Scleral buckling in stages 4B and 5 retinopathy of prematurity

Scleral buckling surgery for stage 4A and 4B retinopathy of prematurity in critically ill neonates

PURPOSE

To determine the efficacy of scleral buckling in eyes with stage 4A and 4B retinopathy of prematurity (ROP).

METHODS

Seven eyes of five premature infants underwent scleral buckling for stage 4 ROP in zone II. Five eyes had stage 4A ROP, and two eyes had stage 4B ROP. Six eyes had previous diode laser photocoagulation, and one eye had received an intravitreal ranibizumab injection. Scleral buckling was the procedure of choice due to lack of access to specialized pediatric vitrectomy instrumentation. Average age at surgery was 3.4 months. Postoperative anatomic retinal status, visual acuity outcome and refractive error were assessed.

RESULTS

The scleral buckle was removed on average 8 months after surgery. Retinal reattachment was achieved in all seven eyes. At final follow-up one eye had macular ectopia and disc dragging, one eye had a macular traction fold and two eyes had optic disc pallor. Average myopic error after buckle removal was -7.5 D.

CONCLUSION

Scleral buckling can be performed safely and effectively in 4A and 4B stage ROP in critically ill infants, when access to specialized pediatric vitrectomy instrumentation is limited. This surgical technique may provide adequate relief of vitreoretinal traction with improved visual potential.

Immediate Sequential Bilateral Vitrectomy Surgery for Retinopathy of Prematurity: A Single Surgeon Experience

Objectives:

We report the safety and efficacy of simultaneous bilateral vitrectomy for stage 4 and stage 5 retinopathy of prematurity (ROP).

Materials and Methods:

Babies who had immediate sequential bilateral vitrectomy surgery for stage 4 or stage 5 ROP were included in this retrospective study. Clinical history, demographic characteristics of the patients, surgical procedure details, perioperative and postoperative ophthalmic and systemic complications, and postoperative anatomical success rates were evaluated. General anesthesia features were also recorded.

Results:

Seventy eyes of 35 babies who had immediate sequential bilateral vitrectomy surgery for stage 4 or stage 5 ROP were reviewed. At the time of surgery, the mean age was 41.4±4.9 weeks. There was preoperative plus disease in 58.6% of the eyes. The mean surgery/eye ratio was 1.2. Mean anesthesia time was 95±64 minutes. The mean follow-up was 28.1 months (3 to 84 months). Anatomical success was 95.7% for stage 4A (44/46 eyes), 83.3% for stage 4B (15/18 eyes), and 50% for stage 5 (3/6 eyes) ROP. Patients with stage 5 ROP had significantly less anatomical success than stage 4A and 4B (p=0.004). None of the patients had endophthalmitis and anesthesiarelated severe complications.

Conclusion:

Immediate sequential bilateral vitrectomy surgery can be considered an option for patients with active bilateral stage 4 and stage 5 ROP. The risk of endophthalmitis should be weighed against the risks of disease progression and anesthesia-related complications.

Long-Term Anatomic and Visual Outcome Following Vitrectomy for Stage 4B and 5 Retinopathy of Prematurity

BACKGROUND AND OBJECTIVES

Surgical indications in stages 4B and 5 retinopathy of prematurity (ROP) are not universally accepted. The authors' purpose is to evaluate the long-term anatomic and visual outcomes of vitrectomy for retinal detachment (RD) associated with stages 4B and 5 ROP.

PATIENTS AND METHODS

Data of patients who consecutively underwent vitrectomy for stages 4B and 5 ROP from 1999 to 2013 were retrospectively reviewed and included grade of retinal attachment and visual acuity (VA) at the last follow-up.

RESULTS

Seventy eyes of 38 infants were included: 23 with stage 4B and 47 with stage 5 ROP. Lens-sparing vitrectomy was performed in 11 eyes, combined lensectomy / vitrectomy in 59 eyes. Mean follow-up was 8.5 years. Anatomic success was maintained in 41 eyes (58.5%), and among them, VA greater than 5/200 was achieved in 17 eyes (41.4%).

CONCLUSION

The long-term visual and anatomic success rates were encouraging for the surgical correction of RD associated with late stages ROP. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:208-214.].

A review of treatment for retinopathy of prematurity

Introduction

Retinopathy of prematurity (ROP) is a leading cause of childhood blindness worldwide.

Areas covered

Recent methods to identify and manage treatment-warranted vascularly active ROP are recognized and being compared to standard care by laser treatment in prospective large-scale clinical studies. Pharmacologic anti-angiogenic (anti-VEGF) treatment has changed the natural history of vascularly active ROP by reducing stage 3 intravitreal neovascularization and extending physiologic retinal vascularization in many infants. Tractional retinal detachments in stage 4 ROP after treatment with anti-VEGF agents show additional fibrovascular complexity compared to eyes treated with laser only. We review current management and outcomes for vascularly active and fibrovascular retinal detachment in ROP (stages 3, 4, 5 ROP), highlighting the evidence from recent clinical studies. Included are technical details important in surgery for retinal detachment in ROP. Literature searches were employed through PubMed.

Expert opinion

Methods in pediatric imaging, safer pharmacologic treatments, and surgical techniques continue to advance to improve future ROP outcomes.

Evolving Concepts in the Management of Retinopathy of Prematurity

PURPOSE

The introduction of anti-vascular endothelial growth factor (VEGF) agents has stimulated considerable reexamination of treatment strategies for the management of retinopathy of prematurity (ROP). Herein we summarize and review evolving concepts and provide a personal perspective on clinical management today and future directions of treatment.

DESIGN

Literature review.

METHODS

To synthesize the evolving management concepts for diagnosis and treatment of retinopathy of prematurity and to provide interpretation and perspective on current emerging therapies.

