Retinopathy of prematurity: An update on screening and management

Pain in Neonates: Perceptions and Current Practices

All newborns experience pain during routine care, which can have long-lasting negative effects. Despite the availability of effective methods to prevent and reduce pain, most infants will receive ineffective or no treatment. Optimal pain management includes the reduction of the number of procedures performed, routine pain assessment and the use of effective pain-reducing interventions, most notably breastfeeding, skin-to-skin contact and sweet-tasting solutions. Parents are an essential component of the comprehensive assessment and management of infant pain; however, a gap exists regarding the uptake of parent-led interventions and the engagement of families. Practice recommendations for infant pain care are discussed.

Flicker electroretinogram in preterm infants

BACKGROUND

Infants born prematurely are at risk of developing retinopathy of prematurity, which is associated with abnormalities in retinal function as measured using electroretinography. The aim of this study was to record non-invasive flicker electroretinograms (ERGs) in preterm infants and compare function of moderate and very or extremely preterm infants.

METHODS

In this non-randomized, cross-sectional study, 40 moderate preterm (gestational age (GA) 34 0/7 to 36 6/7 weeks, Group A) and 40 very or extremely preterm infants (GA ≤ 31 weeks, Group B) were recruited for flicker ERG recording through closed eyelids using the RETeval® device and skin electrodes. Group A was tested within the first week of life and Group B between 34th and 37th week postmenstrual age. Flicker stimuli were presented at 28.3 Hz with stimulus levels of 3, 6, 12, 30 and 50 cd•s/m2. Primary endpoints were peak time (ms) and amplitude (µV).

RESULTS

Flicker ERGs were recordable in most infants with the highest proportion of reproducible ERGs at 30 cd•s/m2. Amplitudes increased with stronger flicker stimulation, while peak times did not differ significantly between stimulus levels nor groups. Amplitudes were significantly greater in Group B at the strongest stimulus level (Mann-Whitney-U-Test=198.00, Z = 4.097, p = <0.001).

CONCLUSIONS

Feasibility of collecting flicker ERG data in most preterm infants was confirmed. We found no evidence of reduced retinal responses to flicker stimuli associated with extreme prematurity. Higher amplitudes in very and extremely preterm infants could indicate acceleration of retinal development following birth, triggered by visual stimulation.

Retinopathy of Prematurity-Targeting Hypoxic and Redox Signaling Pathways

Retinopathy of prematurity (ROP) is a proliferative vascular ailment affecting the retina. It is the main risk factor for visual impairment and blindness in infants and young children worldwide. If left undiagnosed and untreated, it can progress to retinal detachment and severe visual impairment. Geographical variations in ROP epidemiology have emerged over recent decades, attributable to differing levels of care provided to preterm infants across countries and regions. Our understanding of the causes of ROP, screening, diagnosis, treatment, and associated risk factors continues to advance. This review article aims to present the pathophysiological mechanisms of ROP, including its treatment. Specifically, it delves into the latest cutting-edge treatment approaches targeting hypoxia and redox signaling pathways for this condition.

Propranolol: a new pharmacologic approach to counter retinopathy of prematurity progression

Despite the evident progress in neonatal medicine, retinopathy of prematurity (ROP) remains a serious threat to the vision of premature infants, due to a still partial understanding of the mechanisms underlying the development of this disease and the lack of drugs capable of arresting its progression. Although ROP is a multifactorial disease, retinal vascularization is strictly dependent on oxygen concentration. The exposition of the retina of a preterm newborn, still incompletely vascularized, to an atmosphere relatively hyperoxic, as the extrauterine environment, induces the downregulation of proangiogenic factors and therefore the interruption of vascularization (first ischemic phase of ROP). However, over the following weeks, the growing metabolic requirement of this ischemic retina produces a progressive hypoxia that specularly promotes the surge of proangiogenic factors, finally leading to proliferative retinopathy (second proliferative phase of ROP). The demonstration that the noradrenergic system is actively involved in the coupling between hypoxia and the induction of vasculogenesis paved the way for a pharmacologic intervention aimed at counteracting the interaction of noradrenaline with specific receptors and consequently the progression of ROP. A similar trend has been observed in infantile hemangiomas, the most common vascular lesion of childhood induced by pre-existing hypoxia, which shares similar characteristics with ROP. The fact that propranolol, an unselective antagonist of β1/2 adrenoceptors, counteracts the growth of infantile hemangiomas, suggested the idea of testing the efficacy of propranolol in infants with ROP. From preclinical studies, ongoing clinical trials demonstrated that topical administration of propranolol likely represents the optimal approach to reconcile its efficacy and maximum safety. Given the strict relationship between vessels and neurons, recovering retinal vascularization with propranolol may add further efficacy to prevent retinal dysfunction. In conclusion, the strategy of contrasting precociously the progression of the disease appears to be more advantageous than the current wait-and-see therapeutic approach, which instead is mainly focused on avoiding retinal detachment.

Retrospective cohort evaluation of postnatal growth and retinopathy of prematurity (G-ROP) criteria in a tertiary centre in Turkey

PURPOSE

The postnatal growth and retinopathy of prematurity (G-ROP) study has proposed a new model to increase the effectiveness of screening retinopathy of prematurity (ROP). The present study aimed to evaluate the effectiveness of the G-ROP model in a tertiary centre in Turkey.

METHODS

The medical records of infants screened for ROP in our hospital between January 2018 and December 2022 were reviewed retrospectively. Babies with a documented ROP result and regular body weight measurements up to the 40th day of life were included in the study, and the G-ROP model was applied. The sensitivity of the G-ROP prediction model in detecting treated ROP, Type 1 ROP, Type 2 ROP, and low-grade ROP and the reduction in the number of babies to be screened by applying the model were calculated.

RESULTS

The G-ROP model was applied to a total of 242 infants. While 194 babies were determined for screening, 22 of them were treated. The sensitivity to predict treated ROP was 100%, and the specificity was 21.8%. The model successfully predicted all cases of Type 1 ROP in the cohort, while the sensitivity was 90.9% for Type 2 ROP and 90.7% for low-grade ROP. The G-ROP model reduced the number of infants requiring screening by 19.8% in our study.

CONCLUSIONS

The G-ROP model was successfully validated in our cohort in detecting treated ROP and Type 1 ROP, reducing the number of infants requiring screening by approximately 1 in 5.

Non-pharmacological pain relief interventions in preterm neonates undergoing screening for retinopathy of prematurity: a systematic review

OBJECTIVE

The objective of this review was to determine the efficacy of non-pharmacological interventions for pain management during retinopathy of prematurity (ROP) screening.

METHODS AND ANALYSIS

Electronic search of Ovid MEDLINE, PubMed, EMBASE, Cochrane Database of Systematic Reviews, Cumulative Index to Nursing and Allied Health Literature, Google Scholar and ClinicalTrials.gov (USA) was conducted. Search terms from the research question and inclusion criteria were used to select randomised control trials (RCT) published from January 2000 to May 2023. Relevant data were extracted, and risk of bias was assessed using the Cochrane Risk of Bias tool V.2. Critical appraisal and grading of the quality of evidence were done using the Critical Appraisal Skills Programme tool for RCTs and the Grading of Recommendations Assessment, Development and Evaluation, respectively.

RESULTS

Twenty-one RCTs were included; 14 used sweet taste, while 7 used modified developmental care, touch or positioning, multisensory stimulation, non-nutritive sucking or music. Six studies on sweet taste and all seven latter studies showed a difference in the pain scores in favour of the interventions. The quality of evidence was however judged low and moderate due to some concerns in the randomisation process, measurement of outcome assessment and selection of reported results domains.

CONCLUSION

The use of gentle touch, nesting, positioning, music, multisensory stimulation and developmental care in reducing pain during ROP screening is promising, however, larger studies designed to eliminate the identified concerns are needed. More evidence is also needed before sweet taste interventions can be recommended in routine practice.

[10 years of screening for retinopathy of prematurity (2009-2019) : Results analysis of two German level-1 neonatal intensive care units (NICUs) with university on-site screening and a telemedical approach in the non-university NICU]

BACKGROUND

Retinopathy of prematurity (ROP) is one of the most common causes of childhood blindness in Germany and worldwide and adequate screening is essential. The telemedical approach with objective documentation of retinal findings opens up the possibility of reliably diagnosing all ROP stages independent of the examiner, if a team of ophthalmologists specialized in ROP evaluates the images.

