Ophthalmic Insert versus Eye Drops for Mydriasis in Neonates: A Randomized Clinical Trial

[National protocol for diagnosis and care of retinopathy of prematurity: Summary for the attending physician]

Retinopathy of prematurity (ROP, ORPHA: 90050) is the main cause of visual impairment in preterm infants and the leading preventable cause of childhood blindness in high- and middle-income countries. However, severe stages of the disease remain rare. While screening recommendations for the disease are well-established in France, management of ROP requiring treatment is less standardized, especially since new therapeutic options have been approval on this indication. The management of preterm infants requiring treatment for ROP is complex and involves a multidisciplinary team, including pediatric ophthalmologists, vitreoretinal surgeons, neonatologists, pediatric anesthetists, nurses, and orthoptists, within an adapted structure for premature infants care. There is a genuine need to unify national practices, with a strong demand from physicians involved in ROP care along the country. The objective of this National Diagnostic and Care Protocol (PNDS) is to provide guidelines for diagnostic and management for ROP, and to optimize and harmonize the management of this disease across the country. The main treatment indications, the different treatment modalities including laser photocoagulation, anti-VEGF injections, and vitreoretinal surgery as well as follow-up calendar, are reviewed to establish the best practice recommendations on ROP.

Identifying and addressing common contributors to nonadherence with ophthalmic medical therapy

PURPOSE OF REVIEW

To discuss common reasons for nonadherence and review existing and emerging options to reduce nonadherence with ocular medical therapy and optimize therapeutic outcomes.

RECENT FINDINGS

Nonadherence can arise from patient-related issues (e.g. physical, cognitive) and healthcare-related issues (e.g. cost, access to care). Multiple strategies have been developed and evaluated to overcome these barriers to adherence. Identifying nonadherence and its cause(s) facilitates the development of strategies to overcome it.

SUMMARY

Many common causes of nonadherence can be mitigated through a variety of strategies presented.

Alternative mydriasis techniques for retinopathy of prematurity screening

PURPOSE

There is a large variation in mydriatic regimens used in screening for retinopathy in preterm infants. Except for the standard instillation of mydriatic drops in their commercial formulation, other techniques for pupil dilation have also been described. This study aimed to review all techniques that have been used for mydriasis in retinopathy of prematurity eye examination (ROPEE) screening.

METHODS

A comprehensive literature search was performed in PubMed, Cochrane library, Trip database, and Scopus, using the key words: "mydriasis", "techniques", "mydriatics", "dilating drops", "retinopathy of prematurity", "ROP", "phenylephrine", "cyclopentolate", "tropicamide", "smaller mydriatic drops", "reduction in drop size" to February 2019.

RESULTS

Five primary studies were included, assessing the techniques of microdrops, lower conjunctival fornix (LCF) packing and Mydriasert® ophthalmic insert. Reported efficacy was similar to commercial eyedrops instillation. Microdrops appeared to have a superior safety profile. LCF packing and Mydriasert lead to increased blood pressure, without serious complications, necessitating further safety studies.

CONCLUSIONS

Of all alternative mydriasis techniques for ROPEE screening that have been described, microdrops appear to be the safest yet still effective technique in the fragile population of premature infants in risk of ROP.

Oral propranolol in prevention of severe retinopathy of prematurity: a systematic review and meta-analysis

OBJECTIVE

To systematically assess the efficacy of oral beta blockage treatment in primary (before established) and secondary (in threshold stages) prevention of severe retinopathy of prematurity (ROP) in premature infants born ≤32 weeks gestational age.

STUDY DESIGN

Following the PRISMA guidelines, published literature was systematically assessed up to April 27, 2018. Trials and observational studies, in which beta blockage was used to prevent severe ROP (defined as stage ≥3, or requiring treatment) were included. Meta-analyses including random effects models were conducted to determine the overall effect of oral beta blockage on prevention of ROP.

RESULTS

Six studies (five clinical trials and one observational study) including 461 infants met inclusion criteria using propranolol. The pooled relative risk (RR) of severe ROP in the primary and secondary prophylaxis groups were 0.65 (95% CI 0.43-0.98, NNT = 7) and 0.48 (95% CI 0.35-0.65, NNT = 6) in RCTs, respectively. The RR of severe ROP in one observational study was 0.21 (95% CI 0.08-0.55) with a NNT of 3. There were low heterogeneity and publication bias. Side effects occurred in 8.4% of participants on propranolol.

CONCLUSIONS

Systematic assessment of studies showed that prophylactic oral propranolol appeared to be effective in preventing severe ROP in premature infants ≤32 weeks gestational age. Additional well powered, multinational, randomized control trials reporting on long-term outcomes are needed.