Treated Cases of Retinopathy of Prematurity in Germany: 10-Year Data from the Retina.net Retinopathy of Prematurity Registry

PURPOSE

To analyze changes in demographic parameters and retreatment patterns over a 10-year period in a clinical routine setting of infants with retinopathy of prematurity (ROP) requiring treatment documented in the German Retina.net ROP registry.

DESIGN

Multicenter, noninterventional, observational registry study recruiting patients treated for ROP.

SUBJECTS

A total of 692 eyes of 353 infants treated for ROP were documented in the Retina.net ROP registry over a 10-year period between 2011 and 2020. These cases cover about 15% of all infants treated for ROP in Germany.

METHODS

The Retina.net ROP registry was established in 2012 to jointly collect information on infants treated for ROP. The database collects information on demographic parameters (gestational age [GA], birth weight, neonatal comorbidities) as well as treatment parameters (type of treatment, weight and age at treatment, and stage of ROP). A total of 19 centers contributed to the analysis. This is the 10-year analysis of data from 2011 to 2020, in which we focus on changes over time regarding the respective parameters.

MAIN OUTCOME MEASURES

Changes over time in demographic parameters and treatment patterns for ROP in Germany.

RESULTS

The overall incidence of treatment requiring ROP was 3.5% of all infants screened for ROP at participating centers. Gestational age, weight at birth, and weight at treatment remained stable over the 10-year period, whereas postmenstrual and postnatal age at treatment increased moderately but statistically significantly over the years. The most prevalent ROP severity stage at treatment was stage 3+ in zone II (76.6% of all treated eyes). Treatment patterns changed considerably from predominantly laser treatments in 2011 (75% of all treated eyes) to predominantly ranibizumab treatments in 2020 (60.9% of all treated eyes). The overall retreatment rate was 15.6%. Retreatment rates differed between initial treatment modalities (14.1% after laser coagulation, 12% after bevacizumab and 24.5% after ranibizumab). Treatment-associated systemic or ophthalmic complications were rare.

CONCLUSIONS

This data analysis represents one of the largest documented cohorts of infants treated for ROP. The data on demographic parameters and treatment patterns provide useful information for further improvement of ROP management.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Prenatal Risk Factors and Outcomes of Pseudoamniotic Band Sequence following Fetoscopic Laser Surgery: Systematic Review, and Meta-Analysis

BACKGROUND

Pseudoamniotic band sequence (PABS) is a rare iatrogenic consequence of invasive fetal interventions, most commonly fetoscopic laser surgery (FLS) in monochorionic multiple pregnancies complicated by twin-to-twin transfusion syndrome (TTTS).

OBJECTIVES

The aim of this study was to investigate prenatal risk factors and perinatal outcomes for pregnancies involving PABS after FLS for TTTS and compare outcomes between those undergoing fetoscopic band release versus not.

METHOD

We conducted a systematic search of PubMed, Scopus, and Web of Science on studies reporting PABS following FLS for TTTS. A meta-analysis of pooled proportions was conducted.

RESULTS

There were 16 studies covering 47 pregnancies complicated by PABS following FLS, mostly case series and case reports. The incidence of PABS was 2%, with the recipient twin affected in 94% of the cases. Pregnancies complicated by PABS were associated with inter-twin septostomy in 32% and chorioamniotic separation (CAS) in 90%. The mean gestational age (GA) at FLS and delivery were 17.7 and 30.9 weeks, respectively. Preterm premature rupture of membranes (PPROM) happened in 62% of pregnancies. The risk of preterm birth (PTB) <34 weeks, <32 weeks, and <28 weeks were 94%, 67%, and 31%, respectively. There were 41% fetal demises and 64% live births among the affected fetuses. Results of fetoscopic band release versus not were comparable, including GA at delivery, PPROM, and PTB at 32 weeks. It was noted that the likelihood of PTB by 28 weeks (67% vs. 23%) and fetal death (50% vs. 39%) were higher in the band release group. It was similar between groups in terms of postnatal amputation.

CONCLUSIONS

PABS causes amputations or fetal death in more than one-third of cases. Pregnancies with an inter-twin septostomy, CAS, advanced TTTS staging, and early GA are more likely to experience PABS. In addition, more than a third of FLS-treated TTTS resulted in PTB and PPROM. PABS cases with prenatal band release showed higher rates of PTB and fetal death, but the data were from small, heterogeneous studies.

Management of Late Twin-to-Twin Transfusion Syndrome beyond 26 Weeks: Comparison between Fetoscopic Laser Therapy versus Traditional Management

INTRODUCTION

A proportion of monochorionic diamniotic (MCDA) twin pregnancies complicated by twin-to-twin transfusion syndrome (TTTS) can present after 26 weeks of gestation. The aim of this study was to compare perinatal outcomes of late TTTS treated by fetoscopic laser coagulation versus traditional management with amniodrainage and/or emergency preterm cesarean delivery (CD).