OBJECTIVE

A 10-year comparison of ROP screening at two level‑1 neonatal intensive care units (NICU): university and on-site vs. non-university and telemedical.

MATERIAL AND METHODS

Retrospective analysis of screened premature infants by gestational age (GA), birth weight (BW), sex, multiple births, time of ROP occurrence, treatment needs and time as well as examination frequency.

RESULTS

From 2009 to 2019, we screened 1191 infants of whom 29 had been screened before by an external clinic. The internal 1162 infants were screened on-site with 3713 retinal examinations. We diagnosed 34% with ROP and treated 5.4% (3.7% in Giessen, 7.2% in Siegen). Mean GA was 28.9 weeks (± 2.5 weeks); mean BW 1155 g (± 417.5 g). The number of ROP diagnoses increased by 227.3% in Giessen and by 111.1% in Siegen due to the increasing number of premature births in neonatal care.

CONCLUSION

Comparative analysis confirmed nationally and internationally increasing ROP screening and children with acute ROP. Telemedical screening was equivalent to on-site screening and safe. Both screening methods identified infants requiring treatment on time. No child with GA > 29 weeks required treatment, analogous to Swedish ROP registry results; however, in the German ROP registry some premature babies with GA ≥ 30 weeks required treatment.

Retinopathy of Prematurity Outcomes of Neonates Meeting Only a Single Screening Criterion: Proposal of the TWO-ROP Algorithm

PURPOSE

To assess the rates of retinopathy of prematurity (ROP) and treatment-warranted ROP in a modern set of patients meeting 0 or 1 of the current ROP screening criteria.

DESIGN

Retrospective cohort study.

METHODS

Single-center study of 9350 infants screened for ROP from 2009 to 2019. Rates of ROP and treatment-warranted ROP were evaluated in group 1 (birth weight [BW] <1500 g and gestational age [GA] ≥30 weeks), group 2 (BW ≥1500 g and GA <30 weeks), and group 3 (BW ≥1500 g and GA ≥30 weeks).

RESULTS

Of 7520 patients with reported BW and GA, 1612 (21.4%) patients met the inclusion criteria. The number of patients in groups 1, 2, and 3 was 466 (6.19%), 23 (0.31%), and 1123 (14.93%), respectively. The number of patients diagnosed with ROP was 20 (4.29%) in group 1, 1 (4.35%) in group 2, and 12 (1.07%) in group 3 (P < .001). The mean interval between birth and ROP diagnosis was 36.25 days (range 12-75 days) in group 1, 47 days in group 2, and 23.33 days (range 10-39 days) in group 3 (P = .05). No cases of stage 3, zone 1, or plus disease were recorded. No patients met the treatment criteria.

CONCLUSIONS

Patients meeting 1 screening criterion had a low rate of ROP (<5%), with no stage 3, zone 1, or plus disease. No patients required treatment. We propose a possible algorithm (TWO-ROP) in appropriate neonatal intensive care units, with an amendment in screening protocol for this low-risk population to include only an outpatient screening examination within 1 week of discharge, or at 40 weeks if inpatient, to decrease the inpatient ROP screening burden while maintaining safety. Further external validation of this protocol would be required.

Artificial intelligence for the diagnosis of retinopathy of prematurity: A systematic review of current algorithms

BACKGROUND/OBJECTIVES

With the increasing survival of premature infants, there is an increased demand to provide adequate retinopathy of prematurity (ROP) services. Wide field retinal imaging (WFDRI) and artificial intelligence (AI) have shown promise in the field of ROP and have the potential to improve the diagnostic performance and reduce the workload for screening ophthalmologists. The aim of this review is to systematically review and provide a summary of the diagnostic characteristics of existing deep learning algorithms.

SUBJECT/METHODS

Two authors independently searched the literature, and studies using a deep learning system from retinal imaging were included. Data were extracted, assessed and reported using PRISMA guidelines.

RESULTS

Twenty-seven studies were included in this review. Nineteen studies used AI systems to diagnose ROP, classify the staging of ROP, diagnose the presence of pre-plus or plus disease, or assess the quality of retinal images. The included studies reported a sensitivity of 71%-100%, specificity of 74-99% and area under the curve of 91-99% for the primary outcome of the study. AI techniques were comparable to the assessment of ophthalmologists in terms of overall accuracy and sensitivity. Eight studies evaluated vascular severity scores and were able to accurately differentiate severity using an automated classification score.

CONCLUSION

Artificial intelligence for ROP diagnosis is a growing field, and many potential utilities have already been identified, including the presence of plus disease, staging of disease and a new automated severity score. AI has a role as an adjunct to clinical assessment; however, there is insufficient evidence to support its use as a sole diagnostic tool currently.

Premature infants with gestational age less than 25 weeks require increased ophthalmology resources for retinopathy of prematurity

BACKGROUND

It is unclear how increasing survival of low gestational age (GA) infants affects ophthalmologic screening and treatment rates for retinopathy of prematurity (ROP). This study compared the examination and treatment rates of infants born at GA of <25 weeks and those born at GA of at least 25 weeks.

METHODS

This was a retrospective study of patients who met institutional ROP screening criteria and were admitted to two neonatal intensive care units (NICUs) from January 2017 to June 2020. Variables analyzed were GA, birth weight, number of ophthalmology examinations, worst stage of ROP, presence of type 1 ROP, and comorbidities associated with ROP. The χ², Fisher exact, and two-tailed t tests, as well as univariate and multivariable logistic regression, were used for statistical analysis.

RESULTS

Compared to the GA≥25 group, the GA<25 group had a higher number of total exams (10 vs 4.3 [P < 0.001]), higher average worst stage of ROP (1.4 vs 0.3 [P < 0.001]) and higher rate of type 1 ROP (21% vs 1.4% [P < 0.001]), as well as higher mortality (37% vs 8.11% [P < 0. 001]). Multivariable logistic regression analysis controlling for GA, sepsis, and number of transfusions revealed that only GA was significantly associated with developing type 1 ROP.

CONCLUSIONS

Infants with GA <25 weeks had more severe ROP and required significantly more ophthalmologic examinations than GA ≥25. It is important for ROP services to plan for this increased screening load, especially if the number of such lower-weight infants in their NICUs increases.

Effect of Optimizing Oxygen Saturation Targets on the Incidence of Retinopathy of Prematurity in a Quaternary NICU

Introduction

Retinopathy of prematurity (ROP) is a multifactorial disease and a preventable cause of blindness in childhood. Hyperoxia and hypoxia can cause retinal neovascularization resulting in retinal detachment and blindness if left untreated. Besides oxygen treatment, other reasons for ROP development are well known. We prospectively adopt various strategies to keep oxygen saturation (SpO₂) within targets^, between 91 and 95% for those on supplemental oxygen. By adapting this, we postulated that the incidence of severe ROP might be reduced.

Methods

2018-2019 provided pre-intervention and 2020 post-intervention data for the project. For all babies (≤32 weeks, ≤1,500 g with FiO₂ >0.21), target SpO₂ between 91 and 95% was measured as a percentage of time spent within and outside target SpO₂ during 1-4 weeks of life.

Results

112 and 60 preterm neonates were screened for ROP during the pre- and post-intervention phase. Twenty neonates (18.3%) during pre-intervention and 16 (26.7%) in the post-intervention phase developed severe ROP requiring treatment. Despite a statistically significant increase of 10 percent points in time spent within target SpO₂ (91-95%) in the post-intervention phase (p < 0.05), the incidence of severe ROP did not decline. Using a multivariate model, odds of ROP development decreased with gestational age (25%) while increasing with PDA requiring treatment (4.33 times) and glucose ≥10 mg/dL (4.15 times), considering one variable at a time, keeping others constant.

Conclusion

Our QI project showed successful attainment of maximum time; the SpO₂ remained within targets during supplemental oxygen; however, the incidence of severe ROP had not declined. Factors other than SpO₂ might be responsible for a high incidence of ROP in our neonatal intensive care unit.

