The rationale for cryotherapy with a prophylactic scleral buckle for Zone I threshold retinopathy of prematurity

Evaluation of scleral buckling for stage 4A retinopathy of prematurity by fluorescein angiography

PURPOSE

To determine the early efficacy of scleral buckling for active neovascularization by fundus fluorescein angiography (FA) in eyes with stage 4A retinopathy of prematurity.

DESIGN

A retrospective, nonrandomized, observational case series.

METHODS

Patients who underwent scleral buckling for stage 4A ROP at the National Center for Child Health and Development, Tokyo, Japan, from October 2007 through November 2008 were included. Preoperative and postoperative FA and fundus photographs obtained with a wide-field digital pediatric imaging system were reviewed. Three patients (5 eyes; gestational ages at birth, 23 to 25 weeks; birth weights, 574 to 811 g) with zone II stage 4A ROP who underwent postoperative FA, 2 weeks or less after scleral buckling (range, 7 to 12 days; postmenstrual ages at postoperative FA, 41 to 45 weeks) were evaluated. Patients who underwent postoperative FA 2 weeks or more after scleral buckling were excluded.

RESULTS

Despite fluorescein leakage from fibrovascular tissue in all eyes before surgery, markedly decreased leakage occurred only between 7 to 12 days after surgery. The retinas were reattached completely in all eyes after surgery.

CONCLUSIONS

Scleral buckling may prevent progression of retinal detachment in stage 4A ROP by reducing the tractional force and stabilizing the neovascular activity of the fibrovascular tissue.

Involution of retinopathy of prematurity after laser treatment: factors associated with development of retinal detachment

PURPOSE

To identify specific features during the process of involution of retinopathy of prematurity after treatment at threshold that are associated with development of a retinal detachment.

DESIGN

Retrospective case series.

METHODS

The evolution of retinal detachments over time was analyzed retrospectively in 262 treated eyes of 138 infants. Specific features hypothesized to be associated with development of a retinal detachment were analyzed, including vitreous organization defined as clinically important, active stage 3 disease and active plus disease more than 21 days after treatment, and vitreous hemorrhage defined as clinically important.

RESULTS

A retinal detachment developed in 36 (13.7%) of 262 eyes. Vitreous organization meeting our clinically important definition was associated with a 31-fold (confidence interval [CI] 5.37-183.63; P < .0001) and 13-fold (CI 2.97-58.59; P < .0001) increase in the odds for retinal detachment for right and left eyes, respectively. Vitreous hemorrhage defined as clinically important was associated with a 38-fold (CI 2.69-551.19; P = .007) and 15-fold (CI 1.65-144.12; P = .02) increase in the odds for retinal detachment for right and left eyes, respectively. The timing of retinal detachment relative to vitreous hemorrhage was not determined. Prolonged activity of Stage 3 disease or plus disease more than 21 days after treatment was not associated with development of a retinal detachment.

CONCLUSIONS

Clinically important vitreous organization and vitreous hemorrhage were predictive for development of a retinal detachment. Evaluation of preemptive reintervention strategies for eyes at highest risk for developing a retinal detachment may be reasonable.

COMPARISON OF RETINAL OUTCOMES AFTER SCLERAL BUCKLE OR LENS-SPARING VITRECTOMY FOR STAGE 4 RETINOPATHY OF PREMATURITY

PURPOSE

To compare anatomic outcomes after lens-sparing vitrectomy (LSV) or scleral buckle (SB) for stage 4 retinopathy of prematurity (ROP).

METHODS

Nonrandomized, retrospective study of infants consecutively treated for stage 4 ROP by LSV or SB. Outcomes were retinal attachment at 1 month of initial surgery and at the end of follow-up (6 months) and number of procedures to achieve retinal attachment. Exact chi2 methods determined significance, and student's t-test compared mean postmenstrual age and birthweight between the groups.

RESULTS

After one procedure, LSV (72%) was associated with retinal attachment more often than was SB (31%). At the end of follow-up, after one or more procedures, there was no difference in retinal reattachment rate between LSV or SB as the first procedure. There were no differences between the surgical groups by mean postmenstrual age and birthweight or severity of ROP determined by zone, clock hours of ridge elevation, or quadrants of plus disease.