METHODS

Retrospective cohort from January 2012 to January 2023 of consecutive MCDA twin pregnancies complicated by TTTS after 26 weeks and evaluated in our referring centers. We analyzed perinatal outcomes of cases treated with fetoscopic laser surgery at our national referral fetal surgery center in Queretaro, Mexico, and compared them with those managed with traditional management (amniodrainage and/or emergency preterm CD). The primary outcome was survival at discharge and the secondary outcome was gestational age (GA) at birth.

RESULTS

Among the study population, 46 TTTS cases were treated by fetoscopy at 27+6 (26+0-31+0) weeks+days and were compared with a group of 39 cases who underwent emergency preterm CD. In comparison to the group who underwent traditional management, the group treated by laser fetoscopy showed a significantly higher GA at birth (32+3 vs. 29+1 weeks+days, p < 0.001), lower frequency of preterm delivery below 37 weeks (91.3% vs. 100%, p = 0.06), 34 weeks (63.0% vs. 100%, p < 0.001), 32 weeks (50% vs. 74.4%, p = 0.02), or 30 weeks (28.3% vs. 53.8%, p = 0.01), and significantly higher perinatal survival (89.1% vs. 71.8%, p < 0.05 of at least one twin; and 65.2% vs. 38.5%, p = 0.01 of both twins, respectively).

CONCLUSION

MCDA twins complicated with TTTS can be treated with fetoscopic laser surgery between 26 and 31 weeks of gestation, which is a feasible and safe option, and such cases are associated with a higher GA at birth and better perinatal survival than those managed with amniodrainage and/or emergency preterm CD.

Hemorrhoid laser dearterialization: systematic review and meta-analysis

Hemorrhoidal disease is a common and troublesome condition. Excisional hemorrhoidectomy can assure the best chance of cure but it is hampered by postoperative pain and potential long-term morbidity therefore minimally invasive techniques have been developed. Since 2009 a doppler-guided hemorrhoidal dearterialization with laser (the hemorrhoidal laser procedure; HeLP) has been proposed to control symptoms without significant sequelae. The aim of this systematic review is to analyze the benefits and disadvantages of HeLP for symptomatic hemorrhoids. The Medline/PubMed, Embase, and Cochrane library databases were searched from January 2010 to March 2022, language was restricted to English and documents to the full text. Randomized and non-randomized, prospective and retrospective cohort studies were included. Risk of bias assessment was performed using the Risk of bias for non-randomized studies (ROBINS-I) and the RoB2 Tool for randomized clinical trial. Primary outcome was to assess the efficacy of HeLP on symptoms' resolution. Secondary objectives were postoperative pain and complications, comparison with other interventional techniques, and evaluation of long-term recurrence. Whenever possible, a meta-analysis was conducted. The GRADE approach was employed to assess the certainty of evidence. We included six non-randomized and one randomized study. HeLP improved or resolved preoperative symptoms in 83.6 to 100% of patients during follow-up. In the randomized study symptoms resolved in 90% of patients after HeLP and 53.3% after rubber band ligation as comparator. Published data indicate that HeLP is effective, relatively safe, with limited recurrence rate, after a short to medium follow-up. The quality of evidence was however low. There is a paucity of studies assessing the benefits or harms of laser dearterialization for the treatment of hemorrhoids and randomized trials are furthermore rare, therefore trials with adequate power and proper design, assessing the advantages and disadvantages of HeLP versus other minimally invasive techniques, are needed. Furthermore, studies evaluating long-term follow-up are wanted.

Risk Factors for Transurethral Coagulation for Hemostasis During Holmium Laser Enucleation of the Prostate

PURPOSE

We aimed to identify risk factors for transurethral coagulation (TUC) using bipolar electrocautery for hemostasis during holmium laser enucleation of the prostate (HoLEP) surgery for benign prostatic hyperplasia (BPH).

METHODS

We analyzed the clinical outcomes of HoLEP surgery performed by a single surgeon between January 2010 and April 2020 at the Seoul National University Hospital. Patient characteristics and perioperative parameters were used to identify the risk factors for TUC. The TUC group was defined as a case of conversion to hemostasis using electrocautery during the hemostasis step after enucleation.

RESULTS

Of 1,563 patients, 357 underwent TUC (TUC group; 22.8%) as an adjuvant (n=299, 19.1%) or salvage (n=58, 3.7%) therapy. Patients in the TUC group were older (mean±standard deviation, 70.6±7.3 years vs. 69.3±7.0 years; P=0.002), had more 5-alpha reductase inhibitor (5-ARI) use (35.6% vs. 25.9%, P<0.001), higher serum prostate-specific antigen (PSA) (5.4 ±4.8 ng/mL vs. 3.8 ±4.5 ng/mL, P <0.001), larger total prostate volume (TPV) (89.5 ±44.7 mL vs. 66.0 ±32.6 mL, P<0.001), and larger transitional zone volume (TZV) (57.3±34.9 mL vs. 37.7±24.2 mL, P<0.001) than those who did not undergo TUC (non-TUC group). In univariate logistic regression analysis, age, 5-ARI use, PSA, TPV, and TZV correlated with TUC, whereas in multivariate logistic regression analysis, only TZV was associated with TUC. The odds ratios (ORs) of TUC were analyzed per TZV quartile. Compared to TZV<22.3 mL, the OR was 2.42 in 34.1 mL≤TZV<53.5 mL (95% confidence interval [CI], 1.58-3.72; P<0.001), 5.17 in ≥53.5 mL (95% CI, 3.44-7.77; P<0.001).