RESULTS

Although initial treatment strategies focused on ablative therapy for threshold ROP, earlier treatment for type 1 or pre-threshold disease has been found to decrease unfavorable visual and structural outcomes. Vascular endothelial growth factor has emerged as a significant contributor to retinal-vascular diseases in the previous 2 decades. The potential role of anti-VEGF treatment for type 1 ROP has become a focus in recent years, but the protracted recurrence of disease and unknown adverse ocular and systemic effects have caused concern from some clinicians. In addition, the use of telemedicine technologies may provide the ability to screen remote areas with a shortage of ROP providers, thereby reducing the burden of disease.

CONCLUSIONS

The diagnosis and management of ROP has changed over the past 40 years; the role of anti-VEGF therapy remains to be established in current treatment strategies. Screening for initial disease and progression will likely be impacted by the increasing prevalence of telemedicine and relative shortage of clinicians.

Stage 5 retinopathy of prematurity: An update

Retinopathy of prematurity (ROP) is one of the most common causes of preventable blindness in children. In spite of the availability of various treatment options, and favorable results with timely intervention, many infants present to the ophthalmologists in the advanced end stage of the disease due to lack of awareness especially in the developing nations. This blinding or Stage 5 of ROP presents with total retinal detachment and has to be managed surgically. The surgical techniques for Stage 5 ROP are unique and demanding. The successful anatomical results after surgery are only seen in 20%–50% of cases. In spite of a successful anatomical result, the visual outcome may be slow and limited. The use of newer pharmacological adjuncts has shown promising results. Because of heterogeneity of presentation of the disease severity, a genetic predisposition has also been proposed. A concerted effort from the pediatricians, ophthalmologists, and healthcare workers is required to establish effective screening and treatment guidelines to prevent blindness due to ROP. Till then surgical management has to be done. Parents must be educated regarding the limited visual benefits of surgery and the need for prolonged follow-up. This review gives a comprehensive overview of the pathogenesis, clinical aspects, surgical interventions, and their outcomes and future prospects of Stage 5 ROP.

Paediatric retinal detachment: a review

Paediatric retinal detachment (PRD) is an uncommon and challenging disease; it differs from adult detachments in etiology, anatomical characteristics, management and prognosis. PRDs can be particularly challenging, even for the most expert paediatric surgeons due to the higher prevalence of total retinal detachments, late diagnosis and bilateral involvement with respect to those which occur in adulthood. Moreover, the anatomical success, when achieved, is frequently not related to a functional recover. Postsurgical adverse events, refractive errors and amblyopia may additionally undermine the final outcome. Up to date there are few reviews regarding the approach of retinal detachment in children, mainly dealing with rhegmatogenous retinal detachment. In this review, rhegmatogenous, retinopathy of prematurity-related and Coats'-related PRDs were considered. The available literature from the last decades were reviewed and summarized. Epidemiology, etiology and clinical presentation, together with therapeutic approaches and outcomes have been reviewed and discussed.

Iris-fixated phakic intraocular lens implantation in an adult with retinopathy of prematurity: 1-year follow-up

PURPOSE

To report a case of iris-fixated phakic intraocular lens (pIOL) implantation in a patient with an extremely steep cornea, shallow anterior chamber, and small corneal diameter caused by retinopathy of prematurity (ROP) and scleral encircling.

METHODS

Case report.

RESULTS

Iris-fixated pIOLs were implanted in a 19-year-old patient with refraction of -18.5 -0.75 × 180 in the right eye and -15.5 -1.25 × 180 in the left eye. The keratometric values were 53.50 and 51.25 diopters (D) in the right eye and 54.75 and 51.75 D in the left eye. The white-to-white diameter and anterior chamber depth were 10.6 and 3.37 mm, respectively, in the right eye and 10.5 and 3.33 mm, respectively, in the left eye.

CONCLUSION

A small pIOL was used to guarantee a safety distance and resulted in a one-line gain in uncorrected distant visual acuity and stable endothelial cell density 1 year after surgery. An iris-fixated pIOL Vis therefore an effective option for myopic patients with ROP.

Outcome of eyes developing retinal detachment during the Early Treatment for Retinopathy of Prematurity study

OBJECTIVE

To describe the structural and visual outcomes at age 6 years of retinal detachment (RD) from retinopathy of prematurity (ROP) in the Early Treatment for Retinopathy of Prematurity (ETROP) study.

METHODS

Prospective multicenter nonrandomized series of infants with high-risk prethreshold ROP who developed an RD by 6 months corrected age treated with observation or vitreoretinal surgery.

RESULTS

Of 401 patients, 63 (89 eyes) experienced RD. Follow-up at age 6 years was available for 70 eyes (79%) of 49 surviving patients. The RDs were stage 4A in 28 eyes (40%), stage 4B in 14 (20%), stage 5 in 13 (19%), and not classified in 15 (21%). The macula was attached in 17 of 50 eyes (34%) after vitrectomy with or without scleral buckle, in 6 of 9 (67%) after scleral buckle only, and in 2 of 11 eyes (18%) observed. An attached macula at age 6 years after vitreoretinal surgery was present in 5 of 16 eyes (31%) with stage 4A, 6 of 10 (60%) with stage 4B, and 0 of 10 with stage 5. Favorable visual acuity (>20/200) was found in 6 of 70 eyes (9%); 5 had stage 4A, and 1 was not classified.

CONCLUSIONS

Macular attachment was achieved in approximately one-third of eyes with RD and favorable visual acuity in some eyes with stage 4A.