Retinopathy of prematurity, a two-year experience at the ROP screening unit from AL-Zahraa Teaching Hospital, AL-Najaf, Iraq

This study aimed to assess the incidence of retinopathy of prematurity (ROP) in Al Najaf city, define the risk factors of ROP, and assess the performance of the newly implemented ROP screening. This retrospective study was performed in the ROP screening clinic in Al Najaf city between January 2018 and December 2019. 247 neonates were examined at the ROP screening clinic, with gestational age ≤30 weeks, weight ≤1500 g, other fetal and maternal risk factors, and older or heavier newborns with a complicated course. Out of all the neonates, 90 were enrolled in this study because all others lost contact with the ROP clinic. 62 out of 90 enrolled neonates (69%) were diagnosed with ROP. Of them, 82% had stage 1-2 ROP, and 18% had stage 3-4. We found that the higher gestational age was protective for ROP (P-value=0.012, OR=0.434, CI=0.227-0.829). CPAP carried a higher risk of ROP (P-value=0.072, OR=7.276, CI=0.834-63.441). The P-value was significant for maternal age and premature rupture of membranes (PROM) (P-value=0.028 and 0.01, respectively). This study showed the incidence of ROP in the accepted range compared to other countries with similar resources. Furthermore, there was a strong association between ROP and the following factors: decreased gestational age, CPAP, maternal age, and PROM.

Anesthesia in retinopathy of prematurity

Retinopathy of prematurity (ROP) remains among the leading causes of childhood blindness. It affects mainly premature infants who tend to be systematically and clinically unstable and are more prone to complications and anesthesia related adverse effects when undergoing examination or treatment. A better comprehension of different analgesic and anesthetic methods used during screening and treatment may help in choosing a suitable option for ROP screening and treatment. An electronic search was done using MEDLINE, PubMed, and Embase databases. Search terms used included ROP, ROP, ROP screening, ROP treatment, analgesia, and anesthesia. All randomized clinical trials, large case series, and surveys were included in the review. Topical proparacaine is the most commonly used anesthesia during ROP screening and may significantly ease pain during ROP screening. Different comfort measures during screening may help infants recover faster but do not abolish pain. Topical tetracaine seems an effective pain-relieving option during intravitreal injections for ROP treatment. Photocoagulation of the peripheral retina under general anesthesia is considered the most common practice in the treatment of ROP. Further work is necessary to better understand the options of anesthesia methods offered for the treatment of ROP patients. This is a comprehensive review highlighting the available anesthetic methods for ROP patients to aid ophthalmologists in determining the most common and current anesthetic and analgesic practices.

Follow-up care of the extremely preterm infant after discharge from the neonatal intensive care unit

The survival of babies born extremely preterm (EP, <28 weeks gestation) has improved over time, and many have good outcomes and quality of life. They remain at risk for health issues, including neurosensory and neurodevelopmental difficulties requiring monitoring by primary physicians, paediatricians, and specialty clinics. This statement reviews potential medical and neurodevelopmental consequences for EP infants in the first 2 years after discharge and provides strategies for counselling, early detection, and intervention. EP-related conditions to assess for early include bronchopulmonary dysplasia or respiratory morbidity, feeding and growth concerns, neurosensory development (vision and hearing), cerebral palsy, and autism spectrum disorder. Correction for gestational age should be used for growth and development until 36 months of age. Integral to quality care of the child born EP is attention to the emotional well-being of parents and caregivers.

Systematic review of the guidelines for retinopathy of prematurity

As the characteristics of preterm infants with retinopathy of prematurity (ROP) vary, depending on the quality of neonatal care they received, universal screening criteria for ROP are not possible. The purpose of this study was to compare ROP guidelines for those planning to develop guidelines, particularly in resource-poor settings.A systematic review was undertaken of PubMed, Embase and guidelines registers to identify national or international policy statements or guidelines in English, issued or operational in 2010-2021. Bibliographies of two publications were also reviewed. The searches identified 633, 1081 and 317 records, respectively, and 157 records were retrieved from other sources. 23 publications were included in the analysis.Most included documents defined cut-offs for screening as <32 weeks gestational age (GA) or ≤1500g birth weight (BW). The highest values were in the Philippines (<35 weeks GA; <2000g) and India (≤34 weeks GA; <2000g). The lowest were in high-income countries, i.e. the United States of America (≤32 weeks for GA) and New Zealand (<1250g for BW). Most guidelines included additional risk factors to consider. The most frequent indication for when screening should start was a combination of GA and chronological age. All but one document defined when screening could stop. There was general consensus on the indications, timing and methods of treatment. Indications for anti-VEGF therapy varied between countries.Guidelines were identified for a limited number of countries with none from low-income settings. Variation in the indications for screening reflects the varying exposure to risk factors in different settings.

Daily Oxygen Supplementation and Risk of Retinopathy of Prematurity

PURPOSE

Excessive oxygen supplementation increases risk of retinopathy of prematurity (ROP). While numerous oxygen parameters could be considered when predicting ROP (saturation targets, actual saturation, fraction of inspired oxygen, etc.), complicated measures are impractical as screening criteria. We sought to develop a simple, clinically useful measure of daily oxygen supplementation during ages 0-28 days to improve prediction of ROP.

METHODS

Secondary analysis of two Postnatal Growth and ROP (G-ROP) Study cohorts (G-ROP-1 and G-ROP-2) at 45 hospitals. Infants with a known ROP outcome and complete oxygen data were included. Associations between severe ROP and days on supplemental oxygen (FiO2 > 21%), during ages 0-28 days (DSO28) were assessed, controlling for birth weight (BW) and gestational age (GA). New screening criteria incorporating DSO were developed and compared to current guidelines.

RESULTS

Among 8,949 studied infants, 459 (5.1%) developed type 1 ROP. DSO28 was associated with severe ROP (adjusted-OR 1.05 per day supplemental oxygen, 95%CI 1.03-1.07, p < .0001). The following criteria had 100% sensitivity for type 1 ROP and higher specificity than current guidelines: new BW/GA criteria with DSO (BW<901 g, GA<26 weeks, or DSO >3), 23.4% fewer infants examined; modified G-ROP criteria including DSO, 29.0% fewer infants; original G-ROP criteria, 31.8% fewer infants.

CONCLUSION

In high-level neonatal-care settings, incorporating DSO (a simple measure of oxygen supplementation) into screening criteria improves sensitivity and specificity for type 1 ROP over current BW-GA criteria, but does not perform as well as the validated G-ROP criteria.

Oral Ibuprofen Versus Oral Paracetamol in Pain Management During Screening for Retinopathy of Prematurity: A Prospective Observational Study

Screening examinations for retinopathy of prematurity (ROP) are critical to reduce ROP-related vision loss; however, the procedure is painful and uncomfortable, and topical anesthetics do not completely suppress the pain responses. The number of safe and effective pharmacological options to reduce pain during eye examinations for ROP screening in preterm infants is limited. This study compared the efficacy of oral ibuprofen and oral paracetamol in reducing pain during screening for ROP in preterm infants. This prospective observational study was conducted at a tertiary-care neonatal intensive care unit. Forty-four preterm infants with gestational age of 32 weeks and less undergoing ROP screening were included. Each enrolled infant received either oral ibuprofen 10 mg/kg (n = 22) or oral paracetamol 10 mg/kg (n = 22) 1 hour before eye examination. The primary outcome measure was pain assessed by the Neonatal Pain, Agitation, and Sedation Scale (N-PASS). Secondary outcome measures were tachycardia, bradycardia, desaturations, and crying time. The groups were similar for gestational age, birth weight, and postnatal age at examination (P > .05). The mean N-PASS scores were not significantly different between the oral ibuprofen and oral paracetamol groups (8.64 ± 1.57 vs 8.50 ± 1.71, respectively, P = .605). Moreover, no significant intergroup differences were observed in the crying time and the incidence of tachycardia/bradycardia and desaturation (P > .05). Ibuprofen or paracetamol administered orally before ROP screening in preterm infants had similar analgesic effects and did not significantly alleviate pain during eye examination.

The retinal vascular growth rate in babies with retinopathy of prematurity could indicate treatment need

Purpose

To analyze the weekly rate of retinal vascular growth in treatment-naïve babies with various stages of retinopathy of prematurity (ROP) and validate if this could be a predictor of treatment need.

Methods

Retrospective review of medical charts and retinal images of babies with various stages of ROP. The images were enhanced using red-green image enhancement software. Using the length of the horizontal disc diameter (DD) of each eye, the vessel growth was measured from the disc margin up to the vessel tip in fixed quadrants. The rate of vessel growth was the ratio of vessel length to the number of weeks it took to reach this length. The babies were divided into treatment warranting ROP (group 1), low-risk pre-threshold (type II) ROP (group 2,), and no-ROP (group 3) for analysis. The "no-ROP" group acted as normal control. Group 1 was further subdivided into 1A (threshold ROP), IB (aggressive posterior ROP), 1C (hybrid ROP), and ID (high-risk pre-threshold ROP).

