Ocular findings in premature infants with grade IV intraventricular hemorrhage

Optic atrophy in prematurity: pathophysiology and clinical features

Optic atrophy is an important cause of visual impairment in children, and the aetiological profile has changed over time. Technological advancements led by neuroimaging of the visual pathway and imaging of the optic nerve with optical coherence tomography have accelerated the understanding of this condition. In the new millennium, an increasing prevalence of prematurity as a cause of optic atrophy in children has been highlighted. This new shift has been linked with increasing rates of premature births and improved neonatal survival of preterm infants. The available literature is limited to hospital and registry-based cohorts with modest sample sizes, methodological heterogeneity and selection bias limitations. Larger studies that are better designed are required to better understand the contribution of prematurity to the disease burden. In addition to considering other life-threatening aetiologies, screening for premature birth should be covered as part of a comprehensive history when evaluating a child with paediatric optic atrophy.

AFENet: Attention Fusion Enhancement Network for Optic Disc Segmentation of Premature Infants

Retinopathy of prematurity and ischemic brain injury resulting in periventricular white matter damage are the main causes of visual impairment in premature infants. Accurate optic disc (OD) segmentation has important prognostic significance for the auxiliary diagnosis of the above two diseases of premature infants. Because of the complexity and non-uniform illumination and low contrast between background and the target area of the fundus images, the segmentation of OD for infants is challenging and rarely reported in the literature. In this article, to tackle these problems, we propose a novel attention fusion enhancement network (AFENet) for the accurate segmentation of OD in the fundus images of premature infants by fusing adjacent high-level semantic information and multiscale low-level detailed information from different levels based on encoder-decoder network. Specifically, we first design a dual-scale semantic enhancement (DsSE) module between the encoder and the decoder inspired by self-attention mechanism, which can enhance the semantic contextual information for the decoder by reconstructing skip connection. Then, to reduce the semantic gaps between the high-level and low-level features, a multiscale feature fusion (MsFF) module is developed to fuse multiple features of different levels at the top of encoder by using attention mechanism. Finally, the proposed AFENet was evaluated on the fundus images of preterm infants for OD segmentation, which shows that the proposed two modules are both promising. Based on the baseline (Res34UNet), using DsSE or MsFF module alone can increase Dice similarity coefficients by 1.51 and 1.70%, respectively, whereas the integration of the two modules together can increase 2.11%. Compared with other state-of-the-art segmentation methods, the proposed AFENet achieves a high segmentation performance.

Time to normalization of intracranial pressure secondary to intraventricular hemorrhage and the need for retinopathy of prematurity treatment in infants diagnosed with both conditions

PURPOSE

To determine whether time to normalization of increased intracranial pressure (ICP) caused by intraventricular hemorrhage (IVH) is associated with retinopathy of prematurity (ROP) treatment in premature infants diagnosed with both conditions.

METHODS

The medical records of all premature infants born at ≤ 35 weeks' gestation and/or birth weight of ≤ 1500 g diagnosed with both any stage of ROP and any grade of IVH, with or without secondary increased ICP (defined as ≥ 20 cm H(2)O) were retrospectively reviewed. Adjusting for birth weight and gestational age, we compared time to normalization of increased ICP in infants treated for increased ICP only with that of infants treated for both increased ICP and ROP.

RESULTS

A total of 21 infants were included. ICP levels normalized at a significantly older postnatal age in infants treated for both increased ICP and ROP (100 days) than in those treated for elevated ICP alone (45 days), after we adjusted for the results for birth weight and gestational age (P = 0.049).

CONCLUSIONS

Earlier control of increased ICP secondary to IVH may reduce the need for ROP treatment in premature babies initially diagnosed with both conditions.

Retinopathy of prematurity and other ocular problems in premature infants weighing less than 1500 g at birth

PURPOSE

To estimate the incidence of retinopathy of prematurity and other ocular problems in a population of preterm infants.

METHODS

This retrospective study included all infants with gestational age (GA) <32 weeks and birth weight (BW) <1500 g cared for in the neonatal intensive care unit (NICU) over a period of nine years (1992-2000). Ophthalmological examination was started the 4th week of life and included refractive examination, examination of the cornea and funduscopy under mydriasis. An ocular motility test was done after the 2nd month.

RESULTS

The study included 194 infants. Stage I and II retinopathy occurred in 51 infants but regressed spontaneously. Five of the 194 (2.5%) had to undergo cryopexy. Optic disc atrophy was observed in association with peri-intraventricular hemorrhage (PIIVH) (grade IV) in seven infants. Fifteen infants (7.7%) had retinal hemorrhages which were absorbed by three months of age. Almost 20% of the study infants developed high refractive errors and 13.4% strabismus.