Long-term results of lens-sparing vitrectomy for stages 4B and 5 retinopathy of prematurity

PURPOSE

To assess long-term anatomic and visual outcomes and associated complications of lens-sparing vitrectomy (LSV) for treatment of tractional retinal detachments (TRDs) associated with stages 4B and 5 retinopathy of prematurity (ROP).

METHODS

We performed a retrospective review of medical records and data analyses of consecutive patients who presented with stages 4B and 5 ROP and underwent LSV from 1999 to 2007. Retinal reattachment status, visual acuity and postoperative complications were evaluated.

RESULTS

Twenty-one eyes of 20 patients, including 13 eyes with stage 4B ROP and 8 eyes with stage 5 ROP, were examined. The mean follow-up period was 5.6 years. In 9 (43%) out of 21 eyes, retinas were eventually reattached. The anatomic success rates were 62% in stage 4B and 13% in stage 5 ROP. In eyes with reattached retinas, visual acuity better than form vision was shown in 7 eyes (78%), whereas no light perception was present in 10 eyes (83%) among eyes with TRD on final examination. Postoperative intraocular hemorrhage occurred in nine eyes (43%). Long-term complications of cataract, corneal opacity, glaucoma and strabismus developed in 4 (19%), 6 (29%), 7 (33%) and 8 (38%) eyes, respectively, and were more common in eyes with TRD.

CONCLUSIONS

After following-up for a mean of 5.6 years, the anatomical success rate of LSV was encouraging for the correction of TRD associated with stage 4B ROP but not for stage 5 ROP. Retinal reattachment is important for obtaining better visual outcomes and preventing the development of late complications.

Risk factors for recurrent fibrovascular proliferation in aggressive posterior retinopathy of prematurity after early vitreous surgery

PURPOSE

To analyze risk factors for postoperative recurrence of fibrovascular tissue in eyes with aggressive posterior retinopathy of prematurity (AP ROP) treated with early vitreous surgery.

DESIGN

Retrospective, consecutive, observational case series.

METHODS

Thirty-one patients (50 eyes) with AP ROP who underwent early vitreous surgery between March 2005 and April 2008 participated. Eyes with stage 4A or 4B disease in which fibrovascular tissue was not attached to the vitreous base were included; those in which fibrovascular tissue was attached extensively to vitreous base or those without dense photocoagulation to the nonvascularized retina were excluded. Eligible eyes were divided into 2 groups based on postoperative recurrence or no recurrence of fibrovascular tissue. Data on gender, gestational age, birth weight, Apgar score, intubation duration, severe systemic complications, preoperative ROP stage, zone, fibrovascular tissue and vitreous base adhesion, clock hours of fibrovascular tissue, postmenstrual age at the initial application of dense photocoagulation, dense photocoagulation to both vascularized and nonvascularized retina, postmenstrual age at vitrectomy, and intraoperative hemorrhage were collected and analyzed.

RESULTS

Fifty eyes of 31 patients underwent early vitrectomy. Seven (14%) eyes were excluded and 43 eyes (86%) were included. Eight (18%) of 43 eyes had a recurrence of fibrovascular tissue. Both univariate and multivariate analysis indicated application of dense photocoagulation to both the vascularized and nonvascularized retina was a significant factor in the decreased recurrence of fibrovascular tissue (P = .002 and P = .008, respectively).

CONCLUSIONS

Application of preoperative dense photocoagulation to vascularized and nonvascularized retina may be important for lowering the recurrence of fibrovascular tissue in eyes with AP ROP.

Follow-up of 15 children with severe ROP 1987-1989

Between 1987-89 fifteen premature infants with severe retinopathy of prematurity (ROP), at the age of ten months or less, were admitted as outpatients to the Department of Ophthalmology at the Orebro Medical Center Hospital. Initial examination of the infants showed that 6 eyes had stage 3+, 3 eyes had stage 4B and 21 eyes had stage 5 ROP. All 15 infants were born at gestational week 24-28 (mean value 26) and had a birth weight between 600 and 1310 g (mean 907 g). For stage 3+ cryotherapy was performed. For stage 4B and 5 buckling procedure and vitreous surgery was performed in an attempt to re-attach the retina. The children were followed 2-5.5 years. Postoperatively, the retinas of all eyes in stage 3+ and 4B were attached. Four retinas out of seventeen stage 5 eyes were later found to be centrally re-attached. One eye with stage 3+ and four eyes with stage 5 were not treated at all. At follow-up of stage 3+ and 4B, visual acuity was measurable in all eyes; in stage 5 only two out of four eyes with anatomically reattached retinas had perception of light.

Three-year anatomic and visual outcomes after vitrectomy for stage 4B retinopathy of prematurity

PURPOSE

To assess anatomic and visual outcome following vitrectomy for stage 4B retinopathy of prematurity (ROP) after 3 years follow-up.

METHODS

Retrospective analysis of 56 eyes (46 infants) with stage 4B ROP-related retinal detachment. Eyes underwent either lens-sparing vitrectomy (LSV) or combined lensectomy and vitrectomy (LV). Visual outcome after a minimum follow-up of 36 months was ascertained by using either Teller or Snellen acuities, or sweep visual evoked potential.

RESULTS

LSV was performed in 42.9% and LV in 57.1% of eyes. Retinal reattachment was achieved in 73.2% overall (LV 71.8% versus LSV 75%) (P = 0.96). Ambulatory vision (VA better than 20/1900) and near reading vision (better than 20/800) were attained in 97.4% and 42.8% of eyes respectively. Attached retina, LSV, and pretreatment with retinal ablation were associated with a higher incidence of near reading or better vision compared to detached (P < 0.001), undergoing LV (P < 0.001), and non pretreated eyes (P = 0.011).