Results

Out of 436 eyes, groups 1, 2, and 3 had 238, 108, and 90 eyes, respectively. The mean rate of vascular outgrowth along with 95% confidence interval (CI) was 0.490 [0.487,0.520], 0.612 [0.599, 0.638], and 0.719 [0.703, 0.740] DD/week, respectively, for babies with "treatment warranting," "low risk pre-threshold" and "no ROP" groups, respectively. In our estimate, more than 80% of eyes with a vessel growth rate of 0.54 DD/week or less required treatment.

Conclusion

A rate of retinal vascular growth less than 0.54 DD/week can be used to determine treatment requirements in babies with ROP.

Retinopathy of prematurity: a review of epidemiology and current treatment strategies

Retinopathy of prematurity (ROP) is among the most common causes of childhood blindness. Three phases of ROP epidemics have been observed worldwide since ROP was first described in the 1940s. Despite advances in neonatal care, the occurrence of ROP and associated visual impairment has been increasing somewhere on Earth and remains difficult to control. Conventional treatment options for preventing ROP progression include retinal ablation using cryotherapy or laser therapy. With the emergence of anti-vascular endothelial growth factor (anti-VEGF) treatment for ocular diseases, the efficacy and safety of anti-VEGF therapy for ROP have recently been actively discussed. In the advanced stage of ROP with retinal detachment, surgical treatment including scleral buckling or vitrectomy is needed to maintain or induce retinal attachment. At this stage, the visual outcome is usually poor despite successful anatomical retinal attachment. Therefore, preventing ROP progression by timely screening examinations and treatment remains the most important part of ROP management.

Optimization of retinopathy of prematurity screening in a tertiary neonatal unit in Northern Greece based on 16-year data

OBJECTIVE

The optimal modification of retinopathy of prematurity (ROP) screening policy in our unit, by tightening the applicable screening criteria, without missing treatment-requiring ROP (TR-ROP).

STUDY DESIGN

Retrospective analysis of screened infants with gestational age (GA) < 32 weeks and/or birth weight (BW) < 1501 g as well as cases beyond these thresholds but with comorbidities (April 2004 to April 2020).

RESULT

Of 1560 included infants, 18.4% (n = 288) developed any stage of ROP and 3.1% (n = 49) were treated. TR-ROP occurred at a mean (SD) 36^2/7 (2^5/7) weeks PMA, and not before a minimum of 32^3/7 weeks PMA. No treated infant would have been missed if screening criteria were reduced to GA < 30 weeks and/or BW < 1251 g. This modification would have resulted in 826 (52.9%) fewer infants undergoing screening.

CONCLUSION

Modifying the current screening criteria to GA < 30 weeks and/or BW < 1251 g would have spared over half of the screened infants from unnecessary examinations, without missing TR-ROP.

Implementation of telemedicine screening for retinopathy of prematurity in rural areas in Guatemala

PURPOSE

To report findings of a telemedicine retinopathy of prematurity (ROP) screening program in six neonatal units in rural areas of Guatemala, using a portable, noncontact, 40° field digital fundus camera (Pictor Plus) operated by trained technicians.

METHODS

National ROP Program Guidelines screening criteria were used: gestational age <36 weeks and/or birth weight (BW) <2000 g, or GA <36 weeks but BW ≥2000 g, with qualifying medical history. Retinal images were obtained by two technicians and graded by ophthalmologists experienced in ROP. Infants with signs of pre-plus or plus disease in one or both eyes were referred for clinical examination. Screening was stopped when retinal vessels in anterior zone II were normal on two successive evaluations or the infant had reached 45 week's postmenstrual age.

RESULTS

A total of 418 of 1,890 eligible infants (22.1%) were screened. Mean GA was 33.9 ± 2.2 weeks (range, 27-36), and mean BW 1728.3 ± 379.3 g (range, 840-2830 g). Thirty-three infants (8.6%) developed plus or pre-plus disease, and 19 (58%) underwent ophthalmologic examination. Fifteen infants were confirmed with type 1 ROP, and 14 were treated. Mean GA of treated infants treated was 33.6 ± 3.0 weeks (range, 32-34.9), and mean BW was 1,646 ± 245.8 g (range, 1100-1774.1 g).

CONCLUSIONS

Imaging with a noncontact fundus camera can facilitate detection of treatable ROP in countries with limited resources. Strengthening the health systems, including motivation and continued training of neonatal intensive care personnel is essential to improve and maintain program effectiveness. Reasons for, and interventions to address the low uptake of screening need to be explored to extend coverage of ROP screening to district hospitals in Guatemala.

Evaluation and modification of French screening guidelines for retinopathy of prematurity

PURPOSE

To evaluate the current French screening guidelines for retinopathy of prematurity (ROP) and to suggest modifications to it.

METHODS

In this multicentric retrospective, noncomparative, interventional case series we included infants with a gestational age (GA) ≤32 weeks who were screened for ROP by fundus examination between 2011 and 2018. Main Outcome Measures were the presence of ROP and the need for treatment.

RESULTS

A total of 2246 children with a mean GA of 28.9 ± 2.0 weeks and mean birth weight (BW) of 1141.1 ± 332.0 g were screened. Retinopathy of prematurity (ROP) was found in 683 infants (30.4%), of whom 145 (6.5%) had type 2 ROP and 58 (2.6%) had type 1 ROP. Mean GA of infants with type 1 ROP needing treatment was 25.9 + 1.5 weeks (range: 23.6-30) and mean BW was 774.1 ± 173.7 g (range: 540-1400). Both GA and BW had an impact on the development of type 1 and 2 ROP. None of the infants needing treatment had a GA of 31 weeks or more. None of the children needed treatment before 33 weeks of postmenstrual age (PMA) or 6 weeks of postnatal age (PNA).

CONCLUSION

It seems possible to decrease the screening of premature infants to ≤31 weeks of GA and to start screening at 31 weeks PMA for infants having a GA < 26 weeks and at 6 weeks PNA for more mature children.

Retinopathy of Prematurity: Advances in the Screening and Treatment of Retinopathy of Prematurity Using a Single Center Approach

PURPOSE

To focus on the longitudinal evaluation of high-risk infants for the development of retinopathy of prematurity (ROP) at a single tertiary neonatal intensive care unit (NICU), and to evaluate evolving demographics of ROP and the transition of treatment-warranted disease.

DESIGN

Retrospective cohort study.

METHODS

A consecutive retrospective review was performed of all infants screened for ROP between 1990 and 2019 at the Jackson Memorial Hospital neonatal intensive care unit. All inborn infants meeting a birth criteria of <32 weeks' gestational age (GA) or a birthweight (BW) of 1500 g were included. Longitudinal demographic, diagnostic, and treatment data were reported.

RESULTS

Between January 1, 1990, and June 20, 2019, a total of 25,567 examinations were performed and 7436 patients were included. Longitudinal trends over 3 decades demonstrated a decreasing incidence of ROP (P < .05). Although the mean BW and GA increased over 3 decades, patients with ROP demonstrated lower BW and GA over time (P < .05). The prevalence of micro-premature infants (as defined by BW <750 g) continues to rise over time. Micro-preemies demonstrated increasing severity of zone and stage grading, plus disease, and propensity to require treatment (P < .05). The rate of progression of ROP to stage 4 and 5 disease has decreased over time, and there has been an associated increased adoption of intravitreal bevacizumab as primary and salvage therapy.

CONCLUSIONS

Understanding the evolution of ROP infants and treatment over time is critical in identifying high-risk infants and in reducing the incidence of severe-stage ROP. Micro-prematurity is one of the significant risk factors for treatment-warranted ROP that continues to increase as neonatal care improves. NOTE: Publication of this article is sponsored by the American Ophthalmological Society.

Screening for Retinopathy of Prematurity Through Utilization a Pediatric Retinal Camera at Jim Pattison Children's Hospital: A Vision for Improved Care

Retinopathy of Prematurity (ROP) is a vascular proliferative disorder of preterm infants, with increased disease severity and incidence occurring with lower gestational age and birth weight. An alternate approach to ROP screening with wide-field digital retinal imaging helps with the early detection of ROP, especially during the pandemic.

Analysis of the parental satisfaction for retinopathy of prematurity screening using binocular indirect ophthalmoscopy versus wide field retinal imaging

Purpose:

Analysis of the parental satisfaction for retinopathy of prematurity screening using binocular indirect ophthalmoscopy versus wide field retinal imaging.

