Referable Macular Hemorrhage-A Clinically Meaningful Screening Target in Newborn Infants. Position Statement of the Association of Pediatric Retina Surgeons

Universal newborn eye screening facilitates early diagnosis of ocular abnormalities and mitigates vision loss. "Referral warranted" eye disease is present at birth in about 5.5% of term infants, with "macular hemorrhage impinging on the fovea" representing about 50% of referral warranted disease. The Association of Pediatric Retina Surgeons held a symposium on February 9, 2021 that culminated in a position statement on "referable macular hemorrhage" (RMH) in newborn infants. RMH is meaningful in that in can cause amblyopia through deprivation, can be readily captured with wide-angle photography in a safe and efficient manner, and may lead to early intervention with mitigation of vision loss. [Ophthalmic Surg Lasers Imaging Retina. 2022;53:3-6.].

Late-Onset Retinal Findings and Complications in Untreated Retinopathy of Prematurity

PURPOSE

To investigate late retinal findings and complications of eyes with a history of retinopathy of prematurity (ROP) that did not meet treatment criteria and did not receive treatment during infancy.

DESIGN

Retrospective, nonconsecutive, noncomparative, multicenter case series.

PARTICIPANTS

Three hundred sixty-three eyes of 186 patients.

METHODS

Data were requested from multiple providers on premature patients with a history of ROP and no treatment during infancy who demonstrated late retinal findings or complications and included age, gender, gestational age and weight, zone and stage at infancy, visual acuity, current retina vascularization status, vitreous character, presence of peripheral retinal findings such as lattice retinal tears and detachments (RDs), retinoschisis, and fluorescein findings.

MAIN OUTCOME MEASURES

Rate of RDs and factors conferring a higher risk of RDs.

RESULTS

The average age was 34.5 years (range, 7-76 years), average gestational age was 26.6 weeks (range, 23-34 weeks), and average birth weight was 875 g (range, 425-1590 g). Findings included lattice in 196 eyes (54.0%), atrophic holes in 126 eyes (34.7%), retinal tears in 111 eyes (30.6%), RDs in 140 eyes (38.6 %), tractional retinoschisis in 44 eyes (11.9%), and visible vitreous condensation ridge-like interface in 112 eyes (30.5%). Fluorescein angiography (FA) was performed in 113 eyes, of which 59 eyes (52.2%) showed leakage and 16 eyes (14.2%) showed neovascularization. Incomplete vascularization posterior to zone 3 was common (71.6% of eyes). Retinal detachments were more likely in patients with a gestational age of 29 weeks or less (P < 0.05) and in eyes with furthest vascularization to posterior zone 2 eyes compared with zone 3 eyes (P = 0.009).

CONCLUSIONS

Eyes with ROP not meeting the treatment threshold during infancy showed various late retinal findings and complications, of which RDs were the most concerning. Complications were seen in all age groups, including patients born after the Early Treatment for Retinopathy of Prematurity Study. Contributing factors to RDs included atrophic holes within peripheral avascular retina, visible vitreous condensation ridge-like interface with residual traction, and premature vitreous syneresis. We recommend regular examinations and consideration of ultra-widefield FA examinations. Prospective studies are needed to explore the frequency of complications and benefit of prophylactic treatment and if eyes treated with anti-vascular endothelial growth factor therapy are at risk of similar findings and complications.

Spectral-domain optical coherence tomography of the macula in preterm infants treated with bevacizumab for retinopathy of prematurity

BACKGROUND AND OBJECTIVE

To examine the macula in preterm infants treated with bevacizumab (Avastin; Genentech, South San Francisco, CA) for retinopathy of prematurity (ROP) using spectral domain optical coherence tomography (SD-OCT).

PATIENTS AND METHODS

Twenty eyes (of 11 patients) treated with Avastin only or in addition to photocoagulation and vitreous surgery were included. Imaging was performed with a portable spectral-domain optical coherence tomography (OCT) device. Macular measurements, including the foveal and parafoveal index were calculated. RetCam (Clarity Medical Systems, Pleasanton, CA) photographs were obtained for all patients.