CONCLUSION

The risk of TUC during HoLEP surgery increases in patients with TZV >35 mL. Therefore, TUC may be potentially necessary in patients with a large transition zone volume in patients with BPH.

[Epidemiology and treatment of retinopathy of prematurity. The Hannover data in the Retina.net ROP registry from 2001-2017]

BACKGROUND

The Retina.net ROP registry documents data of preterm infants developing stages of retinopathy of prematurity (ROP) that need ROP treatment. The aim of this analysis was to investigate data regarding epidemiology, therapy and changes over time (15 years) in a single participating center (Hannover Medical School, MHH).

METHODS

Analysis of data of infants treated for ROP at a single center over time (birth 2001-2016, ROP treatment in 2002-2017).

RESULTS

Overall, 65 infants were treated (23 female). In 11 infants (16.9%) ROP screening was conducted externally and infants were transferred to the MHH for ROP treatment. Between 2006 and 2016, incidence of ROP requiring treatment among infants screened for the development of ROP was 4.1%. Mean gestational age was 25.7 weeks (standard deviation, SD 1.8), mean birth weight 763 g (SD 235), postmenstrual age at treatment 38.2 weeks (SD 3.2), postnatal age 12.4 weeks (SD 3.2). There was no significant change in parameters over time. ROP zone II, stage 3+ was most frequently treated (57 eyes of 31 infants). 58 infants were treated with laser (114 eyes), 7 infants were treated with anti-VEGF (bevacizumab, bilateral, 14 eyes) from 2014 onwards. Retreatment due to recurrence of ROP was necessary in one infant after initial laser coagulation. Infants with ROP requiring treatment often presented with neonatal comorbidities, ventilation in more than 90%, bronchopulmonary dysplasia, and received transfusions.

CONCLUSION

This is the first monocentric analysis over 15 years originating from the Retina.net ROP registry. In this cohort we see a change in ROP therapy from laser coagulation to anti-VEGF (bevacizumab) from 2014 onwards, demographic data and treatment parameters remained relatively stable over time.

[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.

[Perioperative maternal complications of twin-twin transfusion syndrome after fetoscopic laser photocoagulation]

Objective: To analyze the perioperative maternal complications of twin-twin transfusion syndrome (TTTS) after fetolascopic laser photocoagulation (FLP). Methods: A retrospective study was conducted among 182 cases with TTTS received FLP in Shanghai First Maternity and Infant Hospital from January 2010 to December 2018. The types, incidence and related factors of perioperative maternal complications as well as the changes of maternal laboratory parameters before and after FLP were analyzed. Results: The age of 182 TTTS pregnant women was (29.8±3.9) years old, body mass index (BMI) before pregnancy was (21.3±2.9) kg/m². The median gestational week of FLP treatment was 22.0 weeks, the preoperative cervical length was (34.1±9.0) mm, and the median preoperative maximum vertical pocket was 12.0 cm. During the perioperative period of FLP treatment, 22 cases (12.1%, 22/182) presented maternal complications, among which 4 cases (2.2%, 4/182) presented severe postoperative maternal complications, including 3 cases of pulmonary edema and 1 case of pulmonary embolism accompanied with right cardiac insufficiency. There were 18 cases (9.9%, 18/182) of common maternal complications during the perioperative period, including 6 cases (3.3%, 6/182) of intraoperative hemorrhage, 5 cases (2.7%, 5/182) of intraoperative amniotic fluid leakage into the pelvic cavity, 5 cases (2.7%, 5/182) of premature rupture of membrane 72 hours after the operation, 1 case (0.5%, 1/182) of inevitable abortion, and 1 case (0.5%, 1/182) of infection. The analysis of related risk factors found that maternal complications were only related to BMI before pregnancy, and the BMI of TTTS pregnant women with complications was lower than that of those without complications, the difference was statistically significant (P<0.01). The hemoglobin level, hematocrit and albumin level of TTTS pregnant women were significantly decreased at 4-6 hours and 24 hours after FLP respectively, compared with those before surgery (P<0.01), and there were no significant correlations with the amount of amniodrainage during surgery (P>0.05 for all). Conclusions: The overall incidence of perioperative maternal complications in the treatment of TTTS by FLP is not high, among which the serious complications mainly include pulmonary edema and pulmonary embolism. Timely correction of maternal hemodilution that may occur in TTTS pregnant women could achieve a good prognosis after FLP.

Antenatal Management of Bronchopulmonary Sequestration by Intrafetal Vascular Laser Ablation under Ultrasound Control: Narrative Review of the Literature and Report of Three Cases

OBJECTIVE

The objective of this study is to assess the effectiveness and safety of intrafetal vascular laser ablation (VLA) for fetuses with bronchopulmonary sequestration (BPS) with hydrops.

METHODS

First, we present 3 cases of fetuses with BPS and hydrops treated by VLA. Second, we aimed to conduct a narrative review to identify all reported cases of fetuses with BPS treated by intrafetal VLA.