Methods:

This was an observational, questionnaire survey-based study. The study cohort comprised of parents/legal guardians of consecutive Asian Indian premature infants enrolled for retinopathy of prematurity screening (for infants less than 2000 gms and/or 34-weeks gestational age) using binocular indirect ophthalmoscopy (BIO) with scleral depression and b) wide field retinal imaging using the 3Nethra Neo Camera (Forus Health, India). We evaluated the retina for the presence or absence of stages of ROP and plus disease. The survey analysis used closed-ended (multiple-choice) and open-ended questions for assessing 1) parents’ experience/preference among the two screening modalities namely, BIO and wide field imaging used in the study, 2) knowledge prior to ROP screening, 3) knowledge gained post ROP screening, in the outpatient ophthalmologic care unit in our hospital.

Results:

Parents/legal guardians of 90 infants were included in the study. Among the 90 parents who filled in the questionnaire, 62.3% were referred by their pediatrician, 23.3% came for self check-up and 14.4% incidentally came to the hospital for complaints like ocular discharge and were screened. 93.3% parents were satisfied with either ROP screening modality in our study, with 54.4% stated a preference for retinal imaging. In the study 20% of the parents felt that retinal imaging was painful for the infant and 31.1% felt that BIO was painful for the infant.

Conclusion:

Wide field imaging is increasingly becoming an effective tool and screening tool in ROP screening and helps in better understanding of the disease amongst parents.

An Updated and Comprehensive Meta-Analysis of Association between VEGA -634G > C, -460T > C, +405G > C and +936C > T Polymorphisms and Retinopathy of Prematurity Risk

Previous studies have suggested an association between VEGF-A polymorphisms and retinopathy of prematurity (ROP) risk. But the conclusions are still controversial. The aim of this meta-analysis was to evaluate the association between the VEGF-A polymorphisms and susceptibility of ROP. Methods: We searched PubMed, Scopus, WanFang and CNKI databases for all eligible case-control studies published before September 30, 2019. Results: A total of 27 case-control studies with 5,748 ROP cases and 6,146 controls were selected. The results suggested that there was an association between VEGF-A -460T > C polymorphism and increased risk of ROP under the allele model (C vs. T: OR= 0.879, 95% CI 0.776-0.994, p = 0.040). However, VEGF-A -634G > C, +405G > C and +936C > T polymorphisms were not significantly associated with risk of ROP. The subgroup analysis demonstrated that VEGF-A +405G > C polymorphism was associated with ROP risk in Caucasians. Conclusions: This meta-analysis indicates that VEGF-A -460T > C polymorphism may contribute to the susceptibility for ROP.

[Screening for retinopathy of prematurity-the most important changes in the new German guidelines 2020]

Hintergrund

Durch Verbesserungen in der neonatologischen Versorgung von Frühgeborenen und die Entwicklung neuer Behandlungsmöglichkeiten der Frühgeborenenretinopathie („retinopathy of prematurity“ [ROP]) haben sich die Anforderungen an das ROP-Screening seit der Veröffentlichung der letzten Fassung der deutschen Leitlinie zum ROP-Screening im Jahr 2008 verändert. Auf Grundlage aktueller Studiendaten wurde die Leitlinie in 2020 grundlegend überarbeitet und in einer aktualisierten Fassung veröffentlicht.

Ziel

Dieser Artikel fasst die wichtigsten Änderungen in der neuen Leitlinie zusammen.

Ergebnisse

Die Altersgrenze für einen Screeningeinschluss wurde für Kinder ohne zusätzliche Risikofaktoren auf ein Gestationsalter von unter 31 Wochen gesenkt. Die Mindestdauer für eine Sauerstoffsupplementation, die einen Einschluss in das Screening bei Frühgeborenen erforderlich macht, wurde auf über 5 Tage angehoben. Eine Behandlung bei ROP in Zone II kann nun schon bei jedem Stadium 3 mit Plus-Symptomatik unabhängig von der Anzahl der betroffenen Uhrzeiten erfolgen. Für die Nachkontrollen nach Anti-VEGF („vascular endothelial growth factor“)-Therapie wurden Kriterien zur Frequenz und Dauer definiert. Das verbindliche Dokument für diese und weitere neue Empfehlungen ist die Leitlinie selber.

Schlussfolgerungen

Die Empfehlungen der Leitlinie ermöglichen eine zuverlässige Identifikation von Kindern mit ROP-Risiko für den Einschluss in das Screening und eine rechtzeitige Erkennung fortgeschrittener Krankheitsstadien für die Therapieeinleitung, um so Erblindung durch ROP zu verhindern.

GLYCEMIC VARIABILITY IS ASSOCIATED WITH TREATMENT REQUIRING RETINOPATHY OF PREMATURITY: A Case-Control Study

PURPOSE

To assess the association between glycemic variability (GV) and Type 1 retinopathy of prematurity (ROP) in infants with birth weights of less than 1,251 g.

METHODS

A case-control study of infants with birth weights of less than 1,251 g who developed Type 1 ROP (n = 20) was conducted. Controls had a less severe ROP or no eye disease and were individually matched for gestational age and birth weight (n = 40). Odds ratios of ROP were calculated based on multiple factors including oxygen exposure, respiratory support, incidence of hyperglycemia, and GV. For glucose measurements, a continuous glucose monitoring system was used.

RESULTS

There were no significant differences in gender, antenatal steroid administration, severity of illness, and Apgar score. Univariate analyses suggest increased risk for the development of Type 1 ROP based on incidence of intraventricular hemorrhage Grade 3 or 4 (P = 0.048), duration of oxygen exposure (P = 0.003), incidence of hyperglycemia over 150 mg/dL (P = 0.01), and GV according to significantly higher SD (P = 0.002), coefficient of variation (P = 0.001), and mean amplitude of glucose excursion (P = 0.008). Using a multiple regression model, increased risk of Type 1 ROP was only found to be associated with duration of oxygen exposure and higher GV.

CONCLUSION

Our study demonstrates a relationship between GV and the development of severe ROP.

Incidence and risk factors of retinopathy of prematurity in an Italian cohort of preterm infants

OBJECTIVE

Non-negligible differences in retinopathy of prematurity (ROP) and its risk factors between different neonatal intensive care units (NICUs) are reported. Our aim was to assess the incidence and risk factors for ROP development in a large cohort of very preterm infants who were assisted in two Italian NICUs.

METHODS

Preterm infants with gestational age between 23+ 0 and 29+ 6 weeks were stratified into subgroups of infants who developed ROP and those who did not; their clinical characteristics were compared with univariate and multivariable logistic regression analyses.

RESULTS

We studied a total of 178 infants of whom 67 (38%) developed ROP (stage 1: n = 12; stage 2: n = 41; stage 3: n = 14). Regression analysis demonstrated that maternal milk (OR 0.979, 95% Cl 0.961-0.998) decreased the risk of developing ROP, while intraventricular hemorrhage (IVH) (OR 2.055, 95% Cl 1.120-3.772) increased it. Moreover, maternal milk was found to decrease (OR 0.981, 95% Cl 0.964-0.997) the risk of ROP at discharge, while RBC transfusion increased it (OR 1.522, 95% Cl 1.208-1.916).

CONCLUSIONS

In our cohort the occurrence of ROP was similar to that previously reported. Strategies for promoting the use of mother's own milk, preventing IVH, and standardizing the approach to RBC transfusions could contribute to decreasing the risk of ROP in very preterm infants.

Incidence of retinopathy of prematurity in Germany: evaluation of current screening criteria

OBJECTIVE

To evaluate current screening criteria for retinopathy of prematurity (ROP) by investigating the incidence of ROP requiring treatment in infants with gestational age (GA) ≥30 weeks or postmenstrual age (PMA) <32 weeks in Germany.

METHODS

Three patient databases were analysed, that is, the German Quality Assurance Procedure in Neonatology (years 2011-2017; n=52 461 infants screened for ROP, 1505 infants treated for ROP), the German Retina.net ROP Registry (years 2011-2018; n=281 treated infants) and the ROP screening programme of two German university hospitals (years 2012-2016; n=837 screened infants).

RESULTS

In the analysed cohorts, infants with GA ≥30 weeks represented 33.1%-38.5% of the screening populations but only 1.40%-1.42% of the cases requiring ROP treatment. In a cohort of 281 infants treated for ROP, all 4 infants with GA ≥30 weeks had additional risk factors for ROP including prolonged oxygen supplementation and/or significant comorbidities. Five infants (1.8%) were treated at 32 weeks PMA and none at PMA <32 weeks.