CONCLUSIONS

Not only retinopathy of prematurity, but other serious ocular problems were observed in this population of preterm infants. The role of PIIVH III-IV in the pathogenesis of certain ocular problems needs further elucidation.

Ocular outcomes in low birth weight premature infants with intraventricular hemorrhage

PURPOSE

To study ocular outcomes in very low birth weight premature infants with intraventricular hemorrhage.

METHODS

Parents of 490 consecutive very low birth weight (less than 1500 g) premature infants who were discharged from the neonatal intensive care unit of our hospital between 1994 and 1996 were asked to enroll their child/children in this cross-sectional study. Sixty infants (12%) were recruited and had complete masked ophthalmologic examinations at 12 months corrected gestational age. The medical records of each infant were reviewed after the eye examination was complete. The occurrence of intraventricular hemorrhage and other perinatal comorbidities was documented. Ocular outcomes of infants with no or low-grade (grades I-II) hemorrhages were compared with those of infants with high-grade (grades III-IV) intraventricular hemorrhage.

RESULTS

Of the 60 infants examined, 17 (28%) had neonatal intraventricular hemorrhage. Eleven (18%) had high-grade intraventricular hemorrhage, and 49 (82%) had no or low-grade hemorrhage. Of the 11 infants with high-grade intraventricular hemorrhage, 8 (73%) had strabismus compared with 7 (14%) of 49 infants with no or low-grade hemorrhages who developed strabismus (P<0.001). The high-grade group also had a larger proportion of infants with ocular motility defects (P=0.008), nystagmus (P<0.001), optic nerve atrophy (P<0.001), and abnormal retinal findings (P=0.039). Additionally, these infants were more likely to have stage 3 or worse retinopathy of prematurity (P=0.003).

CONCLUSIONS

These results confirm the findings of our earlier retrospective study, and suggest that the occurrence of high-grade intraventricular hemorrhage in the early postnatal period places these infants at significant risk for adverse ocular outcomes. These infants require close ophthalmologic surveillance.

The incidence of ophthalmologic interventions in children with birth weights less than 1251 grams. Results through 5 1/2 years. Cryotherapy for Retinopathy of Prematurity Cooperative Group

OBJECTIVE

This study aimed to report the frequency of ophthalmologic surgical and medical therapies provided to children with birth weights less than 1251 g who had all stages of retinopathy of prematurity (ROP). In addition, this study aimed to report the initial age at which such procedures are provided and to report the frequency of cerebrospinal fluid shunts.

DESIGN

Observational case series with prospective data collection.

PARTICIPANTS

Children from the Multicenter Trial of Cryotherapy for Retinopathy of Prematurity (CRYO-ROP) with birth weights less than 1251 g served as subjects. Group A included 257 children from all 23 CRYO-ROP study centers who had threshold ROP, who had participated in the randomized trial of cryotherapy, and who had survived to age 1 year. Group B included 1208 children from 5 of the 23 study centers who had varying severity of ROP (69 had threshold ROP) and who had participated in a 5 1/2-year study of the natural history of ROP.

MAIN OUTCOME MEASURES

Investigators documented medical and surgical ophthalmologic interventions through age 5 1/2 years as well as cerebrospinal fluid shunting surgery for hydrocephalus through age 2 years.

RESULTS

Group A was composed of 257 children with threshold ROP who underwent 226 ocular interventions in addition to cryotherapy (0.9 intervention per child). The most common treatments performed on the randomized cohort of children were vitrectomy (26% of patients), lensectomy (18%), amblyopia therapy (20%), and strabismus surgery (10%). Cataract surgery not associated with vitrectomy was performed infrequently (2%) and was performed equally often in treated and control eyes. Amblyopia therapy was prescribed as often for treated as for control eyes. Cerebrospinal fluid shunts were placed in 11% of these children. Group B was composed of 1208 natural history patients who underwent 239 ophthalmologic interventions (0.4 intervention per child). Strabismus surgery was the most commonly performed procedure for the natural history cohort of children (6% of the children). Amblyopia therapy was prescribed for 7% of the natural history patients. Cerebrospinal fluid shunts were required by 3% of the natural history infants, more often in children with more severe ROP.