RESULTS

The review of the literature identified 41 fetuses treated by VLA for BPS with hydrops. The median gestational age of the VLA was 27+0 weeks' gestation [25+0-31+0] with an associated procedure at the same time in 43% of the cases (pleuroamniotic shunt, thoracentesis, and amniodrainage). A second procedure was required in 25% of cases for residual flow in the feeding vessel. No stillbirth or neonatal death was reported. The complications reported were a fetal thoracic hematoma complicated by fetal anemia and 4 preterm deliveries with a rate of 9%.

CONCLUSION

VLA of the feeding vessel can be an effective treatment but is not without complications. In cases demonstrating cardiac output failure, intrafetal VLA should be considered as a treatment for BPS.

The prevalence of brain lesions after in utero surgery for twin-to-twin transfusion syndrome on third-trimester MRI: a retrospective cohort study

OBJECTIVE

Due to the increased risk of antenatal brain lesions, we offer a third-trimester magnetic resonance imaging (MRI) scan to all patients who underwent an in utero intervention for twin-twin transfusion syndrome (TTTS). However, the usefulness of such a policy has not been demonstrated yet. Therefore, we determined the prevalence of antenatal brain lesions detected on third-trimester MRI and the proportion of lesions detected exclusively on MRI.

MATERIALS AND METHODS

We conducted a retrospective cohort study of monochorionic diamniotic twin pregnancies complicated by TTTS that underwent laser coagulation of the vascular anastomoses or fetal reduction by umbilical cord occlusion between 2010 and 2017. We reviewed the third-trimester MRI findings and compared those with the prenatal ultrasonography.

RESULTS

Of the 141 patients treated with laser coagulation and 17 managed by cord occlusion, 112/141 (79%) and 15/17 (88%) patients reached 28 weeks. Of those, 69/112 (62%) and 11/15 (73%) underwent an MRI between 28 and 32 weeks. After laser coagulation, MRI detected an antenatal brain lesion in 6 of 69 pregnancies (9%) or in 6 of 125 fetuses (5%). In 4 cases (67%), the lesion was detected only on MRI. In the 11 patients treated with cord occlusion, no brain lesions were diagnosed.

CONCLUSION

The prevalence of brain lesions detected by third-trimester MRI is higher compared to prenatal ultrasonography alone, making MRI a useful adjunct to detect antenatal brain lesions in twin pregnancies after in utero treatment for TTTS.

KEY POINTS

• In utero interventions for twin-to-twin transfusion syndrome (TTTS) do not prevent the occurrence of antenatal brain lesions. • Fetal magnetic resonance imaging (MRI) has high accuracy in detecting anomalies of cortical development and can be a useful adjunct to ultrasonography in diagnosing certain brain abnormalities. • After laser coagulation of the anastomoses for TTTS, third-trimester MRI diagnosed a brain lesion that was not detected earlier on ultrasound scan in 6% of pregnancies.

[Whole course management is the key to retinal vein occlusion]

Retinal vein occlusion (RVO) is the consequence of obstruction of retinal vein system caused by a variety of etiologies. Its ocular complications include macular edema, retinal ischemia and neovascular glaucoma. Although many drugs for management of RVO are available, some doctors do not fully understand the exact purpose of each treatment. This article starts from the etiology evaluation of RVO, emphasizing that, besides systemic etiology and risk factor management, the treatment of RVO should focus on the three major complications at the same time, rather than just dealing with macular edema. Meanwhile, a regular follow-up for observing the changes of the degree of retinal ischemia is important for whole course management. Anti-vascular endothelial growth factor therapy, the first-line treatment option of RVO, can not only reduce macular edema, but also prevent the complications caused by retinal ischemia and create opportunities for further laser photocoagulation. Laser photocoagulation has an irreplaceable value in the comprehensive treatment of ischemic RVO. Glucocorticoid intraocular implants should not be used alone in the treatment of macular edema secondary to RVO. (Chin J Ophthalmol, 2020, 56:246-249).

Tissue Coagulation in Laser Hemorrhoidoplasty - An Experimental Study

Background

Laser hemorrhoidoplasty (LHP) is a new technique for treatment of hemorrhoids. The exact extent of coagulation is not visible at the time of the procedure. There currently is no experimental or clinical data on the subject.

Objective

To evaluate the length of coagulation defect according to power and activation time of 1470nm diode laser on the perianal tissue model.

Methods

Fresh anorectal tissue of twenty-four pigs was used to produce 54 experimental samples. Each sample was randomly assigned to the laser power of 6, 8 and 10 W and 1, 2 or 3-second pulses. The procedure was performed using Biolitec Ceralas © diode laser with 1.85 mm optical fiber. The fiber was inserted in a manner, similar to intrahemorrhoidal laser application. Samples were evaluated using low-power and high-power light microscopy by a single pathologist. The length of tissue injury was measured on high-magnification microscopy.

Results

The longest tissue injury (mean 3.93 mm) was caused by the longest laser exposure time (3 sec) with no significant difference between laser power used.

Conclusions

8 W 3-second application of the 1470nm diode laser results in coagulation area approximately 4 mm, and further coagulation should be initiated approximately 5 mm from the first one.

