Retinopathy of Prematurity Treatment & Management

Updated: Feb 28, 2015
  • Author: KN Siva Subramanian, MD; Chief Editor: Ted Rosenkrantz, MD  more...
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Treatment

Medical Care

Medical care of retinopathy of prematurity (ROP) consists of ophthalmologic screening of appropriate infants. No standard medical therapies are available at this time.

Ongoing research is examining the potential use of intravitreally injected antineovascularization drugs, such as bevacizumab (Avastin). [17] These drugs have been successfully used in patients with other forms of neovascularization, such as diabetic retinopathy. Other treatments may involve restoring normal levels of insulinlike growth factor (IGF)-1 and omega-3-polyunsaturated fatty acids (PUFAs) in the developing retina, as proposed by Chen and Smith. [18, 19, 20] One small study compared treatment with laser therapy over intravitreal bevacizumab monotherapy. Intravitreal bevacizumab showed better results for zone I but not zone II disease. Laser therapy led to permanent destruction of the peripheral retina, wheras the peripheral retinal vessels continued to develop after treatment with bevacizumab. [21]

The Supplemental Therapeutic Oxygen for Prethreshold Retinopathy of Prematurity (STOP-ROP) Trial assessed the effect of supplemental oxygen in reducing the probability of progression to threshold retinopathy of prematurity and the need for peripheral retinal ablation in infants with prethreshold retinopathy of prematurity. [5] The results of the trial showed no reduction in the infants who required ablative surgery. A post hoc subgroup analysis showed that infants without plus disease may be more responsive to supplemental oxygen therapy (46% progression in the conventional arm vs 32% progression in the supplemental arm) than infants with plus disease (52% progression in the conventional arm vs 57% in the supplemental arm). Supplemental oxygen increased the risk of adverse pulmonary events (8.5% conventional arm vs 13.2% in the supplemental arm).

A study by Sjöström et al indicated that in preterm infants born prior to 27 weeks’ gestation, low energy intake during the first 4 weeks following birth is an independent risk factor for severe retinopathy of prematurity. The study included 498 infants, 172 of whom had severe retinopathy of prematurity. The investigators found a significant relationship between higher intakes of energy (including fat and carbohydrates, but not protein) and a decreased risk of severe retinopathy. Indeed, an increased energy intake of 10 kcal/kg/day correlated with a 24% reduction in the severe form of the disease. [22]

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Surgical Care

Ablative surgery

If threshold disease is present, perform ablative surgery.

Ablative therapy currently consists of cryotherapy or laser surgery to destroy the avascular areas of the retina.

The average gestational age (GA) at which surgery is necessary is usually 37-40 weeks.

If the retinopathy of prematurity continues to progress, more than one treatment may be required.

Cryotherapy

A randomized prospective trial of cryotherapy showed a 50% reduction in retinal detachment in treated eyes versus nontreated eyes.

Beneficial effects were observed in infants with threshold disease, defined as 5 contiguous clock hours of stage III disease with plus disease or 8 noncontiguous clock hours of stage III disease with plus disease.

Laser surgery

Currently, laser surgery is preferred to cryotherapy because it may be more effective in treating zone I disease and causes less inflammation. Laser photocoagulation appears to be associated with outcomes in structure and function that are at least as good as those of cryotherapy 7 years after therapy. [23, 24] In addition, visual acuity and refractive error data suggest that laser surgery may have an advantage over cryotherapy, and evidence suggests that laser surgery is easier to perform and better tolerated by the infants. Cryotherapy is still the preferred treatment option when the view of the retina is limited by media opacities.

Laser surgery has been used more recently than cryotherapy, and whether the slightly improved outcomes with laser surgery are attributable to changes in the care of high-risk neonates (eg, antenatal glucocorticoid therapy, surfactant use) is unclear. However, cryotherapy has been rigorously evaluated in a multicenter prospective randomized fashion, and the 10-year follow-up data show long-term value in preserving visual acuity in eyes with threshold retinopathy of prematurity. [10]

Early treatment

The Early Treatment for Retinopathy of Prematurity (ET-ROP) Trial showed that early treatment of high-risk prethreshold retinopathy of prematurity significantly reduced unfavorable retinopathy of prematurity outcomes at age 9 months and at age 2 years. [25, 26] Patients in this study had one eye randomized to "early" retinal ablative therapy. Eyes treated had type 1 retinopathy of prematurity, defined as zone I with plus disease and any stage retinopathy of prematurity; zone I with stage III and no plus disease; or zone II, stage II or III, and plus disease.

The investigators subsequently compared their results from this ET-ROP study with those of the Cryotherapy for Retinopathy of Prematurity (CRYO-ROP) study, with respect to incidence and early course of retinopathy of prematurity. The incidence, time of onset of any disease and prethreshold disease, and rate of progression have changed little since the mid 1980s. The ET-ROP had more cases of prethreshold disease (36.9% in ET-ROP and 27.1% in CRYO-ROP) and more zone I retinopathy of prematurity.

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