± 2.4 mg/dl, respectively. There was a significant difference between controls and neonates with ROP with regard to birth weight, duration of intermittent positive pressure ventilation (IPPV), duration of oxygen therapy, first and fifth minute Apgar scores, the maximum level of bilirubin and gestational age (P < 0.05). It was observed that the maximum level of bilirubin was lower in neonates with higher stages of ROP.

CONCLUSION

According to the results of this study, higher levels of bilirubin in neonates may be a protective factor against ROP. Moreover, increased levels of bilirubin are associated with reduced severity of ROP. Therefore, prophylaxis phototherapy in premature infants may need to be reconsidered.

Retinopathy of Prematurity: A Study of Incidence and Risk Factors in a Tertiary Hospital in Vietnam

Objective

To determine the incidence and risk factors for the development of retinopathy of prematurity (ROP) in the neonatal intensive care unit (NICU) of Hue Central Hospital, Vietnam.

Methods

A prospective study was performed in 214 preterm infants with gestational age (GA) ≤33 weeks and/or ≤1800 grams of birth weight (BW) or infants with a GA >33 weeks and a BW >1800 grams with an unstable clinical course who were screened for ROP in Hue Central Hospital, Vietnam.

Results

Fifty-eight infants (27.1%) developed ROP; 39.7% cases were stage 1, 34.5% cases were stage 2, and 25.8% cases were stage 3. Gestational age (GA), birth weight, anemia, sepsis, respiratory distress syndrome, total days on oxygen supplementation > 1 week, continuous positive airway pressure (CPAP), mechanical ventilation, blood transfusion, and surfactant had a significant association with ROP in univariate analysis (p<0.05). Using multivariate analysis, GA less than 32 weeks, sepsis, and CPAP/mechanical ventilation remained independent risk factors for ROP development.

Conclusion

The incidence of ROP in Vietnam was 27.1%. A GA less than 32 weeks, sepsis, and CPAP/mechanical ventilation are important risk factors for developing ROP.

Screening and Risk Factors for Retinopathy of Prematurity in a Tertiary Care Hospital in Cairo, Egypt

Purpose

To evaluate the retinopathy of prematurity (ROP) prevalence, risk factors and screening outcome in a tertiary hospital in Cairo, Egypt.

Methods

A prospective observational study was done in Neonatal Intensive Care Unit in Ain Shams University Hospital. A total of 159 premature infants were screened for ROP based on the most inclusive criteria reported to date. Screening included premature infants with gestational age (GA) of ≤34 weeks or birth weight (BW) of ≤2000 grams, or GA >34 weeks or BW >2000 grams, with multiple co-morbidities. The prevalence of ROP, plus disease and their correlation with risk factors of interest were studied.

Results

The GA of the included infants ranged from 27 to 36 weeks, mean (SD) 31.87 (± 1.81) weeks. The BW ranged from 640 to 3900 grams, mean (SD) 1784.71 (± 560.30) grams. The prevalence of ROP more than stage 0 was 25.8% (41 infants), 7.3% of the cases (11 infants) showed plus disease and 6.3% (10 infants) showed severe ROP requiring treatment. Of those, 2 cases (20%) fell outside the British Guideline's criteria for Screening. There was a highly significant (p < 0.0001) correlation between ROP more than stage 0 and low GA, low BW, mechanical ventilation, respiratory distress syndrome, necrotizing enterocolitis, intraventricular haemorrhage, and blood transfusion. No significant correlation was found between appearance of ROP more than stage 0 and gender (p = 0.911), patent ductus arteriosus (p =0.187), or sepsis (p =0.998).

Conclusion

ROP is a significant problem in the premature infants in Egypt. Extremely premature infants with lower BW are more prone to develop ROP. However, cases with higher GA and BW than mentioned in the British guidelines screening criteria especially with multiple comorbidities showed severe ROP requiring intervention, which implies the need to develop a screening guideline for the Egyptian population.

Incidence and Characteristics of Retinopathy of Prematurity Patients With Late Gestational Age and Large Birth Weight in South China

Purpose

To investigate the incidence and characteristics of retinopathy of prematurity (ROP) premature infants with late gestational age (GA) and large birth weight (BW) and show a 7-year trend of ROP incidence in South China.

Methods

This retrospective, cross-sectional study included premature infants who received ROP screening in a 7-year period (from 2010 to 2016) at the Sun Yat-sen Memorial Hospital (SYSMH), Guangzhou, South China. Infants were screened if they had GA <37 weeks or BW <2,500 g. All screened infants were divided into two groups: Group 1 (with both GA ≥ 35 weeks and BW ≥ 1,750 g) and Group 2 (others). The characteristics of ROP infants in Group 1 were analyzed and compared with those in Group 2.