Outcome of Pregnancies Diagnosed with TRAP Sequence Prenatally: A Single-Centre Experience

INTRODUCTION

Twin reversed arterial perfusion (TRAP) sequence is a phenomenon seen in 1-3% of monochorionic twin pregnancies, where the acardiac fetus is found to have multiple anomalies. The normal pump twin maintains its own perfusion in addition to that of its acardiac co-twin. As a result, if the acardiac twin increases in size, the burden on the pump twin is increased, leading to cardiac failure, hydrops fetalis, polyhydramnios, premature delivery, and perinatal death. The outcome of pregnancy is largely dependent on the growth of the acardiac twin. In view of high perinatal loss, surgical techniques to interrupt the blood flow to the acardiac twin have been evaluated.

METHODS

We evaluated interstitial laser therapy, which is the main mode of therapy in our unit, of TRAP pregnancies referred over a 5-year period. Interstitial laser was offered if the blood flow in the acardiac twin was found to be persistent at 2 consecutive examinations or if there were cardiac or hydropic changes in the pump twin at the first examination.

RESULTS

A total of 18 cases of TRAP were referred during this period and all were counselled regarding fetal therapy if the situation were to deteriorate; 5 couples (27.7%) opted for termination of pregnancy; of the remaining 13, 7 (53.8%) agreed to perform intervention following confirmation of a normal karyotype. Six (85.7%) and 1 (14.3%) lasers were performed in the second and third trimesters, respectively; all 7 had a normal outcome of the pump twin. There were 6/13 (46.2%) in the expectant group who continued the pregnancy with no intervention, with 2 term live births (33.3%).

CONCLUSIONS

Our study confirms that there is a high risk of spontaneous loss in untreated pregnancies with TRAP, primarily due to polyhydramnios and fetal hydrops. In the pregnancies that underwent interstitial laser, there was a more favourable outcome. Interstitial laser is minimally invasive, safe, and feasible in experienced hands.

Reproductive Outcomes following Laser Surgery for Twin-Twin Transfusion Syndrome

BACKGROUND

There are limited studies describing future reproductive outcomes in women who have had selective fetoscopic laser photocoagulation (SFLP) for twin-twin transfusion syndrome (TTTS).

OBJECTIVE

Our study aims to compare reproductive outcomes following monochorionic multiple gestational pregnancies complicated by TTTS requiring SFLP to those not requiring SFLP.

METHODS

This is a retrospective cohort study that analyzed records of patients who were evaluated at the Cincinnati Fetal Center (2007-2014) for monochorionic multiple gestations. A questionnaire regarding reproductive, obstetric, gynecologic, and psychological outcomes following the index pregnancy was administered to consented participants by electronic distribution. The data was compared between pregnancies with prior SFLP versus no prior SFLP.

RESULTS

There was a higher response rate in the SFLP group (219/474, 46.2%) versus the referent group (62/187, 33.2%). The median interval between the index pregnancy and survey completion was 74 months and 46 months in the SFLP and referent groups, respectively. Approximately 38 and 37% of the women in the SFLP and referent groups attempted conception after the index pregnancy with a >90% pregnancy success rate in both groups. Use of assisted reproductive technology was highly prevalent in both the index and subsequent pregnancies, with no significant difference between the groups. Over 60% of the women in each group did not attempt future pregnancy. Of those, approximately 1 in 3 cited the outcome of the index pregnancy as the primary reason for not pursuing future conception. There were no significant differences in selected maternal-fetal complications and new-onset gynecologic problems. More than 1 in 4 women in both groups were diagnosed with a mental health disorder following the index pregnancy.

CONCLUSION

SFLP does not appear to be associated with adverse reproductive, obstetric, or gynecologic outcomes. The data may help facilitate evidence-based counseling for this patient population.

[Review of clinical trials in retinopathy of prematurity : Current state and future perspectives]

BACKGROUND

The treatment of retinopathy of prematurity (ROP) has gained a new dynamic since the introduction of anti-vascular endothelial growth factor (VEGF) therapy. This review summarizes clinical trial data in order to aid informed decision-making.

METHODS

In this article, pivotal clinical trials are summarized and discussed with regard to their implications for ROP therapy.

RESULTS

The longest follow-up phase exists for children treated in the CRYO-ROP study, which used retinal cryocoagulation to treat ROP. Based on results of the ETROP study and others, retinal laser therapy has replaced cryotherapy as standard of care. For anti-VEGF treatment, three controlled clinical trials exist to date: BEAT-ROP, CARE-ROP, and the PEDIG study. Combined, these studies demonstrate efficacy of anti-VEGF in treating acute ROP. However, they also emphasize the risk of (late) recurrences and the largely unsolved questions regarding choice of drug and dose as well as long-term safety.

CONCLUSION

Treatment of ROP remains a highly individual decision in which many variables need to be considered. The data discussed in this article can help in decision-making and emphasize the unique characteristics of the available therapeutic approaches, in particular regarding postoperative follow-up.