CONCLUSIONS

In the investigated cohorts, preterm infants with GA ≥30 weeks carried a very low or no risk for developing treatment-requiring ROP unless additional risk factors were present, and no treatment was performed earlier than 32 weeks PMA. These findings are of relevance for the ongoing re-evaluation of ROP screening criteria.

Efficacy of the WINROP algorithm for retinopathy of prematurity screening in Southern China

AIM

To evaluate the predicting efficacy of severe retinopathy of prematurity (ROP) by the WINROP algorithm (http://winrop.com) in Southern China.

METHODS

All preterm infants with the gestational age (GA) less than 32wk were included. Their ROP screening results and serial postnatal body weight were analysed retrospectively. Weekly body weight was entered into and measured by the WINROP system. The outcomes were analysed, and the sensitivity, specificity, positive predictive value and negative predictive value (NPV) were calculated.

RESULTS

Totally 432 infants with a median GA of 30.0 (24.0-31.9)wk, and a median birth weight (BW) of 1360 (540-2700) g were included. Among these 432 infants, 50 were diagnosed as type 1 ROP but only 28 were identified by the WINROP algorithm. The sensitivity was 56% (28/50) and the NPV was 92% (252/274). However, for infants with BW <1000 g or GA <28wk, the sensitivity was 93.8% (15/16) and 93.3% (14/15), respectively. Meanwhile, with several postnatal complications added as additional risk factors, the sensitivity was increased to 96% (48/50).

CONCLUSION

The sensitivity of the WINROP algorithm from the Southern Chinese cohort is not as high as that reported in developed countries. This algorithm is effective for detecting severe ROP from extremely small or preterm infants. Modification of the algorithm with additional risk factors could improve the predictive value for infants with a GA>28wk in China.

Optimised retinopathy of prematurity screening guideline in China based on a 5-year cohort study

PURPOSES

To develop an optimised retinopathy of prematurity (ROP) screening guideline by adjusting the screening schedule and thresholds of gestational age (GA) and birth weight (BW).

METHODS

A multicentre retrospective cohort study was conducted based on data from four tertiary neonatal intensive care units in Shanghai, China. The medical records of enrolled infants, born from 2012 to 2016 who underwent ROP examinations, were collected and analysed. The incidence and risk factors for ROP were analysed in all infants. Postnatal age (PNA) and postmenstrual age (PMA) of infants, detected to diagnose ROP for the first time, were compared with the present examination schedule. The predictive performance of screening models was evaluated by internally validating sensitivity and specificity.

RESULTS

Of the 5606 eligible infants, ROP was diagnosed in 892 (15.9%) infants; 63 (1.1%) of them received treatment. The mean GA of ROP patients was 29.4±2.4 weeks, and the mean BW was 1260±330 g. Greater prematurity was associated with an older PNA at which ROP developed. The minimum PMA and PNA at which diagnosis of treatable ROP occurred were 32.43 and 3 weeks, respectively. The optimised criteria (GA <32 weeks or BW <1600 g) correctly predicted 98.4% type 1 ROP infants, reducing the infants requiring examinations by 43.2% when internally validated.

CONCLUSIONS

The incidence of type 1 ROP and the mean GA and BW of ROP infants have decreased in China. The suggested screening threshold and schedule may be reliably used to guide the modification of ROP screening guideline and decrease medical costs.

Natural history and outcomes of stage 3 retinopathy of prematurity persisting beyond 40 weeks of post-menstrual age: Dilemma for treatment and follow up

IMPORTANCE

To evaluate the natural history and outcomes of infants with stage-3 retinopathy of prematurity (ROP) persisting beyond 40-weeks of post-menstrual age (PMA).

BACKGROUND

There are no specific screening guidelines for stage-3 ROP persisting beyond 40 weeks of PMA. Persistent stage-3 disease in zone II without plus disease or in zone III with or without plus disease poses a dilemma for treatment.

DESIGN

Retrospective chart review.

PARTICIPANT

Neonates with stage-3 ROP persisting beyond 40-weeks of PMA.

METHODS

Demographic data and ROP parameters were collected. Univariate/multivariate analyses were utilized to assess risk factors associated with requiring treatment.

MAIN OUTCOME MEASURES

Evaluating the structural outcomes for infants with stage-3 ROP persisting beyond 40 weeks of PMA.

RESULTS

Out of 2356 screened infants, 115 infants (4.9%, 172 eyes) met inclusion criteria. In 95 infants (139 eyes, 80.8%), ROP resolved spontaneously. Twenty-one infants (33 eyes, 19.2%) were treated with laser-photocoagulation; 16 eyes had reached type 1 ROP and 17 eyes had non-type 1 ROP. No eye had unfavourable structural outcome. On multiple regression, non-type 1 ROP with ≥2 continuous clock hours of persistent stage-3 temporally crossing the horizontal midline was a significant risk factor associated with receiving treatment (OR = 27.29, 95% CI = [1.61, 462.92], P = .0221).

CONCLUSION AND RELEVANCE

The majority of stage-3 ROP persisting beyond 40-weeks of PMA resolve spontaneously. In eyes that do not reach type 1 ROP, ≥2 continuous clock hours of persistent stage-3 crossing the temporal horizontal midline and history of pre-plus were considered important risk factors for macular drag and treatment can be considered.

Screening premature infants for retinopathy of prematurity in a tertiary hospital in Saudi Arabia

BACKGROUND

Early detection of retinopathy of prematurity (ROP) in preterm infants is critical, especially with advancements in neonatal care and improved survival rates. However, a balance should be found between not missing any ROP requiring treatment and minimizing workload, saving resources, and reducing unnecessary examinations to fragile neonates.

OBJECTIVE

Ascertain whether our current inclusion criteria in screening ROP could be modified to ≤1250 g (while keeping the gestational age at ≤30 6/7 weeks) to reduce the number of screened babies without missing any type I ROP requiring treatment.

DESIGN

Retrospective, record-based study.

SETTING

Referral center.

MAIN OUTCOME MEASURES

ROP outcome and risk factors.

PATIENTS AND METHODS

Neonates screened for ROP in the neonatal intensive care unit of our institution between January 2016 and November 2018 were included. Data collected for each neonate included demographics, ROP details and risk factors. We used a revised version of ROP screening guidelines by the American Academy of Pediatrics.

SAMPLE SIZE AND CHARACTERISTICS

155 neonates (median birth weight, 1035 g; range, 527-1982 g; and gestational age range, 23-39 weeks).

RESULTS

Of 1393 live births, 155 babies met the inclusion criteria. ROP occurred in 60/155 (38.7%) screened babies while sixteen developed threshold ROP. All 16 babies who required treatment had both a birthweight ≤1000 g and a gestational age of ≤30 weeks. Using the screening recommendations of the Canadian Policy, more infants would have been screened without diagnosing a case of ROP of any stage, and no case of ROP requiring treatment would have been missed compared to the AAP recommendations.

CONCLUSION

ROP requiring treatment is a rare occurrence in premature infants with a gestational age >30 weeks and body weight >1000 g at our institute. Nonetheless, this is not an attempt to alter national screening guidelines. A multicenter prospective study with an adequate sample size is needed to assess whether guidelines for ROP screening should be altered in this category of neonates.

LIMITATIONS

Retrospective design.

CONFLICT OF INTEREST

None.

Risk Calculator for Retinopathy of Prematurity Requiring Treatment

Importance: Vascular delay that occurs early in the development of retinopathy of prematurity (ROP) is a risk factor that can be compensated by ensuring a good rate of retinal vascularization to avoid ROP that requires treatment. Background: The objective of the present study was to determine the association between ROP that requires treatment and risk factors such as the extent of the temporal avascular area of the retina and the number of days of mechanical ventilation (MV). Design: Observational retrospective case-control study. Participants: Two hundred and twenty-eight premature newborns included in the screening protocol for retinopathy of prematurity. Methods: Subjects underwent retinal examination in the 4 and 6th postnatal weeks. Main Outcome Measures: The temporal avascular area was measured in disc diameters (DD), while the MV time was measured in days of treatment. Results: Patients with a longer MV time had a higher risk of treatment (R ²: 24.7, p < 0.0001; increase in risk of 8.1% for each additional day), as did those who showed greater avascular area (R ²: 24.7, p < 0.0001; increase in risk of 111% for each additional DD). An online calculator system and a table are presented for calculating the risk of ROP requiring treatment as a function of these two risk factors. Conclusions and Relevance: The temporal avascular area of the retina and MV time must be taken into account in the first examination of the newborn to predict the need for ROP treatment.