CONCLUSION

After 3 years, more than 40% of eyes operated for ROP stage 4B in this series had a visual acuity compatible for near reading or better. Eyes undergoing LSV and with prior peripheral retinal ablation had better visual outcomes.

Treatment of retinopathy of prematurity

Retinopathy of prematurity is a potentially blinding disorder of premature infants. Retinal ablation of the avascular retina originally described using cryotherapy but now most commonly undertaken with laser photocoagulation, reduces the unfavourable structural outcomes and improves the functional visual acuity outcome. The CRYO-ROP study showed the long-term benefit of treatment of threshold disease compared with no treatment, however even with cryoablation 44.4% of treated eyes had a visual acuity of 6/60 or worse at 10 year follow-up. The ETROP study of earlier treatment for high-risk pre-threshold disease, rather than treatment at threshold, has shown that pre-threshold treatment of type 1 disease produces a significantly improved outcome. Despite treatment some infants develop retinal detachment for which various surgical treatments have been described, although not always with a good functional outcome. Future treatment modalities may include the use of anti-VEGF therapies.

Three-port lens-sparing vitrectomy for aggressive posterior retinopathy of prematurity: early surgery before tractional retinal detachment appearance

PURPOSE

Aggressive posterior retinopathy of prematurity (APROP) may suddenly develop into tractional retinal detachment (TRD), often resulting in poor vision if untreated. The aim of the current study is to examine the anatomic results and complications of lens-sparing vitrectomy (LSV) for stage 3 APROP, before TRD appearance.

METHODS

A retrospective, noncomparative, consecutive case series of 13 eyes of 9 patients (mean gestational age 24.1+/-0.9 weeks [range: 23-25 weeks], mean birthweight of 725.8+/-107.9 grams [range: 598-897 grams]) with stage 3 APROP was carried out. The eyes did not respond to at least one session of retinal laser photocoagulation, showing signs of disease progression. All eyes underwent 20-gauge LSV before retinal detachment appearance.

RESULTS

All eyes underwent 20-gauge three-port LSV and intraoperative additional laser photocoagulation. At the end of the surgery, five eyes were tamponaded with air; in eight eyes, a balanced salt solution was left in the vitreous cavity. After 13.5+/-5.3 months of follow-up (range: 4-22), the retina was completely attached in all eyes, without any signs of progression. The authors did not observe any intraoperative or postoperative complications.

CONCLUSIONS

Surgical approach to stage 3 APROP refractory to laser photocoagulation could be effective and safe in order to avoid the progression of the disease.

Anatomical and visual outcome of stages 4 and 5 retinopathy of prematurity

AIM

To describe our experience in surgical management of stages 4 and 5 retinopathy of prematurity (ROP) and assess its anatomical and visual outcome.

MATERIALS AND METHODS

This study is a retrospective, interventional, consecutive case series. It involved 33 eyes of 29 infants. The data were retrieved retrospectively for each case from their medical records. All the eyes underwent primary vitrectomy with additional procedures like scleral buckling (two eyes), lensectomy (14 eyes), subretinal fluid drainage (two eyes), and one case of corneal transplant (open sky vitrectomy). The anatomical and visual outcome was reviewed at the final follow-up.

RESULTS

The mean gestational age was 29.7 weeks (range 25-34 weeks) and mean birth weight was 1332 g (range 650-2050 g). Anatomical success for stage 4A was defined as complete retinal attachment with undistorted or minimally distorted posterior pole. For stage 4B, partial residual retinal detachment and for stage 5 at least posterior pole attachment. Visual acuity was measured in anatomically successful eyes that were cooperative. The anatomical outcome was 90% (9/10 eyes) for stage 4A, 44.4% (4/9 eyes) for stage 4B, and 14.3% (2/14) for stage 5. The mean follow-up was 19.1 months. Posterior retinotomy was the commonest complication for stage 4B (66.7%).

CONCLUSION

Anatomical and visual success was the best for stage 4A ROP. Surgery for stage 4A can halt progression to stages 4B or 5 ROP. Aggressive peeling of posterior membranes should be avoided for stage 4B. Anatomical and visual outcome is very poor for stage 5.

Early vitreous surgery for aggressive posterior retinopathy of prematurity

PURPOSE

To assess the efficacy of early vitrectomy for aggressive posterior retinopathy of prematurity (ROP) to stop progression of retinal detachment.

DESIGN

Retrospective, noncomparative, consecutive case series.

METHODS

Twenty-two eyes (15 patients) with aggressive posterior ROP underwent vitrectomy with or without lens sparing, because retinal photocoagulation failed to stop progression of fibrovascular proliferation, despite being performed early, densely, and with early retreatment. We assessed the status of retinal attachment and foveal formation ophthalmoscopically and the presence or absence of fixation of visual behavior.

RESULTS

Follow-up ranged from six to 12 months (mean, 9 months). Six eyes (100%) in which a lens-sparing vitrectomy was performed developed a large tractional retinal detachment. In contrast, the retinas were completely reattached in 16 eyes (100%) in which vitrectomy with lensectomy was performed, nine eyes (56%) had foveal configuration, and 14 eyes (88%) had steady fixation.

CONCLUSIONS

These results suggest that early vitrectomy is effective for preventing retinal detachment in aggressive posterior ROP.

LENSECTOMY AND VITRECTOMY WITH AND WITHOUT INTRAVITREAL TRIAMCINOLONE ACETONIDE FOR VASCULARLY ACTIVE STAGE 5 RETINAL DETACHMENTS IN RETINOPATHY OF PREMATURITY

PURPOSE

To determine the anatomical success rate of lensectomy and vitrectomy with and without intravitreal triamcinolone acetonide (TA) for vascularly active stage 5 tractional retinal detachments due to retinopathy of prematurity (ROP).