[Treated cases of retinopathy of prematurity in Germany : 5-year data from the Retina.net ROP registry]

BACKGROUND

Retinopathy of prematurity (ROP) is one of the main reasons for childhood blindness. The number of infants requiring treatment, however, is low for individual centers. The Retina.net ROP registry has been founded to allow a joint analysis of treatment patterns and courses post treatment.

OBJECTIVE

This paper reports treatment patterns over 5 years.

MATERIAL AND METHODS

All infants born between January 2011 and December 2015 who were entered into the treatment registry by one of the 12 participating centers were analyzed.

RESULTS

The data of 150 infants (292 eyes) were analyzed and ROP 3+ in zone II was the most prevalent treatment indication. Gestational age and birth weight remained stable over the years. The treatment patterns, however, changed with anti-VEGF treatment (bevacizumab or ranibizumab) accounting for only 10% of treated eyes in 2011 but for 56% and 30% in 2014 and 2015, respectively. Almost all eyes with AP-ROP or zone I disease received anti-VEGF treatment. Zone II disease was predominantly treated with laser photocoagulation. Recurrences were more common and appeared later in the anti-VEGF group compared to the laser group (23%/interval 60 days vs. 17%/interval 23 days). Perioperative complications were evenly distributed across treatment groups.

CONCLUSION

The data in this analysis represent about 10-15% of treated infants in Germany. The results provide evidence for an increasing use of anti-VEGF agents for ROP. The data reflect a selection bias for anti-VEGF treatment in eyes with a more aggressive disease. This needs to be considered when interpreting data such as disease recurrence rates. The risk for late recurrences after anti-VEGF treatment is of particular clinical significance.

[Analysis of the quality of life and the influencing factors in patients with diabetic retinopathy before and after receiving pan-retinal photocoagulation]

Objective: Quality of life and the influencing factors in patients with diabetic retinopathy before and after receiving treatment of pan-retinal photocoagulation (PRP) were studied. Methods: Prospective study. A total of 55 diabetic retinopathy patients were collected at Beijing Friendship Hospital, Capital Medical University from November 2016 to August 2017 and were surveyed using Vision Function Questionaire (VFQ-25) to evaluate their quality of life before and 3 months after treatment with PRP. According to diagnostic criteria, the patients were divided into two groups: severe nonproliferative diabetic retinopathy(NPDR) and proliferative diabetic retinopathy group(PDR). SPSS was used for statistical analysis. Results: The score of VFO-25 general health before PRP treatment was 62.73±14.20, obviously lower the other sub scale scores of VFO-25. The results of variance analysis there was significant statistical difference between the composite score and the different educational levels (F=2.94, P<0.05), but there was no statistical difference for diabetes duration (F=3.01, P<0.05). The composite score was significantly significance between the severe NPDR and PDR group(t=8.95, P<0.05). The patients with hyperlipidemia (t=-3.21, P<0.05), hypertension(t=-2.32, P<0.05) and renal insufficiency(t=-2.05, P=0.045) has lower composite score. There was high relationship for age among the factors of worse logMAR vision, better logMAR vision and age (r=-0.47, P<0.05; r=-0.38, P<0.05; r=-0.26, P<0.05). The scores of VFQ-25 subscale of social function (t=-2.07, P<0.05) , role limitations (t=-2.38, P<0.05) , dependency (t=-2.99, P<0.05) and mental health (t=-2.26, P<0.05) was significantly increased after treatment of PRP. The score of ocular pain was obviously decreased (t=4.19, P<0.001) ; there were no significance in other sub scale scores. Conclusions: This study showed that the degree of visual acuity, the severity of DR and age were an important factor affecting the quality of life in DR patients. PRP therapy could improve the mental health and social field of DR patients, but failed to improve the scores of other visual functions in the patients. (Chin J Ophthalmol, 2018, 54:611-616).

Prenatal growth characteristics and pre/postnatal management of bronchopulmonary sequestrations

PURPOSE

The prenatal natural history of intralobar and extralobar bronchopulmonary sequestrations (BPSs), including lesion growth patterns and need for prenatal intervention, have not been fully characterized. We review our series of BPSs to determine their natural history and outcomes in the context of the need for prenatal intervention.

METHODS

A retrospective review of the pre/postnatal course of 103 fetuses with an intralobar (n=44) or extralobar BPS (n=59) managed at a single institution between 2008 and 2015 was performed. Outcomes included prenatal lesion growth trajectory, presence of hydrops, need for prenatal intervention, survival, and postnatal surgical management.

RESULTS

Most extralobar (71%) and intralobar BPSs (94%) decreased in size or became isoechoic from initial to final evaluation. Peak lesion size occurred at 26-28weeks gestation. Eight fetuses developed hydrothorax, four of which (all extralobar BPSs) also developed hydrops. All four hydropic fetuses received maternal betamethasone, and three hydropic fetuses underwent thoracentesis and/or thoracoamniotic shunt placement with subsequent hydrops resolution. All fetuses survived. Forty-one intralobar (93%) and 35 extralobar BPSs (59%) were resected after birth.

CONCLUSIONS

BPSs tend to decrease in size after 26-28weeks gestation and rarely require fetal intervention. Lesions resulting in hydrothorax ± hydrops can be effectively managed with maternal steroids and/or drainage of the hydrothorax.