Results

A total of 911 premature infants were screened, with 282 infants in Group 1 and 629 in Group 2. Both the incidences of any ROP (6.7 vs. 8.3%, p = 0.50) and Type 1 ROP (1.4 vs. 1.7%, p = 0.72) in Group 1 were comparable with those in Group 2. Lower proportions of respiratory distress (15.8 vs. 71.2%, p < 0.001), blood transfusion (5.3 vs. 32.7%, p = 0.028), and oxygen administration (31.6 vs. 86.5%, p < 0.001) among ROP patients in Group 1 than those in Group 2 were revealed. Vaginal delivery [OR: 4.73 (1.83–12.26)] was identified as a factor associated with ROP among the infants in Group 1. Forty percent (6/15) of Type 1 ROP in this study would have been missed under the current screening criteria in China (GA ≤ 34 weeks and/or BW ≤ 2,000 g). Trends of increased incidence of Type 1 ROP and decreased BW were exhibited in the 7-year study period.

Conclusions

These findings indicate that even the premature infants with late GA and large BW also have a high risk of developing ROP, especially for those delivered by vagina. The findings may provide a significant reference for ROP screening and neonatal care in South China and other regions with similar conditions.

Risk of Retinopathy of Prematurity in Preterm Births with Respiratory Distress Syndrome: A Population-Based Cohort Study in Taiwan

Background

Methods

Results

Conclusion

Effectiveness of Developmentally Supportive Education Program on Nursing Knowledge of Retinopathy of Prematurity in Neonatal Intensive Care Unit

Background

Retinopathy of Prematurity (ROP) is a preventable cause of childhood blindness. India accounts for nearly 10% of the worldwide estimate of blindness and visual impairment due to ROP. Nurses are pillars of neonatal intensive care units (NICUs) and play a critical role in the prevention and management of ROP. The primary aim of this study was to evaluate the effect of developmentally supportive education program on knowledge regarding prevention and management of ROP among nurses working in NICU.

Materials and Methods

A hospital based pre-experimental, one group pre-test-post-test study was carried out among 32 staff nurses working in the NICU of a tertiary care center during January to February 2019. Knowledge regarding the prevention and management of ROP was assessed before and after the implementation of developmentally supportive education program using a structured knowledge questionnaire.

Results

Pre-test knowledge score was mean (Standard Deviation [SD]) 9.00 (3.68) and after the educational program post-test knowledge score was found to be mean (SD) 14.53 (2.39). Paired t-test was used to evaluate the effect of developmentally supportive education program and was found to be statistically significant (t₃₂= 10.09, p < 0.001).

Conclusions

Developmentally supportive educational program can be used as an effective intervention for improving the knowledge regarding ROP among nurses in NICU.

Clinical parameters in different stages, zones, and remission/progression statuses of retinopathy of prematurity

Background

Retinopathy of prematurity (ROP) is a vasoproliferative retinal disease in premature infants that causes lifetime visual impairment and blindness in the early ages. In this study, we investigated the differences in the values of clinical laboratory parameters between different ROP and its remission/progression statuses regarding stages and zones.

Methods

This historical cohort study includes 828 infants divided into two groups after the first examination containing ROP infants and controls. The biochemical and hematological parameters of the two groups have been collected from the patient's history.

Results

In infants with ROP, the hematopoiesis-related parameters, including the mean level of hemoglobin, total bilirubin, potassium, calcium were significantly less than controls (P=0.039, P=0.001, P=0.001, and P=0.046, respectively). The percentages of reticulocyte and the levels of BUN in ROP patients were significantly higher than in normal infants (P=0.015 and p <0.001, respectively). Moreover, the levels of hemoglobin and BUN were significantly different in the different zones of ROP (P=0.017 and P=0.001, respectively). Also, higher hemoglobin levels, total bilirubin, and CRP were observed in the reduced stages of ROP (P=0.041, P=0.045, and P=0.039, respectively).

Conclusion

Laboratory parameters are different in different stages, zones and remission/ progression ROP infants.

Analysis of a two-year independent screening effort for retinopathy of prematurity in rural Egypt

BACKGROUND

The third epidemic of retinopathy of prematurity (ROP) has majorly involved middle income countries in which tailored screening and local guidelines require development. The data regarding ROP prevalence and cutoff numbers for screening in Egypt are lacking.

METHODS

Retrospective analysis of an independent screening effort spanning 2 years (February 2019 to February 2021) and involving 32 neonatal care units within Sharkia governorate, Egypt. Infants of gestational age (GA) ≤ 34 weeks and/or birth weight (BW) ≤ 2000 g were included, as well as those with unstable clinical course. Two eyecare centers located in Sharkia and Cairo governorates served as referral centers for any required interventions.