METHODS

In a retrospective, interventional, single-surgeon, consecutive case series, the records of 21 eyes of 21 patients presenting with stage 5 retinal detachment secondary to ROP who underwent primary pars plicata vitrectomy with lensectomy from February 1998 to January 2004 were evaluated. All eyes were vascularly active at the time of surgery. Eleven eyes underwent the surgical procedure without TA (group 1), and 10 eyes received TA at the end of the procedure (group 2). The main outcome measure, retinal reattachment, was reviewed at the final follow-up visit, which ranged from 6 months to 42 months (mean, 28 months) after surgery.

RESULTS

None (0/11) of the eyes in group 1 maintained attachment, while 6 (60%) of 10 eyes in group 2 maintained at least posterior pole reattachment at the final visit. None of the group 2 eyes exhibited plus disease during follow-up. None of the eyes in either group exhibited signs of increased intraocular pressure after surgery. All six eyes that maintained posterior pole reattachment were able to fix and follow light at the last follow-up visit.

CONCLUSIONS

Vascularly active stage 5 ROP detachments portend a poor progress. The use of TA as a postoperative adjunct may improve the likelihood of retinal reattachment in select cases.

ANATOMICAL SUCCESS RATE AFTER PRIMARY THREE-PORT LENS-SPARING VITRECTOMY IN STAGE 5 RETINOPATHY OF PREMATURITY

PURPOSE

To assess the anatomical success rate after three-port lens-sparing vitrectomy (LSV) in stage 5 (total) retinal detachments secondary to retinopathy of prematurity.

METHODS

In a retrospective, interventional, single-surgeon, consecutive case series, the records of 33 eyes of 21 patients presenting with stage 5 retinal detachment secondary to retinopathy of prematurity who underwent primary three-port LSV from February 1998 to January 2004 were evaluated. Twenty-one eyes (63.6%) had open anteriorly-open posteriorly and 12 (36.4%) had open anteriorly-narrow posteriorly in terms of anatomical configuration. The main outcome measure, retinal reattachment, was reviewed at final follow-up visits, which ranged from 6 months to 48 months (mean, 32 months) after LSV.

RESULTS

Fifteen eyes (45.5%) maintained attachment and 18 eyes (54.5%) remained detached at the final visit. Open anteriorly-open posteriorly configuration eyes had a statistically significant higher anatomical success rate than eyes with an open anteriorly-narrow posteriorly configuration (P<0.001).

CONCLUSIONS

Three-port LSV may achieve anatomical success in stage 5 retinopathy of prematurity-related detachments. The open anteriorly-open posteriorly configuration portends a better prognosis; thus, surgery should be performed before closure of the posterior retina into a funnel configuration, if possible.

Lens-sparing vitrectomy for stage 4 and stage 5 retinopathy of prematurity

Purpose

To describe the results of lens-sparing vitrectomy for the correction of retinal detachment associated with retinopathy of prematurity (ROP) and its associated complications.

Methods

Seventeen patients who underwent a lens-sparing vitrectomy for stage 4 and stage 5 ROP with plus disease at Seoul National University Children's Hospital between 1999 and 2003 were enrolled in this study. The patients who had bilateral retinal detachment of ROP underwent a lens-sparing vitrectomy in one eye and a scleral buckling surgery or lensectomy-vitrectomy in the other eye. The patients who had a retinal detachment in one eye and a regressed ROP in the other eye underwent unilateral lens-sparing vitrectomies. A review of their preoperative clinical findings (including the status of retinal detachment and plus disease), post-operative results, and any complications encountered was performed.

Results

In 17 patients, the postoperative success rate of lens-sparing vitrectomy was 58.8%. However, lens-sparing vitrectomy as a treatment for stage 5 ROP (25.0%) produced more negative post-operative results than it did when used to treat either those for stage 4a (75,0%) or 4b (66.7%) ROP. Among the 10 eyes in which the retina was attached, form vision was shown in six eyes, light could be followed by three eyes, and no light perception was present in one eye. Intra- and post-operative complications included retinal break formation, cataracts, vitreous hemorrhages, and glaucoma in patients with stages 4b and stage 5 ROP.

Conclusions

Lens-sparing vitrectomy resulted in encouraging surgical outcomes in the correction of retinal detachment of ROP, especially in stage 4 patients. Therefore, a lens-sparing vitrectomy for stage 4 ROP patient may be beneficial, although it is still associated with some intra- and post-operative complications.

Retinopathy of prematurity: the life of a lifetime disease

PURPOSE

To provide information on retrolental fibroplasias (RLF), later known as retinopathy of prematurity.

DESIGN

Review of the literature on the subject and a first-person account of what was then RLF by one of the authors (A.P.) who was involved in the earliest days in research regarding RLF.

METHODS

MEDLINE search on the topics of RLF and retinopathy of prematurity plus a first-person historic review of original work that dealt with RLF.

RESULTS

In 1942, elevated levels of oxygen were thought to play a major role in the development of the disease; at that time, no treatment was available. During the lifetime of this disease, other possible causes have been investigated. These include vitamin E as a prophylaxis against retinopathy of prematurity and the efficacy of light reduction to prevent retinopathy of prematurity. It has been shown that the light reduction does not play a role in reducing the progression of retinopathy of prematurity. Vitamin E studies were inconclusive; some studies show a positive effect and others do not. A major advance occurred with the development of the International Classification of Ophthalmology in 1984, which laid the groundwork for collaborative studies to determine whether cryotherapy of the avascular zone of retina would reduce the incidence of blindness in newborn infants, when compared with control subjects. The study showed that cryotherapy was effective; this was followed by laser photocoagulation when lasers became portable enough to take to the neonatal intensive care unit. At the same time, improved surgical techniques moved from scleral buckling for retinal detachment to vitrectomies (some lens sparing) for more desperate cases that had progressed to stage 4 and stage 5 retinopathy of prematurity. Late changes in adults who were born before any treatment and are now baby boomers ran the gamut from the dragging of the retina in the posterior pole to retinal detachment, cataract, and myopia.