Effect of Eye Masks on Neonatal Stress Following Dilated Retinal Examination: The MASK-ROP Randomized Clinical Trial

Importance

Although screening examinations for retinopathy of prematurity (ROP) prevent blindness, they are physiologically stressful for infants. Photosensitivity during mydriasis may contribute to postexamination stress, and reducing light stimulation may make infants more comfortable.

Objective

To determine the effect of a phototherapy mask worn during mydriasis on infant stress in the 12-hour period following ROP screening.

Design, Setting, and Participants

The Effect of Eyemasks on Neonatal Stress Following Dilated Retinal Examination (MASK-ROP) randomized clinical trial with patient recruitment from April 2016 to June 2017 at neonatal intensive care units at St Michael's Hospital and Sunnybrook Health Sciences Center in Toronto, Ontario, Canada. A consecutive series of infants with birth weight of less than 1500 g and/or gestational age of less than 32 weeks undergoing their first ROP screening were analyzed beginning in July 2017. Analysis was intention to treat.

Interventions

Patients were randomized to wear a phototherapy mask for a minimum of 4 hours after dilating drop instillation in addition to standard comfort measures.

Main Outcomes and Measures

Number of desaturation, bradycardic, or apneic events during the 12-hour postexamination period.

Results

Of 51 infants who were examined, 28 (54.9%) were randomized to the treatment group (ie, used a mask) and 23 (45.1%) to the control group. Overall, 10 (35.7%) and 13 infants (56.5%) received ventilator support at the time of examination in the treatment and control groups, respectively. The mean (SD) gestational age was 27.9 (2.4) weeks, 32 (63%) were boys, and the mean (SD) birth weight was 1058.6 (312.0) g. The number of all stressful events were lower in the treatment group compared with controls in the 12-hour postexamination period, adjusted for events prior to examination and ventilation status (mean [95% CI] events, 1.0 [0.6-1.8] vs 1.7 [1.0-1.7]; rate ratio [RR], 0.57; 95% CI, 0.3-1.2; P = .12). Risk factors associated with increased stress included younger gestational age (RR, 1.32; 95% CI, 1.2-1.5 per week), lower birth weight (RR, 1.39; 95% CI, 1.2-1.5 per 100 g), ventilator support around the time of examination (RR, 2.67; 95% CI, 1.3-5.6), intraventricular hemorrhage (RR, 3.78; 95% CI, 1.9-7.3), and hyponatremia (RR, 3.42; 95% CI, 1.8-6.6). No adverse events occurred while using eye masks.

Conclusions and Relevance

This randomized clinical trial found that light sensitivity may play a role in stress observed in the late postexamination period. However, unequal distribution of infants receiving ventilator support placed certain neonates at higher risk of stress, and the clinical significance of this intervention's benefit could not be concluded with confidence.

Trial Registration

ClinicalTrials.gov identifier: NCT03824782.

Retinopathy of prematurity occurrence and evaluation of screening policy in a large tertiary Greek cohort

PURPOSE

To assess the frequency of retinopathy of prematurity (ROP) and evaluate the appropriateness of screening guidelines in a tertiary hospital in Thessaloniki, Greece.

METHODS

Retrospective review of consecutive infants admitted to the IInd Department of the Neonatal Care Unit of Aristotle University in the period April 2004-2015. ROP screening took place according to the Royal College of Paediatrics and Child Health and Royal College of Ophthalmologists (UK) guidelines [i.e. gestational age < 32 weeks and/or birth weight < 1501 g)], plus a few additional cases due to comorbidity.

RESULTS

1178 out of the 8782 admitted infants underwent ROP screening. ROP was detected in 232 (19.7%) infants of whom 87 developed severe form of the disease (i.e. ≥ stage 3). Treatment was required in 30 (2.5%) infants, all of whom fulfilled the screening criteria. Two of the 206 infants who were additionally screened due to comorbidity developed severe ROP which regressed spontaneously. Disease regression was achieved in 27/29 (93%) treated infants who survived.

CONCLUSIONS

The frequency of ROP observed in this cohort was as low as that reported in other developed countries. The currently used screening criteria permitted identification of all infants who were at risk and, therefore, need not be changed.

Development of Modified Screening Criteria for Retinopathy of Prematurity: Primary Results From the Postnatal Growth and Retinopathy of Prematurity Study

Importance

Current retinopathy of prematurity (ROP) guidelines, which are based on studies of high-risk infants and expert opinion, have low specificity for disease requiring treatment. Postnatal weight gain-based models improve specificity but have been limited by complexity and small development cohorts, which results in model overfitting and resultant decreased sensitivity in validation studies.

Objective

To develop a birth weight (BW), gestational age (GA), and weight gain (WG) prediction model using data from a broad-risk cohort of premature infants.

Design, Setting, and Participants

The Postnatal Growth and ROP Study was a retrospective multicenter cohort study conducted in 29 hospitals in the United States and Canada from 2006 to 2012 that included 7483 premature infants at risk for ROP with a known ROP outcome. A hybrid modeling approach was used that combined BW/GA criteria, weight comparison with expected growth from infants without ROP, multiple growth-interval assessments, consideration of nonphysiological WG, and user-friendly screening criteria. Numerous BW/GA levels, postnatal age periods, time intervals, and WG percentile thresholds were evaluated to identify the most robust parameters.

Main Outcome and Measures

Sensitivity for Early Treatment of ROP Study type 1 ROP and potential reduction in infants who require examinations.

Results

Of 7483 infants, the median (SD) BW was 1099 (359) g, the median GA was 28 weeks (range, 22-35), 3575 (47.8%) were female, 3615 (48.4%) were white, 2310 (30.9%) were black, 233 (3.1%) were Asian, 93 (1.2%) were Pacific Islander, and 40 (0.5%) were American Indian/Alaskan Native. Infants who met any of 6 criteria would undergo examinations: (1) a GA of younger than 28 weeks; (2) a BW of less than 1051 g; a WG of less than 120 g, 180 g, or 170 g during ages 10 to 19, 20 to 29, or 30 to 39 days, respectively; or hydrocephalus. These criteria predicted 459 of 459 (100%) type 1 (sensitivity, 100%; 95% CI, 99.2%-100%), 524 of 524 (100%) treated, and 466 of 472 (98.7%) type 2 cases while reducing the number of infants who required examinations by 2269 (30.3%).

Conclusions and Relevance

This cohort study, broadly representative of infants who are undergoing ROP examinations, provides evidence-based screening criteria. With validation, the Postnatal Growth and ROP Study criteria could be incorporated into ROP screening guidelines to reduce the number of infants who require examinations in North America.

India to gear up to the challenge of "third epidemic" of retinopathy of prematurity in the world

Many of the causes of childhood blindness are avoidable, being either preventable or treatable. Retinopathy of prematurity (ROP) remains one of the most preventable causes of childhood blindness worldwide. Currently, India is facing the third epidemic of ROP. In India, the health system involving the mother and child health services needs to be strengthened with a policy to cover the existing inadequacies in neonatal care and implementation of program covering newborn, especially premature. The access, availability, and affordability of services related to the care of premature babies need strengthening in India. ROP-trained ophthalmologists and neonatal care pediatricians and a professional togetherness is a big issue. Inadequacies in awareness of ROP among the parents, health care workers, counsellors add up to the problem. Community-based health workers such as Accredited Social Health Activist are a good dependable force in India and are needed to be trained in awareness and establishing a proper identification for prompt referral. ROP prevention needs a multidisciplinary team approach. ROP management stands as a good example of all the strategies for prevention, which includes primary prevention (improving obstetric and neonatal care), secondary prevention (screening and treatment programs), and tertiary prevention (treating complications and rehabilitation to reduce disability). Given its demographic and cultural diversity, India faces numerous challenges, with significant rural-urban, poor-rich, gender, socioeconomic, and regional differences. So, we need to gear up to face the present challenge of the third epidemic of ROP and prevent ROP-related childhood blindness as it is the need of the hour.

Refining evidence-based retinopathy of prematurity screening guidelines: The SCREENROP study

Purpose

Retinopathy of prematurity (ROP) is a potentially blinding condition affecting premature infants for which less than 10% of babies undergoing screening require treatment. This study assessed and validated predictors of developing clinically significant ROP (type 2 or worse) and ROP requiring treatment.

Design

Nationwide retrospective cohort study.