CONCLUSION

This study supports the hypothesis that vitrectomy by LSV stops progressive stage 4 ROP. As an initial procedure, LSV was associated with retinal attachment more often than SB. Future prospective studies can determine the effects of LSV and SB on visual development in progressive stage 4 ROP.

Scleral buckling surgery for active stage 4A retinopathy of prematurity

OBJECTIVE

To examine the effectiveness of scleral buckling surgery for active stage 4A retinopathy of prematurity.

DESIGN

Retrospective noncomparative case series.

PARTICIPANTS

Eight eyes of seven infants were examined. All except one had previous peripheral ablation (cryotherapy-laser) but retinal detachment was actively progressing.

INTERVENTION

Scleral buckling surgery was performed by one surgeon.

MAIN OUTCOME MEASURES

Anatomic retinal status and visual acuity outcome after average follow-up of 23 months were measured.

RESULTS

Six (75%) of eight eyes had a complete retinal reattachment (+/- macular ectopia) after a single buckling procedure. Two eyes progressed to stage 4B despite scleral buckling but after closed limbal vitrectomy with lensectomy and membrane peeling, the retinas were reattached.

CONCLUSIONS

Scleral buckling for stage 4A retinopathy of prematurity is an effective means of preventing further progression of retinal detachment. The authors believe that the effect of the buckle not only relieves vitreoretinal traction but also plays a role in preventing ischemia in the detached retina that alters the natural progression of the disease.

Scleral buckling surgery in stage 4 retinopathy of prematurity

BACKGROUND

Technical advances in neonatal intensive care have significantly increased the number of very low birth-weight babies that survive the perinatal period. Some of these infants develop severe retinopathy of prematurity that may lead to retinal detachment.

METHODS

Between November 1988 and January 1994, 28 eyes from 15 preterm babies underwent scleral buckling for stage 4 retinopathy of prematurity at a mean age of 4.2 months. Cryotherapy was performed preoperatively on 12 eyes and intraoperatively in the remaining 16 eyes. The mean follow-up period was 35 months.

RESULTS

Scleral buckling produced retinal reattachment in 13 eyes (46.4%). Severe myopia (-5 D to -15 D) was found in all 13 of these eyes, 12 also presented convergent strabismus. Mean visual acuity, measured in 6 eyes from children over the age of 3 years was 20/40. In 7/28 eyes of the younger children of this group we found a fix and follow the light capability. No light perception was detected in 11/28 eyes; in the remaining 4/28 eyes there was only light perception. Scleral buckling failed to prevent the progression to stage 5 in 15 eyes (53.6%). Additional surgery was excluded for 9 of these eyes based on ultrasonography findings; the other 6 eyes underwent vitrectomy, which led to macular reattachment in 4 cases.

CONCLUSIONS

Clinical experience shows that scleral buckling is not always capable of preventing progression of the disease to stage 5. Furthermore, even when the anatomic results of this procedure are good, the functional outcome is often complicated by severe visual impairment.

Diode-laser photocoagulation for zone 1 threshold retinopathy of prematurity

We used the diode-laser indirect ophthalmoscope in the treatment of 17 (30 eyes) infants with zone 1 (a circle centered on the optic disk with a radius of twice the distance from the disk to the fovea) threshold retinopathy of prematurity (at least five continuous or eight cumulative 30-degree sectors [clock hours] of ridge with extraretinal fibrovascular proliferation in the presence of plus disease). Mean follow-up was 31.2 weeks. Two eyes (6.7%) required retreatment of missed areas that had persistent plus disease (enlarged posterior veins and tortuous arterioles). A favorable outcome was attained in 25 eyes (83.3%). Five eyes (16.7%) developed retinal detachments, three of which remained stable at Stage 4A (extrafoveal retinal detachment) and two of which ultimately progressed to Stage 5 (total retinal detachment). Both eyes that went on to Stage 5 had severe posterior pole hemorrhages at the time of treatment. Two eyes that developed retinal detachments (one, stage 4A and one, stage 5) had rhegmatogenous components. Among 14 infants followed up for more than three months, four developed nystagmus, and six developed strabismus. In contrast to cryoablation, diode-laser photoablation of the peripheral retina was found to be an effective treatment for threshold retinopathy of prematurity located in zone 1. Portability and ease of use of the laser system, precision of treatment, and minimal postprocedural adnexal inflammation are further advantages of this therapeutic modality.