CONCLUSION

Retinopathy of prematurity is a lifetime disease for which preventive and better treatment modalities continue to evolve.

Anatomic Success Rate after 3-Port Lens-Sparing Vitrectomy in Stage 4A or 4B Retinopathy of Prematurity

PURPOSE

To assess the anatomic success rate after 3-port lens-sparing vitrectomy (LSV) in stage 4A and 4B tractional retinal detachments (TRDs) due to retinopathy of prematurity (ROP).

DESIGN

A chart review and data evaluation of 108 eyes of 102 consecutive patients presenting with stage 4A (32 eyes) or 4B (76 eyes) TRDs that underwent primary LSV from February 1998 to January 2004 were performed.

INTERVENTION

Three-port LSV was performed on all eyes by the same surgeon (ERH).

MAIN OUTCOME MEASURES

Retinal reattachment status was reviewed at final follow-up visit, which ranged from 6 to 48 months (mean, 32 months) after LSV.

RESULTS

Ninety-two of 108 (85.2%) eyes were reattached after a single LSV and 102 of 108 (94.4%) eyes ultimately achieved at least partial posterior pole reattachment at the final follow-up visit. All 4A eyes achieved complete reattachment and 70 of 76 (92.1%) 4B eyes achieved partial or complete reattachment. Reversal or complete arrest of dragging of the macula was noted in all eyes that maintained partial or complete reattachment (94.4%). Six (5.6%) 4B eyes remained detached despite additional vitreoretinal procedures; 4 (66.7%) of these had intraoperative retinal tears.

CONCLUSIONS

Eighty-five percent of eyes with 4A and 4B TRDs secondary to ROP were completely reattached with a single 3-port LSV procedure and nearly 95% were ultimately at least partially reattached at the posterior pole by the final follow-up visit. The development of retinal tears intraoperatively portended a poor prognosis for reattachment.

Lens-sparing vitrectomy for stage 4 retinopathy of prematurity

PURPOSE

To investigate the anatomic results of lens-sparing vitrectomy for tractional stage 4 retinopathy of prematurity (ROP).

DESIGN

Retrospective, noncomparative consecutive case series.

PARTICIPANTS

Thirty-seven eyes (24 patients) with tractional stage 4 ROP.

INTERVENTION

Lens-sparing vitrectomy.

MAIN OUTCOME MEASURE

Anatomic status of the retina.

RESULTS

Twenty-five eyes had stage 4A ROP, and 12 eyes had stage 4B ROP. With a median follow-up of 13 months (range, 6-27), 32 of 37 eyes (86%) had complete reattachment of the retina. Among eyes with 4A ROP, 21 of 25 eyes (84%) had complete retinal reattachment. Among eyes with 4B ROP, 11 of 12 eyes (92%) had complete retinal reattachment. At last follow-up, 29 of 37 eyes (78%) were able to fix and follow.

CONCLUSIONS

These results indicate that lens-sparing vitrectomy is effective for achieving retinal reattachment in tractional stage 4 ROP. This article contains additional online-only material available at .

Visual outcomes after lens-sparing vitrectomy for stage 4A retinopathy of prematurity

PURPOSE

To assess the visual outcomes of patients with stage 4A retinal detachments (RDs) from retinopathy of prematurity (ROP).

DESIGN

Retrospective review of a consecutive case series of children referred to the pediatric retina service of Associated Retinal Consultants, Royal Oak, Michigan.

PARTICIPANTS

Forty-five eyes of 39 children.

METHODS

The stage of RD for each patient was determined during an examination under anesthesia. All patients underwent a lens-sparing pars plana vitrectomy (PPV) with membrane peeling. Postoperative anatomic status was determined by ophthalmoscopy either during an office examination or during an examination under anesthesia. Visual outcomes were ascertained by consulting pediatric ophthalmologists using either Teller or Allen acuities.

MAIN OUTCOME MEASURES

Anatomic and visual outcomes.

RESULTS

Formalized visual acuity (VA) measurement was performed in 23 eyes of 20 children, and was not performed in 22 eyes of 19 children. All 23 eyes that were formally tested had successful retinal reattachment. The macula appeared to be normal and without distortion in 19 of 23 eyes (83%) during the follow-up period. Average logarithm of the minimum angle of resolution VA was 20/58. Three eyes had acuities of 20/200, and 4 had acuities of 20/100. All other eyes were 20/80 or better. Average age at time of VA was 3.51 years.

CONCLUSIONS

Patients with ROP and stage 4A RDs can be treated successfully with respect to anatomic and visual outcome utilizing lens-sparing PPV.

Outcomes of primary scleral buckling for stage 4 retinopathy of prematurity

BACKGROUND

Scleral buckling is an option for stage 4 retinopathy of prematurity (ROP). This study evaluated the anatomic results of a primary scleral buckling procedure for the treatment of this condition.

METHODS

Retrospective analysis of cases in which premature infants were treated solely with a primary scleral buckling procedure for stage 4 ROP by 1 retinal specialist between January 1990 and April 2001. The 20 eyes, of 14 infants, had previously been treated with cryotherapy or laser photocoagulation ablation for threshold ROP, but stage 4 ROP had developed. Maintenance of an attached macula was the desired anatomic result of surgical treatment.