CONCLUSIONS

These premature infants underwent a large number of ophthalmologic treatments during the first 5 1/2 years of life. The long-term costs of both extreme prematurity and ROP include not only the initial ablative therapy for ROP and societal loss due to blindness that still occurs in some cases, but also the ongoing costs of caring for eye problems.

Grating acuity and visual-field development in children with intraventricular hemorrhage

Visual development was studied in 171 preterm children who had intraventricular hemorrhage (IVH) and in 73 healthy preterm (HPT) children who did not develop IVH. Binocular grating acuity was assessed at age 1 month; monocular grating acuity and binocular visual-field extent were assessed at 4, 8, 12, 17, 24, 30, 36, and 48 months; and monocular H, O, T, V letter recognition acuity was tested at 36 and 48 months. A significantly greater proportion of IVH subjects than HPT subjects had ocular abnormalities. IVH subjects had significantly poorer grating acuity than HPT subjects at 1, 4, 8, 36, and 48 months, poorer recognition acuity than HPT subjects at 36 and 48 months, and smaller average field extent than HPT subjects at 4, 12, and 17 months. Acuity deficits were not related to grade of IVH or to the presence of periventricular leukomalacia, but may have been associated with the presence of ocular abnormalities or cerebral palsy in some IVH subjects.

Ocular morbidity in very low birth-weight infants with intraventricular hemorrhage

PURPOSE

To document ocular outcomes and prevalence of ocular disease in very low birth-weight infants with intraventricular hemorrhage.

METHODS

We retrospectively reviewed the records of all surviving very low birth-weight infants (1,500 g or less) admitted to the neonatal intensive care unit of our institution during 1992 and 1993. Of 252 survivors, 74 had complete ophthalmologic examinations at a mean adjusted age of 11 months. Of these 74 infants, 38 had intraventricular hemorrhage. Chi-square and multivariate analysis were used for statistical testing, in controlling for race, sex, and birth weight, and for other disease processes associated with prematurity.

RESULTS

Of 38 infants with intraventricular hemorrhage, strabismus occurred in 14 (37%), esotropia in 12 (32%), and exotropia in two (5%). Of the 20 infants with grades III and IV intraventricular hemorrhage, 11 (55%) had esotropia; none had exotropia. Infants with grades III and IV intraventricular hemorrhage were at significantly greater risk for the development of esotropia than were infants with less severe or no hemorrhage (odds ratio, 5.0; P = .04). Mean adjusted age at diagnosis of strabismus was 8.5 months. Infants with periventricular leukomalacia (odds ratio, 6.3; P = .036) and neonatal seizures (odds ratio, 7.3; P = .019) were at significantly greater risk of developing optic atrophy.

CONCLUSIONS

Very low birth-weight infants with more severe neurologic morbidity are at significant risk for development of esotropia and optic atrophy. Ophthalmologic screening of all very low birth-weight survivors may allow earlier diagnosis and intervention for these at-risk infants.

Visual function of prematurely born children with and without perceptual-motor difficulties

The relationship between visual and perceptual-motor abilities at 6 years of age was investigated in a cohort of 141 prematurely born children without cerebral palsy. Visual acuity was assessed using the Sonksen-Silver Acuity System and stereopsis with the Titmus stereo test. Perceptual motor abilities were evaluated using the Movement Assessment Battery for Children and the Developmental Test of Visual-Motor Integration. The results showed a higher incidence of abnormalities both of linear acuity and stereopsis in the study group when compared to a group of reference children. Whereas abnormalities of linear acuity were not associated with perceptual-motor difficulties, abnormal stereopsis was significantly associated with poor performance on both perceptual-motor tests. Our results suggest that infants born preterm, even in the absence of other major neurological signs, are at risk for abnormal visual function and perceptual-motor difficulties. As these could interfere with everyday life and school performance, a longitudinal assessment of both areas of competencies is recommended so that diagnosis and possible intervention can take place as early as possible.

Are the pupils of premature infants affected by intraventricular hemorrhage?

The size and reactivity to light of the pupil in infants with intraventricular hemorrhage has been variously described in the literature. These descriptions have included miosis, reactivity to light, nonreactivity to light, and anisocoria. We studied the size and light reactivity of 20 infants with intraventricular hemorrhage compared with 30 controls. Both groups displayed a mean pupil diameter in relative darkness of 3.0 to 4.0 mm at various postconceptional ages (P > .05). The age of first response to light was about 30 weeks after conception in each group (P > .05). The severity of intraventricular hemorrhage as determined by ultrasound was not related to the pupil diameter in relative darkness. In general, the pupils of neonates are not affected by intraventricular hemorrhage.