Methods

This study included infants born between January 2014 and June 2016, admitted to level 3 neonatal intensive care units across Canada who underwent ROP screening. Data were derived from the Canadian Neonatal Network database. Predefined ≥ 1% risk for clinically significant retinopathy or prematurity and ROP requiring treatment was set as threshold for screening. Thirty-two potential predictors were analyzed, to identify and validate the most important ones for predicting clinically significant ROP. The predictors were determined on a derivation cohort and tested on a validation cohort. Multivariable logistic regression modeling was used for analysis.

Results

Using a sample of 4,888 babies and analyzing 32 potential predictors, capturing babies with ≥1% risk of developing clinically significant ROP equated to screening babies with birth weight (BW) <1,300 g or gestational age (GA) <30 weeks while capturing babies with ≥1% risk of requiring ROP treatment equated to screening babies with BW <1,200 g or GA <29 weeks.

Conclusions

The Canadian ROP screening criteria can be modified to screen babies with BW <1,200 g or GA <30 weeks. Using these criteria, babies requiring treatment would be identified while reducing the number of babies screened unnecessarily.

Influence of oxygen in the development of retinopathy of prematurity

ABSTRACT Objective: to describe the influence of oxygen in retinopathy of prematurity (ROP) in premature newborns (PTNB) hospitalized in neonatal units of intensive care and undergoing ophthalmological follow-up procedures after hospital discharge. Method: retrospective cohort study, from January 2014 to June 2016, whose data collection totaled 181 charts. Descriptive and inferential statistical analysis. Results: when using oxygen (O2) in 148 PTNB (81.7%), both mask (n=141; 77.9%; p-value <0.001) and the tracheal tube predominated (n=100; 55.25; p-value <0.001) for 15 days in average. The time of use and O2 concentration of the tracheal tube (p-value <0.001), the time of mask use (p-value <0.001) and the time and concentration of O2 of the continuous positive airway pressure (CPAP) (p-value <0.001) were significant to cause ROP in 50 PTNB (11.31%). Conclusion: the oxygen therapy has influenced the development and severity of ROP, indicating the need to adopt protocols for its use.

Neurodevelopmental Outcomes after Intravitreal Bevacizumab Therapy for Retinopathy of Prematurity: A Prospective Case-Control Study

PURPOSE

To evaluate the neurodevelopmental and ocular developmental outcomes in premature children who have undergone intravitreal bevacizumab injection (IVB) for treatment of type 1 retinopathy of prematurity (ROP).

DESIGN

Prospective case-control study.

PARTICIPANTS

We enrolled 3 groups of premature patients: premature children who had no history of ROP (group 0), premature children with history of ROP without treatment (group 1), and premature children with ROP who had received a single IVB (0.625 mg; group 2).

METHODS

Ocular developmental assessment, including cycloplegic refractometry, axial length, Cardiff acuity, and neurodevelopmental assessment via the Bayley Scales of Infant and Toddler Development, Third Edition (Bayley III), were performed at 1 to 3 years of age and were compared between groups.

MAIN OUTCOME MEASURES

Ocular developmental outcomes and Bayley III scores.

RESULTS

A total of 148 patients (85 boys and 63 girls) were included. The mean age at assessment was 1.49±0.59 years. Group 0 patients demonstrated significantly higher gestational age (GA), birth weight, and Apgar scores compared with group 1 and 2 patients. There were no significant differences between groups 1 and 2 in demographics or systemic risk factors except for lower GA in group 2. The cylindrical power was significantly larger in groups 1 and 2 compared with group 0. The spherical equivalent was significantly more myopic and the Cardiff acuity was significantly poorer in group 2 than in group 0. There were no significant differences between groups 1 and 2 in refractive status, axial length, or Cardiff acuity. Neurodevelopmental assessment using Bayley III showed no significant difference among the 3 groups in any aspect after adjusting for GA and other systemic risk factors. The risks for poor neurodevelopmental outcomes also were not significantly different.

CONCLUSIONS

At the mean age of 1.5 years, children with prior history of IVB (group 2) showed similar refractive and visual outcomes and similar neurodevelopmental outcomes compared with premature patients with ROP without requirement of treatment (group 1), although there is a possibility that a small but clinically significant difference may not have been detected in the current study.

Prediction of ROP Treatment and Evaluation of Screening Criteria in VLBW Infants-a Population Based Analysis

BACKGROUND

The incidence of retinopathy of prematurity (ROP) and ROP screening criteria differ between countries. We assessed whether ROP screening could be reduced based on the local ROP incidence.

METHODS

Observational cohort study of infants born in Switzerland between 2006 and 2015 <32 0/7 weeks. Chronological and postmenstrual ages at ROP treatment were analyzed. A model to identify ROP treatment on patients born between 2006 and 2012 (training set) was developed and tested on patients born between 2013 and 2015 (validation set).

RESULTS

Of 7817 live-born infants, 1098 died within the first 5 weeks of life. The remaining 6719 infants were included into analysis. All patients requiring ROP treatment would have been identified if screening had been performed before reaching 60 days of life or 37 3/7 weeks postmenstrual age, whichever came first. The training and validation sets included 4522 and 2197 preterm infants encompassing 56 and 20 patients receiving ROP treatment, respectively. All patients would have required screening to reach 100% sensitivity. To reach a sensitivity of 95.0% and a specificity of 87.6%, we predicted a reduction in 13.2% of patients requiring screening (c-statistic = 0.916).

CONCLUSIONS

A substantial reduction of infants requiring screening seems possible, but necessitates prospective testing of new screening criteria.

Retinopathy of prematurity screening at ≥30 weeks: urinary NTpro-BNP performance

AIM

Urinary N-terminal B-type natriuretic peptide NTproBNP levels are associated with the development of retinopathy of prematurity (ROP) in infants <30 weeks of gestation. The incidence of ROP in more mature infants who meet other ROP screening criteria is very low. We therefore aimed to test whether urinary NTproBNP predicted ROP development in these infants.

METHODS

Prospective observational study in 151 UK infants ≥30 + 0 weeks of gestation but also <32 weeks of gestation and/or <1501 g, to test the hypothesis that urinary NTproBNP levels on day of life (DOL) 14 and 28 were able to predict ROP development.

RESULTS

Urinary NTproBNP concentrations on day 14 and day 28 of life did not differ between infants with and without ROP (medians 144 vs 128 mcg/mL, respectively, p = 0.86 on DOL 14 and medians 117 vs 94 mcg/mL, respectively, p = 0.64 on DOL28).

CONCLUSION

The association previously shown for infants <30 completed weeks between urinary NTproBNP and the development of ROP was not seen in more mature infants. Urinary NTproBNP does not appear helpful in rationalising direct ophthalmoscopic screening for ROP in more mature infants, and may suggest a difference in pathophysiology of ROP in this population.

Pain-Relieving Interventions for Retinopathy of Prematurity: A Meta-analysis

CONTEXT

Retinopathy of prematurity eye examinations conducted in the neonatal intensive care.

OBJECTIVE

To combine randomized trials of pain-relieving interventions for retinopathy of prematurity examinations using network meta-analysis.

DATA SOURCES

Systematic review and network meta-analysis of Medline, Embase, Cochrane Central Register of Controlled Trials, Web of Science, and the World Health Organization International Clinical Trials Registry Platform. All databases were searched from inception to February 2017.

STUDY SELECTION

Abstract and title screen and full-text screening were conducted independently by 2 reviewers.

DATA EXTRACTION

Data were extracted by 2 reviewers and pooled with random effect models if the number of trials within a comparison was sufficient. The primary outcome was pain during the examination period; secondary outcomes were pain after the examination, physiologic response, and adverse events.

RESULTS

Twenty-nine studies (N = 1487) were included. Topical anesthetic (TA) combined with sweet taste and an adjunct intervention (eg, nonnutritive sucking) had the highest probability of being the optimal treatment (mean difference [95% credible interval] versus TA alone = -3.67 [-5.86 to -1.47]; surface under the cumulative ranking curve = 0.86). Secondary outcomes were sparsely reported (2-4 studies, N = 90-248) but supported sweet-tasting solutions with or without adjunct interventions as optimal.

LIMITATIONS

Limitations included moderate heterogeneity in pain assessment reactivity phase and severe heterogeneity in the regulation phase.

CONCLUSIONS

Multisensory interventions including sweet taste is likely the optimal treatment for reducing pain resulting from eye examinations in preterm infants. No interventions were effective in absolute terms.