RESULTS

Of the 20 eyes, 14 (70%) had an attached macula postoperatively. During a follow-up period of 3.5 to 28 months the retina redetached in 2 eyes, which became phthisical. The other 6 eyes also became phthisical, despite additional surgical treatment.

INTERPRETATION

Primary scleral buckling has a high anatomic success rate in infants with stage 4 ROP, a rate thought to be higher than would occur with natural progression of the disease. Because an attached macula is associated with improved visual potential, timely primary scleral buckling is reasonable for these infants, offering a 60% chance of useful vision.

Efficacy of removal of buckle after scleral buckling surgery for retinopathy of prematurity

BACKGROUND OR PURPOSE: A series of encouraging reports over the past decade indicate that scleral buckling (SB) surgery may lessen or eliminate vitreoretinal traction in advanced retinopathy of prematurity (ROP). The effects of SB surgery on refraction and ocular growth, however, have not been demonstrated. We investigated the effects of postoperative removal of buckle in infants whose retinas were reattached in stage 4 ROP.

METHODS

Selected for study were 6 eyes of 3 patients whose retinas had been reattached by placing an encircling buckle, 2.5 mm in width, around the eye and whose buckles were subsequently removed. Axial lengths and refractive errors were compared before and after removal of the buckles. The patients were examined for at least 3 years after removal.

RESULTS

There was high myopia in all eyes treated for stage 4 ROP with SB. All retinas remained attached after removal of the buckle. Although there was a variable degree of increase in axial length, myopic refractive error tended to decrease after removal of the buckle.

CONCLUSIONS

There was some decrease in degree of myopia without resulting in retinal detachment or continued vitreous traction after buckle removal following SB surgery for ROP.

Silicone oil in the repair of pediatric complex retinal detachments: a prospective, observational, multicenter study

OBJECTIVE

To report anatomic and visual acuity outcomes, as well as complications, after using 1000-centistoke silicone oil as a retinal tamponade for the treatment of complex retinal detachments in a pediatric population.

DESIGN

A prospective, observational, multicenter study.

PARTICIPANTS

The study cohort consisted of 205 patients 16 years of age or younger (211 eyes) treated at community and university-based ophthalmology clinics for complex retinal detachments associated with trauma, proliferative vitreoretinopathy (PVR), giant retinal tear (GRT), or retinopathy of prematurity (ROP).

INTERVENTION

Vitrectomy surgery for complex retinal detachment with 1000-centistoke silicone oil as the retinal tamponade.

MAIN OUTCOME MEASURES

Anatomic outcomes include complete retinal attachment and macular attachment. Visual acuity outcomes include ambulatory vision (> or = 4/200) and preservation of preoperative visual acuity. Complications include rates of secondary intraocular pressure (IOP) elevation (> or = 30 mmHg), hypotony (< or = 5 mmHg), corneal opacification (including band keratopathy, corneal edema, and corneal abrasions), oil emulsification, and cataract. All outcome measures were assessed 6, 12, and 24 months after surgery and at last examination.

RESULTS

At the 6-month examination, the retina was completely attached in 43 (57%) of 76 eyes in the trauma group, 24 (63%) of 38 PVR eyes, 23 (68%) of 34 GRT eyes, and 6 (33%) of 18 ROP eyes. The macula was attached in 60 (79%), 33 (87%), 26 (76%), and 8 (44%) eyes, respectively. Ambulatory vision was achieved in 19 (25%) eyes in the trauma group, 18 (47%) PVR eyes, 19 (56%) GRT eyes, and 4 (22%) ROP eyes. Visual acuity was preserved in 53 (70%), 26 (68%), 28 (82%), and 9 (50%) eyes, respectively. The corresponding rates of complications for traumatic, PVR, GRT, and ROP eyes were: elevated IOP-3 (4%) of 76, 1 (3%) of 38, 1 (3%) of 34, and 0 (0%) of 18; hypotony--9 (12%), 3 (8%), 2 (6%), and 2 (11%); corneal opacity--25 (33%), 8 (21%), 15 (44%), and 5 (28%); emulsification--4 (5%), 1 (3%), 3 (9%), and 1 (6%); and cataract in phakic eyes--1 (33%) of 3, 2 (67%) of 3, 2 (50%) of 4, and 1 (33%) of 3.

CONCLUSIONS

Retinal reattachment and preserved visual acuity were achieved in the majority of eyes using vitrectomy and silicone oil retinal tamponade. Complete retinal and macular attachment was achieved less frequently in ROP eyes than in eyes in the other diagnostic groups. Use of 1000-centistoke silicone oil can be considered in the management of pediatric complex retinal detachments associated with multiple etiologies.

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.

Advanced cicatricial retinopathy of prematurity--outcome and complications

AIMS

To assess the outcome and complications of patients with advanced retinopathy of prematurity (ROP).

METHODS

All patients with eyes achieving stage 4 or 5 retinopathy of prematurity were reviewed. Twenty one eyes were diagnosed during ROP screening in maternity hospitals and 10 eyes were of infants transferred for treatment.

RESULTS

Thirty one eyes of 17 patients were included. Thirteen eyes were treated for acute disease but progressed to stage 4 or 5; seven had cryotherapy and six diode laser photocoagulation. Cataract was found in 17 eyes (54.8%), glaucoma in seven eyes (22.6%), microphthalmos in 15 (48.4%), and corneal opacification in four eyes (12.9%). Fifteen eyes had surgical procedures; two (6.5%) had trabeculectomy, four (12.9%) had lensectomy, and nine (29%) retinal detachment repair. Transferred infants had their initial eye examination later than infants in hospitals screened by the authors and 80% of them had progressed beyond threshold ROP by the time they were transferred for treatment. Twenty nine eyes (93.6%) had visual acuities of 3/60 or less and only two eyes (6.5%) achieved 6/18 or less.