RESULTS

Mean age of patients at OCT examination was 28.9 months (range: 4 to 50 months). Thirteen eyes (65%) developed foveal contour (FC), and seven eyes (35%) did not. Earlier gestational age and zone I disease were associated with absence of FC development. In patients without FC, two of the five eyes had vision better than 20/400, compared with 10 of 11 eyes with FC.

CONCLUSION

Vision tends to be better in Avastin-treated eyes when an FC is present. Morphological characteristics of retinal anatomy may predict visual function.

ZONE I RETINOPATHY OF PREMATURITY

PURPOSE

To study the clinical characteristics and treatment outcomes after laser and surgical treatment in a series of infants with zone I retinopathy of prematurity (ROP).

METHODS

Preterm infants less than 1,500 g at birth diagnosed with zone I ROP were studied. Fifty-seven consecutive eyes in 29 infants with zone I ROP were treated with indirect diode laser. Within zone I, two anatomic subgroups (anterior and posterior) were defined. Additionally, 27 eyes (15 patients) with retinal detachment secondary to zone I ROP were surgically treated. Structural outcomes were evaluated 3 months after surgery.

RESULTS

Atypical morphologic characteristics were observed. Thirty-one out of 48 eyes (64.6%) with anterior zone I ROP and none of the 9 eyes with posterior zone I ROP had a favorable outcome (P < 0.001) after photocoagulation. In the surgery group, 14 out of 19 (74%) eyes with stage 4 and 1 out of 8 (13%) eyes with stage 5 had favorable outcomes.

CONCLUSIONS

Atypical clinical features can be observed in zone I ROP. A posterior localization of the disease carries a worse prognosis after laser photocoagulation. Surgical intervention can effectively reattach the retina in a significant number of zone I ROP-related retinal detachments.

Retinal pigment epithelium translocation after choroidal neovascular membrane removal in age-related macular degeneration

PURPOSE

To test the feasibility of a new surgical technique and to assess visual function over the translocated retinal pigment epithelium (RPE) cells in patients operated on for subfoveal choroidal neovascularization (CNV) secondary to age-related macular degeneration (ARMD).

DESIGN

Retrospective, noncomparative, interventional case series.

PARTICIPANTS

Nine patients with previously untreated exudative ARMD underwent surgical excision of the subfoveal CNV with RPE translocation and were observed for 12 to 32 months.

METHODS

The surgery consisted of a standard three-port pars plana vitrectomy, excision of the CNV, and RPE translocation. Pre- and postoperative ocular examination included best-corrected visual acuity measurement, fundus color stereo photography, and fundus fluorescein angiography. Optical coherence tomography and confocal laser scanning ophthalmoscopy (cLSO) were performed after surgery. A crossfixation target and a single-point flashing light were projected on different areas of the posterior pole using a cLSO. Photopic 10 to 2 perimetry, photopic fine matrix mapping, and cLSO microperimetry were also performed after surgery in six patients.

MAIN OUTCOME MEASURES

Optical coherence tomography cross-sectional scans and cLSO RPE autofluorescence were recorded to detect the presence of viable translocated RPE. Visual acuity, fixation, photopic 10 to 2 perimetry, photopic fine matrix mapping, and cLSO microperimetry were used to test central visual function.

RESULTS

Retinal pigment epithelium was translocated successfully at the time of CNV removal from the edge of the RPE defect to a subfoveal location in seven of nine patients. One patient experienced proliferative vitreoretinopathy, but significant hemorrhage was not a feature. Optical coherence tomography showed the translocated RPE as an area of increased optical reflectivity with optical shadowing external to it. Confocal laser scanning ophthalmoscopy showed autofluorescence of the translocated RPE. The crossfixation target was seen when projected on the translocated RPE. During eccentric fixation, the patients could see a flashing point-target projected on the translocated RPE. Photopic 10 to 2 perimetry, photopic fine-matrix mapping, and cLSO microperimetry showed the presence of central visual function.

CONCLUSIONS

The authors propose that translocation of RPE at the time of CNV removal, from the edge of the RPE defect to a subfoveal location, may have a role in the surgical management of ARMD.