LEVEL OF EVIDENCE

IV.

Selective intrauterine growth restriction in monochorionic diamniotic twin pregnancies

Selective intrauterine growth restriction (sIUGR) affects 10-15% of all monochorionic pregnancies. Early severe forms are associated with intrauterine demise or neurological adverse outcome for both twins. The characteristics of umbilical artery (UA) Doppler in the IUGR fetus determine three clinical types: (I) normal UA Doppler and associated with good prognosis; (II) persistently absent/reverse UA end-diastolic flow and associated with early deterioration of the IUGR twin and very preterm delivery; (III) intermittently absent/reverse end-diastolic flow in the UA, and associated with unexpected fetal demise or neurological injury in one or both twins. Types II and III pose important challenges for management. Placental laser or cord occlusions do not seem to increase survival, but they might improve the outcomes of the larger twin. The use of an algorithm with severity criteria may help in counseling and planning management.

[Choice of treatment for diabetic macular edema]

Diabetic macular edema (DME), which is the consequence of the failed blood-retinal barrier, has become a leading cause of blindness in diabetic patients. Vascular endothelial growth factors (VEGF) and a series of inflammatory factors participate in the pathophysiology of DME. Laser photocoagulation was accepted as the first-line therapy before anti-VEGF therapy was proved to be more effective by several clinical trials. Anti-VEGF therapy has been regarded as the standard treatment, but there are still lots of cases resistant to anti-VEGF therapy. Corticosteroid treatment has also been proved effective, especially in refractory DME. This demonstrates that inflammation plays a role in DME as well. Here we discuss the situation of anti-VEGF and anti-inflammation therapies for DME. (Chin J Ophthalmol, 2017, 53: 724-728).

[Familial exsudative vitreoretinopathy (FEVR) in childhood]

A case of secondary neovascularization of the optic disc in familial exsudative vitreoretinopathy (FEVR) is reported. A 12-year-old girl presented with decreased visual acuity of the right eye to 0.05. Funduscopy showed a prominent fibrovascular neovascularization of the optic disc covering the macula. Fluorescein angiography demonstrated circular peripheral ischemia as well as vascular anomalies in both eyes. Peripheral laser coagulation of the ischemic retina of the right eye was conducted with the patient under general anesthesia. The central neovascularization regressed and visual acuity increased up to 0.4. Molecular genetic examination detected the LRP5 gene for FEVR.

[Intestinal complications in twin-to-twin transfusion syndrome (TTTS) treated by laser coagulation (LC)]

AIM OF THE STUDY

The hemodynamic imbalance due to placental vascular anastomoses in TTTS but also vascular changes generated after intrauterine treatment may lead to hypoxic-ischemic complications. Different intestinal complications in TTTS are reviewed in this paper.

METHODS

Retrospective review of TTTS cases treated by laser coagulation (LC) from 2012-2015. Demographic data, fetal therapy, prenatal diagnosis (US, MRI) and perinatal outcome were recorded. We describe cases with intestinal complications and their postnatal management. Results are expressed by median and range.

RESULTS

29 monochorionic pregnancies with TTTS were treated (23 LC, 4 cord occlusions and 2 cord occlusions after LC). The diagnosis was made at 19 (16-26) weeks and 86% presented stage of Quintero ≥ II. In 70% of mothers survived at least one fetus with a median of 31 (24-37) weeks at birth. Four patients had intestinal complications (1 jejunal atresia, 2 ileal atresia, 1 perforated necrotizing enterocolitis), half of them had prenatal diagnosis. Postnatal resections of the affected segments and ostomies were performed. Intestinal transit was restored and there were no severe digestive sequelae after 21 (8-38) months of follow up.

CONCLUSIONS

Different types of intestinal complications were associated with TTTS and LC. US and MRI enable prenatal diagnosis of these complications and this allows prompt decisions after birth.

Angiographic features and disease outcomes of symptomatic retinal arterial macroaneurysms

PURPOSE

Symptomatic retinal arterial macroaneurysms (RAM) are primarily investigated by fundus fluorescein angiography after presenting with visual disturbance. The natural history includes spontaneous regression and occasionally occlusion of the arteriole distal to the aneurysm. RAM may be managed conservatively. Interventional treatment options include focal argon laser photocoagulation, Nd:YAG laser hyaloidotomy, and pars plana vitrectomy. The purpose of this study was to elicit the rates of distal vessel occlusion and aneurysm thrombosis in RAM at presentation, and their relevance to the treatment of RAM. Furthermore, visual outcomes were examined.

METHODS

Retrospective review of cases of RAM presenting to a tertiary ophthalmology care centre was accomplished in a university teaching hospital. The angiographic features, treatment indications, and visual outcomes in patients with RAM were recorded. Angiographic features noted were distal vessel patency and aneurysm thrombosis at presentation.