CONCLUSION

The visual outcome of the eyes undergoing retinal re-attachment surgery was disappointing. Cataract, microphthalmos, and glaucoma were the most frequent complications, and surgical intervention was often required. The need for children who are blind as a result of ROP to have long term follow up is shown.

Visual acuity of eyes after vitrectomy for retinopathy of prematurity: follow-up at 5 1/2 years. The Cryotherapy for Retinopathy of Prematurity Cooperative Group

PURPOSE

To provide long-term follow-up on the structural status and visual function at 5 1/2 years of age for 128 eyes of 98 infants who participated in the multicenter randomized clinical trial of cryotherapy for retinopathy of prematurity in whom total retinal detachment developed from retinopathy of prematurity (ROP) by the 3-month study examination. Fifty-four patients had lensectomy-vitrectomy procedures in one or both eyes before 1 year of age (n=72 eyes), and 44 patients did not (n=56 eyes).

METHODS

When the children were 5 1/2 years of age, an eye examination was performed and residua of ROP was assessed. Recognition acuity (Early Treatment of Diabetic Retinopathy Study chart) and grating visual acuity (Teller acuity card procedure) assessments were undertaken by testers who were masked to the status of each of the child's eyes.

RESULTS

At least partial retinal attachment was present at 5 1/2 years in 21% compared with 28% at 1 year of age (not significant). All except one of the eyes tested at 5 1/2 years had vision limited to light perception or no light perception, regardless of whether a vitrectomy had been performed. One eye that underwent vitrectomy had minimal pattern vision. The two eyes that were reported previously to have minimal pattern vision at 1 year of age were blind at the longer-term follow-up.

CONCLUSIONS

The poor visual outcome after a lensectomy-vitrectomy procedure for retinal detachment due to ROP demands that emphasis be placed on prevention of retinal detachment in premature infants.

Severe retinopathy of prematurity in infants from the southern regions of Sweden

We studied children born in 1986-1989 with severe retinopathy of prematurity (ROP) defined as stage 3 "plus" or more. Sixteen children from the southern and central areas of Sweden were identified and 15 of these were referred to Orebro Medical Center Hospital for surgical treatment of ROP. The incidence of severe ROP was estimated as 0.8 per 10,000 newborns per year. All children were born before 29 weeks' gestation and weighed less than 1310 g; they also needed ventilatory support for a long time. The overall neonatal morbidity was high. A model for eye examination in premature newborns is suggested.

The surgical management of retinopathy of prematurity using a perfluorocarbon liquid

Retinopathy of prematurity with retinal detachment continues to present a challenge to the vitreoretinal surgeon despite many advances in technique. We report on two eyes with stage 4 and 5 ROP operated on using vitrectomy techniques and a perfluorocarbon liquid (Vitreon). The surgical technique is described in detail.

Scleral buckling for retinopathy of prematurity

PURPOSE

This study was undertaken to determine the anatomic effectiveness of scleral buckling on eyes with stages 4A, 4B, and 5 retinopathy of prematurity.

METHODS

Seventy eyes of 44 infants had scleral buckling performed by one surgeon and were followed for at least 6 months. All except one child had previous bilateral peripheral ablation (cryo/laser).

RESULTS

Twelve (70%) of 17 stage 4A eyes, 29 (67%) of 43 stage 4B eyes, and 4 (40%) of 10 stage 5 eyes had complete retinal reattachment or dry folds attached at their last follow-up visit. All eyes referred as stage 5 retinopathy of prematurity that reattached had a rhegmatogenous component.

CONCLUSION

Scleral buckling appears to play a role in reducing progression from stage 4 to stage 5 retinopathy of prematurity.

Glaucoma as a cause of poor vision in severe retinopathy of prematurity

Despite surgical reattachment of the retina in infants with severe retinopathy of prematurity (ROP), visual acuity may decline. We performed gonioscopy and applanation tonometry on 26 eyes of 17 infants with severe ROP who were randomly selected and followed prospectively for 2 years. Of these 26 eyes, one eye of one patient had only peripheral retinocryopexy for threshold stage III disease and had an attached retina before enrollment into the study. Sixteen infants subsequently underwent vitrectomy, scleral buckle, or both. Retinal reattachment of the posterior pole was present in at least one eye each of 10 of the 17 infants. Glaucoma was diagnosed in 5 of the 10 patients; all 5 showed a decrease in visual acuity of greater than 1 octave. Of the 5 infants without glaucoma, 3 showed visual improvement, and 2 remained the same. Although we studied a small number of cases, our results suggest that glaucoma may be a cause of visual decline in infants with severe ROP. A decline in visual acuity in infants with severe ROP and surgical retinal reattachment may warn us of glaucoma, as this diagnosis is difficult to make in these small infants.

Retinopathy of prematurity--current diagnosis and management

Despite advances in ophthalmological care of premature infants, retinopathy of prematurity (ROP) remains a still unsolved problem for paediatricians as well as ophthalmologists. A survey of the current literature concerning drug therapy and surgical management as related to the different stages of ROP is given. The classification system for ROP according to the International Committee is presented as well as our screening policy in relation to the literature. The effectiveness in preventing severe cases of ROP and the toxicity of vitamin E supplementation in high-risk premature infants is still disputed and no recommendations can be given. Cryotherapy is recommended in symmetric cases of stage 3 + ROP. Nevertheless, quite a number of eyes still progress to more severe stages of ROP. Scleral buckling procedures and vitrectomy may lead to anatomical success in a few cases of retinal detachment, however, the visual outcome of such an operation is usually very poor despite reattachment of the central retina.