Retinal pigment epithelium translocation and central visual function in age related macular degeneration: preliminary results

PURPOSE

To test the feasibility of a new surgical technique, and to assess visual function over the translocated retinal pigment epithelium (RPE) cells in patients operated upon for subfoveal choroidal neovascularization (CNV) secondary to age-related macular degeneration (AMD).

MATERIALS AND METHODS

Six patients presenting previously untreated exudative AMD underwent surgical excision of the subfoveal CNV with RPE translocation and were followed from 1 to 10.5 months. The surgery consisted of a standard three port pars plana vitrectomy (TPPPV), excision of the CNV and RPE translocation. Pre and post-operative ocular examination included best-corrected visual acuity measurement, fundus color stereo photography and fundus fluorescein angiography. Optical coherence tomography (OCT) and confocal laser scanning ophthalmoscopy (cLSO) were performed post-operatively. A cross fixation target and a single-point flashing light were projected on different areas of the posterior pole using a cLSO. Photopic 10-2 perimetry, photopic fine matrix mapping, cLSO microperimetry were also performed pre and post-operatively in four patients. OCT cross-sectional scans and cLSO RPE autofluorescence were recorded to detect the presence of viable translocated RPE. Visual acuity, fixation, photopic 10-2 perimetry, photopic fine matrix mapping and cLSO microperimetry were tested for the presence of central visual function.

RESULTS

RPE could be effectively translocated at the time of CNV removal from the edge of the RPE defect to a subfoveal location. OCT showed the translocated RPE as an area of increased optical reflectivity with optical shadowing external to it. cLSO showed autofluorescence of the translocated RPE. The cross fixation target was seen when projected on the translocated RPE. During eccentric fixation, the patients could see a flashing point-target projected on the translocated RPE. Photopic 10-2 perimetry, photopic fine matrix mapping and cLSO microperimetry showed presence of central visual function.

CONCLUSIONS

The authors propose that translocation of RPE at the time of CNV removal, from the edge of the RPE defect to a subfoveal location, may have a role in the surgical management of AMD.

Vitreoretinal management of posteriorly dislocated plate haptic silicone intraocular lenses

PURPOSE

To report the vitreoretinal management of posteriorly dislocated plate haptic silicone intraocular lenses (PHSIOLs) and to present a surgical algorithm for this problem.

METHODS

A retrospective analysis of 12 cases of immediate and delayed posterior dislocation of a PHSIOL after phacoemulsification was performed.

RESULTS

The ages of the patients ranged from 26 years to 82 years (mean, 68 years); six of the patients were male. Delayed posterior dislocation of the PHSIOL occurred in 7 eyes (after Nd:YAG laser capsulotomy in 4 cases), while intraoperative dislocation occurred in 5 eyes. Defects of the anterior capsulorhexis rim or posterior capsule were present in nine eyes. The mean time from PHSIOL dislocation to definitive treatment was 4.8 months (range, 0.25-13 months). All patients underwent pars plana vitrectomy and implant exchange or repositioning. The dislocated PHSIOL was removed through the transpupillary route in 8 cases, while it was segmented and delivered through the pars plana in 3. Two patients underwent implant repositioning in the ciliary sulcus, although subsequent redislocation in one case required transpupillary removal and exchange. The mean follow-up period was 6.5 months (range, 2-18 months), with a final best corrected visual acuity of 6/12 or better in 10 eyes.

CONCLUSIONS

Delayed and immediate dislocation of PHSIOL can occur in eyes with a defect in capsular integrity. The implant may be repositioned or exchanged following vitrectomy with either transpupillary or pars plana removal, resulting in generally excellent postoperative visual acuity and minimal complications.

Zone I retinopathy of prematurity

INTRODUCTION

Patients with zone I retinopathy of prematurity (ROP) have poor outcomes despite treatment. We analyze the clinical characteristics and treatment outcome of patients with zone I disease and compare them with patients with zone II disease.

