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Retinopathy of Prematurity Ophthalmologic Approach Treatment & Management

  • Author: Mounir Bashour, MD, PhD, CM, FRCSC, FACS; Chief Editor: Hampton Roy, Sr, MD  more...
 
Updated: Mar 21, 2016
 

Medical Care

Although oxygen therapy has been blamed for ROP progression in the past, many physicians believe that maximizing the oxygen saturation in these critical babies will induce regression in prethreshold disease. STOP-ROP (Supplemental Therapeutic Oxygen for Prethreshold Retinopathy Of Prematurity), a multicentered national study, found that no benefit was achieved by keeping the oxygen saturation above 95%. However, higher oxygen saturation levels were not found to worsen the disease in prethreshold babies.

Because ROP progresses sequentially and timely treatment can reduce the risk of visual loss, at-risk preterm infants must be examined at proper times and intervals. A January 2013 policy statement from the American Academy of Pediatrics on screening for ROP provides screening recommendations, including descriptions of the following[1] :

  • Criteria for screening
  • Equipment and methods for retinal examinations for ROP
  • Examiner qualifications and reporting criteria
  • Timing of the first retinal examination, based on the infant’s postmenstrual age (gestational age at birth plus chronologic age)

There appears to be a lower incidence of very high myopia (≥8.00 diopters) when ROP is treated with intravitreal bevacizumab compared with conventional lasers,[15, 16] on the basis of results from the Bevacizumab Eliminates the Angiogenic Threat for ROP (BEAT-ROP) Cooperative Group study, which randomized 109 children (211 eyes) as infants to intravitreal bevacizumab or conventional laser treatment and then compared refractive outcomes at age 2.5 years. Moreover, myopia in the laser group was linked to greater numbers of laser applications, with an increase of -0.14 D for every 100 laser applications.[16]

Among infants with zone I ROP, very high myopia developed in 2 of 52 eyes (3.8%) in the bevacizumab group and 18 of 35 eyes (51.4%) in the laser group (P  < .001); among those with zone II posterior ROP, very high myopia developed in 1 of 58 eyes (1.7%) in the bevacizumab group and in 24 of 66 eyes (36.4%) in the laser group (P  < .001).[15, 16]

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Surgical Care

Cryotherapy was the original mode of treatment (since the 1970s). The procedure may be completed with general or topical anesthesia. It involves approximately 50 applications of a freezing probe under direct visualization with cryo applications to the avascular retina anterior to the fibrovascular ridge. The stress of the procedure may require assisted ventilation after the procedure. The most common complications include intraocular hemorrhage, conjunctival hematoma, conjunctival laceration, and bradycardia.

Laser surgery (eg, xenon, argon, diode) has been shown to be as effective as cryotherapy for ROP. The systemic adverse effects are significantly less, the ocular tissues are less traumatized, posterior zone 1 disease is treated easily, general anesthesia is not necessary, and, as many studies show, there is less incidence of late complications. Complications include corneal haze, burns of the iris, cataracts, and intraocular hemorrhages.

The use of diode laser therapy in extremely preterm infants with ROP appears not only to halt disease progression but also leads to good visual outcomes for most of these infants, thereby apparently offering similar structural and visual outcomes to those of low and very low birth weight infants with this condition.[17, 18]

Scleral buckling surgery and/or vitrectomy is usually performed for stages 4 and 5. Some surgeons recommend surgery for stage 4A, while others do not think surgery should be performed because of the risks and unproven benefit. Although some surgeons advocate surgery for stage 5, the surgeon with the most experience (S.T. Charles, MD, personal communication) no longer recommends surgery because of the poor anatomical and visual prognosis.