RESULTS

Ten patients with RAM were identified. Ninety percent had an angiographically patent distal arteriole, with 40 % showing spontaneous thrombosis of the aneurysm sac at presentation. Patients presenting with a spontaneously thrombosed RAM were managed conservatively, those with flow within the aneurysm wall were treated with focal laser, and those with subhyaloid haemorrhage underwent Nd:YAG laser hyaloidotomy. LogMAR visual acuity improved from 0.3 (±0) at presentation to 0.15 (±0.1) in the conservative group, and from 0.78 (±0.23) to 0.24 (±0.18) in those who underwent one intervention. One patient lost vision after multiple RAM.

CONCLUSION

Thrombosis within the aneurysm wall is an important feature in deciding to treat RAM, and selective use of interventions improves vision in affected patients.

[Diabetic maculopathy]

Diabetic maculopathy is the result of multifactorial and complex alterations of the retinal capillaries in association with diabetes mellitus and is divided into two forms, ischemic maculopathy and diabetic macular edema. Diabetic macular edema is the leading cause of blindness among people of working age. The functional and morphological results of intravitreal pharmacotherapy in cases of fovea-involving macular edema using vascular endothelial growth factor (VEGF) inhibitors such as ranibizumab and aflibercept obtained in large randomized clinical trials are excellent and are superior to results obtained with focal or grid laser coagulation alone. Steroids including dexamethasone and fluocinolone implants represent approved alternatives, although flucinolone is considered a second-line therapy in refractory and chronic cases. VEGF inhibitors can be used in different treatment strategies such as PRN and treat and extend strategies. Focal laser photocoagulation remains the gold standard for macular edema not involving the fovea (and therefore usually good visual acuity). Laser is also still indicated as a panretinal photocoagulation of peripheral retinal ischemic areas in order to prevent neovascular complications. It remains to be proven whether panretinal photocoagulation can have an effect on the treatment intervals of intravitreal pharmacotherapy, too. Surgical treatments such as vitrectomy are today limited to cases of macular edema with concomitant obvious tractional pathologies at the vitreoretinal interface.

[Selective termination of pregnancy for monochorionic twins: a national survey of professional practice]

OBJECTIVES

Selective Termination of Pregnancy (STOP) for discordant fetal condition in monochorionic twin pregnancy is a rarely performed procedure raising technical and ethical considerations. There are no epidemiological data available in France concerning STOP and no guideline or scientific consensus on how or when to perform has been published.

MATERIALS AND METHODS

We conducted a study of national practice using a declarative questionnaire sent by e-mail to each medical coordinator of every 48 Multidisciplinary Center for Prenatal Diagnosis in France. The questions focused on the issues of 2010 and 2011. Two reminders were sent in case of no answer.

RESULTS

The response rate to the questionnaire was 56 %; 81 % of centers have experienced at least once during the two years 2010-2011 a discordant fetal anomaly in monochorionic twin pregnancy. Only 59 % of centers perform all the techniques of STOP. When interruption of the umbilical blood flow is considered, bipolar forceps coagulation is the most used (75 %). Achieving STOP during a cesarean section is a common practice (75 % of centers). Locoregional anesthesia is the preferred mode of anesthesia for STOP.

DISCUSSION AND CONCLUSION

STOP on monochorionic twin pregnancy is not practiced in all Multidisciplinary Center for Prenatal Diagnosis in France. The most widely practiced and most studied technique is bipolar forceps coagulation. The option of an expectant management should always be considered and its risks should be balanced with those of STOP. The practice of STOP during cesarean section is not unusual.

[Early treatment of idiopathic vasculitis, aneurysms and neuroretinitis (IRVAN). A case report]

CASE REPORT

A 55 year old woman presented with retinal vasculitis, multiple aneurysms, macular exudation and widespread retinal nonperfusion and was diagnosed with IRVAN. She was treated with panretinal laser photocoagulation. After 3 years of follow up visual acuity remains stable and there are no complications due to ischaemic sequelae.

DISCUSSION

IRVAN syndrome with neovascularisation can progress rapidly despite laser treatment. Panretinal laser photocoagulation has to be considered in the early stages as it is effective in stopping the progression of ischaemia.

[Clinical course of pars planitis in patients treated with selective photocoagulation]

INTRODUCTION

Pars planitis is an intermediate uveitis with bilateral and asymmetric presentation. The etiology is unknown and pathogenesis is unclear. Treatment follows the algorithm of Foster, which includes selective photocoagulation. The mechanism of action of photocoagulation is still unknown.

MATERIAL AND METHODS

An observational, longitudinal, ambispective cohort study was performed with the objective of evaluating the course of inflammation in patients with pars planitis treated with a selective argon laser.

RESULTS

The study included 29 patients (10 female and 19 male) diagnosed with pars planitis and were treated with selective laser. The mean age of onset was 11.77 years. Eighteen (62.1%) patients were not immunosuppressed at the time of receiving the selective laser, and 11 (37.9%) were taking immunosuppressants. Indications for selective laser were; following the algorithm, 19 (65.55%), vitreous hemorrhage 7 (24.1%), vitrectomy 2 (6.98%), and neovascularization 1 (3.4%). The mean time for inflammation reduction was 5.9 months, and 17 patients (58.6%) had no relapse. Visual acuity showed improvement post-laser (OD P=.025 and OI P=.022). There was also an improvement in vitreous cells.

CONCLUSION

Selective laser was effective in 58.6%% of patients.