METHODS

Preterm infants weighing less than 1500 g at birth were screened by the authors at age 4 to 6 weeks (group A). Group B was composed of referral patients that had been screened elsewhere. Findings were recorded according to the International Classification of Retinopathy of Prematurity. We classified all patients as either zone I, zone II, or zone III disease. If a retinopathy spanned 2 zones in one eye, it was classified in the most posterior zone as indicated by the International Classification of Retinopathy of Prematurity. Threshold was defined as in the Cryotherapy for Retinopathy of Prematurity study. Indirect diode-laser treatment was used to ablate the avascular retina. At the 3-month follow-up, outcome was judged according to Cryotherapy for Retinopathy of Prematurity criteria. Differences between eyes with zone I or zone II ROP were analyzed.

RESULTS

Group A was composed of 222 infants; 2 presented with zone I ROP. Of 63 patients comprising group B, 9 had zone I ROP: a total of 11 infants with zone I ROP, 22 eyes. At 3 months, 8 of 20 eyes with zone I ROP that were included in follow-up had an unfavorable outcome (40%). Mean birth weight and gestational age were similar in zone I and zone II cases, but mean gestational age at treatment was significantly different (35.2 weeks in zone I cases vs 37.2 weeks in zone II cases, P =.006). Unusual signs such as a demarcation vessel between vascular and avascular retina and excessive intraretinal neovascularization were observed in zone I eyes but not observed in eyes with zone II or zone III ROP.

DISCUSSION

Zone I ROP appears to be different from zone II ROP. Earlier treatment age suggests either an early start, faster progression, or both. Special attention should be given to atypical morphology present in zone I ROP.

Syncope: etiology, prognosis, and relationship to age

Syncope is a common and particularly troublesome problem in the elderly population. In a series of 146 patients admitted for syncope to an acute care hospital in Chile during a 4-year period, 2/3 (68%) were aged 65 years and older. A specific etiology could be established in 62%, and 3/4 of these were cardiovascular in origin. Diagnosis was established entirely on history, physical examination, resting ECG, and 24-hour cardiac monitoring in most cases but in some, more sophisticated measures (i.e., echocardiography, electrophysiologic studies, blood tests, EEG) were needed, and mostly to confirm clinically suspected problems. In-hospital mortality was 2.1% and mortality at the end of the approximately 2-year follow-up period was 18.1%. Mortality was higher for persons over age 65 than for younger persons (23.9% vs 2.3%), and for persons with cardiovascular syncope than for persons with other kinds of syncope (28.3% vs 8.9%). This study confirms the particular lethality of syncope in the elderly population and outlines a relatively simple strategy with which most syncope patients can be diagnosed without resorting to expensive procedures.

[Syncope: recurrence and prognosis during 2 years]

We followed up 143 patients that had been admitted to intensive care units of a general hospital with syncope. 127 patients (89%) remained in follow up for a mean of 24 months (range 3 to 54 months). There were 70 men and 57 women and the mean age was 71.5 years. Recurrences were observed in 21 patients (17%) and were similar for patients whose syncope had a cardiovascular origin (10%), non cardiovascular origin (25%) or an undetermined cause (18%). Mortality from cardiac or vascular causes was 20% in the cardiovascular origin group, and 5 and 4.2% in the other groups, respectively (p less than 0.005). Recurrence did not influence mortality. A history of hypertension, cerebrovascular accidents and ventricular arrhythmias was associated to higher mortality risk (p less than 0.05).

[Syncope: general characteristics and its relation to age]

We retrospectively analyzed the clinical data of 146 patients admitted to a general hospital with the diagnosis of syncope. A definite or highly likely cause was identified in 91 patients (62%). These were of cardiovascular origin in 78%: conduction defects (31), sinus node disease (9), obstructive causes (8), ventricular arrhythmia (8), ischemia (5) and miscellaneous (14). A non cardiovascular origin was present in 22% of patients: intoxication (7), hysteria (5), hypoxemia (3), vasovagal (2), gastrointestinal bleeding (2) and 2 others. The final diagnosis in patients with a known cause was established by the history and physical examination in 16, the ECG in 42, Holter 9, ECG monitoring in ICU 8 and echocardiogram 6. No difference in the distribution of causes was present between patients below or above 65 years of age. In hospital mortality was 2%.