According to the largest reported case series in the world, lens-sparing vitrectomy to correct early degrees of retinal detachment results in excellent lens clarity and vision in the majority of infants with retinopathy of prematurity. Success rates for retinal reattachment with a single surgery were approximately 89% for infants with stage 4A retinopathy. Success rates for stage 4B retinopathy were 60%. The procedure was less successful in infants with stage 5 retinopathy, with an 18% success rate.[19]

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Consultations

An ophthalmology consultation is essential in a premature infant born weighing less than 1500 g and/or younger than 32 weeks' gestation (as defined by the attending neonatologist). Also, selected infants with a birth weight of 1500-2000 g or a gestational age of more than 32 weeks with an unstable clinical course, including those requiring cardiorespiratory support and who are believed by their attending pediatrician or neonatologist to be at high risk, should have retinal screening examinations performed after pupillary dilation using binocular indirect ophthalmoscopy to detect ROP. One examination is sufficient only if it unequivocally shows the retina to be fully vascularized in each eye. The ophthalmologist chosen should be one with the most experience in screening or treating this disease. A review of two randomized crossover trials performed in single centers found that the application of topical proparacaine 30 seconds before the evaluation brings about a reduction in pain scores, particularly atthemoment of speculum insertion.[20]

An ophthalmologist experienced in this modality should perform laser or cryotherapy surgery.

Scleral buckle surgery and vitrectomy techniques in these small eyes should be left in the hands of experienced surgeons.

Practitioners involved in the ophthalmologic care of premature infants should be aware that the retinal findings that require strong consideration of ablative treatment were revised according to the Early Treatment for Retinopathy of Prematurity Randomized Trial study. The finding of threshold ROP, as defined in the Multicenter Trial of Cryotherapy for Retinopathy of Prematurity, may no longer be the preferred time of intervention.

Treatment may also be initiated for the following retinal findings:

  • Zone 1 ROP - Any stage, with plus disease
  • Zone 1 ROP - Stage 3, with no plus disease
  • Zone 2 ROP - Stage 2 or 3, with plus disease

The number of clock hours of disease may no longer be the determining factor in recommending ablative treatment. Treatment should generally be accomplished, when possible, within 72 hours of determination of treatable disease to minimize the risk of retinal detachment.

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Diet

Vitamin E is not recommended in infants who weigh less than 1500 g.

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Contributor Information and Disclosures
Author

Mounir Bashour, MD, PhD, CM, FRCSC, FACS Assistant Professor of Ophthalmology, McGill University Faculty of Medicine; Clinical Assistant Professor of Ophthalmology, Sherbrooke University; Medical Director, Cornea Laser and Lasik MD

Mounir Bashour, MD, PhD, CM, FRCSC, FACS is a member of the following medical societies: American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, American College of International Physicians, American College of Surgeons, American Medical Association, American Society of Cataract and Refractive Surgery, American Society of Mechanical Engineers, American Society of Ophthalmic Plastic and Reconstructive Surgery, Biomedical Engineering Society, Canadian Medical Association, Canadian Ophthalmological Society, Contact Lens Association of Ophthalmologists, International College of Surgeons US Section, Ontario Medical Association, Quebec Medical Association, Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Coauthor(s)

C Corina Gerontis, MD Consulting Staff, Departments of Pediatrics and Ophthalmology, Schneider Children's Hospital/Long Island Jewish Medical Center

C Corina Gerontis, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, American Medical Association

Disclosure: Nothing to disclose.

Johanne Menassa, MD Staff Physician, Department of Ophthalmology, University of Laval Hospital, Quebec City

Disclosure: Nothing to disclose.

Specialty Editor Board

Simon K Law, MD, PharmD Clinical Professor of Health Sciences, Department of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine

Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, Association for Research in Vision and Ophthalmology, American Glaucoma Society

Disclosure: Nothing to disclose.

Steve Charles, MD Director of Charles Retina Institute; Clinical Professor, Department of Ophthalmology, University of Tennessee College of Medicine

Steve Charles, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Retina Specialists, Macula Society, Retina Society, Club Jules Gonin

Disclosure: Received royalty and consulting fees for: Alcon Laboratories.

Chief Editor

Hampton Roy, Sr, MD Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy, Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Additional Contributors

V Al Pakalnis, MD, PhD Professor of Ophthalmology, University of South Carolina School of Medicine; Chief of Ophthalmology, Dorn Veterans Affairs Medical Center

V Al Pakalnis, MD, PhD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, South Carolina Medical Association

Disclosure: Nothing to disclose.

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Retinopathy of prematurity consultation form and fundus drawing.
 
 
 
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