RESULTS

Of the 276 screened infants, 133 (48.2%) had some form of ROP that was bilateral in 127 (95.5%) of them. Aggressive posterior ROP (AP-ROP) was detected in both eyes of 24 infants (8.7%). The median (IQR) GA of infants with ROP was 32 (30-34) weeks, and the median (IQR) BW was 1600 (1350-2000) g. Sixty-three infants (47.4%) required treatment. Of the total 84 eyes that primarily were treated, 73 (86.9%) received intravitreal ranibizumab, 8 (9.5%) underwent laser ablation therapy, and 3 eyes (3.6%) underwent surgery. Recurrence rate was 16.7% (14 eyes). Final outcome was favorable in 83 eyes (98.8%). Applying the American Academy criteria would have led to the missing of 36.8% of infants with ROP and 28.6% of those requiring treatment in our sample.

CONCLUSION

The incidence of both ROP and AP-ROP in the Egyptian rural setting appears to be in the high end of global reported rates. Prevention measures should urgently be planned and implemented.

Cluster Analysis of Early Postnatal Biochemical Markers May Predict Development of Retinopathy of Prematurity

Purpose

Growth factors and inflammatory and angiogenetic proteins are involved in the development of retinopathy of prematurity (ROP). However, no early biochemical markers are in clinical use to predict ROP. By performing cluster analysis of multiple biomarkers, we aimed to determine patient groups with high and low risk for developing ROP.

Methods

In total, 202 protein markers in plasma were quantified by proximity extension assay from 35 extremely preterm infants on day 2 of life. Infants were sorted in groups by automated two-dimensional hierarchical clustering of all biomarkers. ROP was classified as stages I to III with or without surgical treatment. Predictive biomarkers were evaluated by analysis of variance and detected differences by two-sided paired t-test with Bonferroni corrections for multiple comparisons.

Results

Differences in 39 biochemical markers divided infants without ROP into two control groups (control 1, n = 7; control 2, n = 5; P < 0.05). Sixty-six biochemical markers defined differences between the control groups (n = 13) and all ROP infants (n = 23; P < 0.05). PARK7, VIM, MPO, CD69, and NEMO were markedly increased in control 1 compared to all ROP infants (P < 0.001). Lower TNFRSF4 and higher HER2 and GAL appeared in infants with ROP as compared to control 1 and/or 2 (P < 0.05, respectively).

Conclusions

Our data suggest that early elevated levels of PARK7, VIM, MPO, CD69, and NEMO may be associated with lower risk of developing ROP. Lower levels of TNFRSF4 with higher levels of HER2 and GAL may predict ROP development.

Translational Relevance

Cluster analysis of early postnatal biomarkers may help to identify infants with low or high risk of developing ROP.

Effect of red blood cell transfusion on the development of retinopathy of prematurity: A systematic review and meta-analysis

BACKGROUND

The effect of red blood cell (RBC) transfusion on retinopathy of prematurity (ROP) is difficult to establish, because ROP may also be influenced by other factors. Therefore, we carried out a systematic review and meta-analysis to explore the relationship between RBC transfusion and the development of ROP.

METHODS

The PubMed, Embase, Cochrane Library and Web of Science databases were searched from their inception to September 1, 2019. Observational studies that reported the relationship between RBC transfusion and ROP after adjusting for other potential risk factors were included. The combined result was analyzed by a random effect model. Heterogeneity and publication bias were tested, and sensitivity analysis was performed.

RESULTS

Of the 2628 identified records, 18 studies including 15072 preterm infants and 5620 cases of ROP were included. A random effect model was used and revealed that RBC transfusion was significantly associated with ROP (pooled OR = 1.50, 95% CI: 1.27-1.76), with moderate heterogeneity among the included studies (I2 = 44.2%). Subgroup analysis indicated that RBC transfusion was more closely related to ROP in the group with a gestational age (GA) ≤32 weeks (OR = 1.77, 95% CI: 1.29-2.43) but not in the groups with a GA ≤34 weeks (OR = 1.36, 95% CI: 0.85-2.18) or a GA <37 weeks (OR = 1.25, 95% CI: 0.86-1.82). No obvious publication bias was found based on the funnel plot and Egger's test. Removing any single study did not significantly alter the combined result in the sensitivity analysis.

CONCLUSIONS

Our study revealed that RBC transfusion is an independent risk factor for the development of ROP, especially in younger preterm infants. However, there seemed to be no evidence to support an effect of RBC transfusion on ROP in older groups. Further studies addressing this issue in older preterm neonates are warranted.