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Without Retinopathy Ofprematurity 93 BritishJournalofOphthalmology 1993; 77:91-94 91 Follow-up study on premature infants with and without retinopathy of prematurity Br J Ophthalmol: first published as 10.1136/bjo.77.2.91 on 1 February 1993. Downloaded from Rosemary Robinson, Michael O'Keefe Abstract first screened at 6 weeks. When discharged from The ocular complications in population of 131 the neonatal unit, they continue to attend for premature infants, with and without retino- follow up at the Children's Hospital. Follow up pathy of prematurity (ROP) are reported. An is determined by the degree ofvascularisation of increased incidence of strabismus (20% with the retina. If fully vascularised, the child is seen ROP and 25% without ROP) and myopia again at 3 months and then yearly until age 5 (27-5% with ROP and 8-8% without ROP) was years, unless strabismus or amblyopia develop. shown. Significant visual loss occurred in If ROP is diagnosed, assessment is every 3-4 10-7% overall, increasing to 35% with stage 3 weeks if stage 1-2 is present and weekly if stage disease and 100% with stage 4. With the 3. If stage 3 threshold disease is noted then increased survival rate of premature infants, cryopexy is applied. After treatment, all infants the relevance to future management of this are seen at 3 monthly intervals for the first year expanding group of young people is and every 6 months for 5 years, then annually. considered. We classified ROP according to the (BrJ7 Ophthalmol 1993; 77: 91-94) international classification7 and defined signifi- cant ROP as stage 3 or 4 disease. Since 1986, infants who reached stage 3 threshold disease, as Retinopathy of prematurity (ROP) is a leading defined by the CRYOROP group,' (that is, stage cause of blindness in children and one of the 3+ disease involving five contiguous or eight commonest causes of blindness in the perinatal cumulative 30 degree sectors in zone 1 or zone 2) period.' The incidence of ROP has increased received cryotherapy. This subgroup has been in recent years, owing to improvement in the discussed elsewhere.9 survival rate of low birth weight infants.234 This prospective study examines the outcome Gibson et al examined, in detail, the incidence of of 131 premature children born between January ROP-induced blindness from 1952-1986, in 1983 and December 1990, who were screened British Columbia. They showed that since the during the neonatal period and continue to mid 1960s there has been an increase in the total attend the Children's Hospital for assessment. A incidence of ROP-induced blindness and that total of 117 were born after January 1986; all this is due principally to increased survival of were under 1500 g or under 30 weeks' gestation http://bjo.bmj.com/ infants weighing 750-999 g. Phelps et all at birth. ROP was present in 160 eyes and 102 estimated that 550 children go blind every year eyes were normal. from ROP, in the United States. Since 1988 cryotherapy has become the accepted mode of therapy in advanced disease Follow-up assessment included visual acuity, and reduced the poor outcome from 47-7% to orthoptic assessment, cycloplegic refraction, and 25 7% at 1 year ofage.6 As ophthalmologists can funduscopy. The method of visual assessment on September 23, 2021 by guest. Protected copyright. now influence the outcome ofthis disease, active included fixation patterns, Sheridan Gardiner, screening of these infants should be mandatory. Allen picture cards, and Snellen acuity, This has also led to an increased number of depending on the age and mental ability of the premature children attending paediatric child. ophthalmology units. In this study, we examined the incidence of ocular complications in a population of premature children who attended Results the ophthalmology unit, at the Children's A total of 131 infants, with 262 eyes, form the Hospital, Dublin. study; 102 (39%) eyes were normal. Stage 1 ROP was noted in 75 (29%) eyes, stage 2 in 37 (14%) eyes, stage 3 in 34 (13%) eyes and 14 (5%) eyes Methods had stage 4 disease. Zone 2 of the retina was All premature neonates born in three maternity affected in 56 eyes and zone 3 in % eyes. Since hospitals in Dublin were screened by the 1986, we applied cryotherapy for stage 3 thres- consultant staff of the Children's Hospital. hold disease to 21 (8%) eyes; four (1-5%) eyes The Children's Hospital, These three hospitals deliver 18 000 infants per had retinal detachment repair. Temple Street, Dublin 1 R Robinson year, with 0-8% under 1500 g at birth, and 0-6% Figures 1 and 2 show the distribution ofROP, M O'Keefe (108) surviving beyond the neonatal period. This within the cohort, versus gestational age and Correspondence to: premature population of neonates accounts for birth weight, respectively. Gestational age was Mr Michael O'Keefe, Department of about a third ofall premature infants born in the not documented in six eyes. Thirty eyes were Ophthalmology, The Republic of Ireland each year. We began an from infants of under 26 weeks' gestation. Of Children's Hospital, Temple Street, Dublin 1, Ireland. active screening programme in each hospital in these, 25 (83%) developed ROP, including nine Accepted for publication January 1986. All infants, born under 30 weeks' (30%) with significant disease (stage 3 or 4). Of 17 September 1992 gestation and/or birth weight under 1500 g, are the 60 eyes with gestational age between 26-28 92 Robinson, O'Keefe weeks, 51 (85%) developed ROP, including 20 two eyes were from infants with weights between (33%) with significant disease. Between 28-32 1000-1500 g; 43 (47%) had ROP, of which eight weeks' gestation, 80/164 (49%) developed ROP, (9%) had significant disease. At between 1500- Br J Ophthalmol: first published as 10.1136/bjo.77.2.91 on 1 February 1993. Downloaded from with 17/164 (10%) having significant disease. 2000 g, 7/30 (23%) developed ROP and 2/30 ROP was not seen in two eyes of over 32 weeks' (7%), had significant disease. gestation. A total of 217 (82-9%) had a normal retinal Birth weight was not documented in 30 eyes. outcome. Cicatricial disease developed in 14 Forty two (75%) of 56 eyes, in infants under (5-3%) eyes. Total retinal detachment occurred 750 g, developed ROP, including 11 (20%) with in 17 (6-5%), seven of which developed significant disease. There were 84 eyes in infants microphthalmos. Cryotherapy scars, with a between 750-100 g; 66 (79%) developed ROP, normal posterior pole, were noted in 10 (3 8%) with 27 (32%) having significant disease. Ninety eyes. Four (1 -5%) eyes, with documented ROP, had peripheral scars unrelated to cryotherapy. Significant visual loss, that is, visual acuity 100- * No ROP <6/60, Snellen equivalent, developed in 28 84 E] Stage 1 (10-7%) eyes. Twenty five (89%) had significant ROP. Two eyes in one infant had stage 1 disease. 80- Q Stage 2 Poor vision was due to optic nerve hypoplasia Un * Stage 3 rather than ROP. One eye, without ROP, had strabismic amblyopia. The incidence of poor (D 60- O Stage 4 0 vision with stage 3 was 12/34 (35%) and 100% a) with 4 disease. .0 stage E 40- Myopia was noted in 53 eyes (>-1-00 DS z spherical equivalent). Figure 3 shows the distri- bution ofmyopia within the group. Of those eyes 20- which were normal, nine (8-8%) developed 9 7 5 6 myopia, nine (12%) with stage 1 and 13 (34%) 2 0 0 0 0 with stage 2 disease. A significant increase, 19 0 I 1'I_ _ 1 <26 26-27 28-32 >32 (56%), occurred with stage 3 disease. Strabismus developed in 29 (22%) children. Gestational age (weeks) (n = 256) Twenty eight had an esotropia. ROP was present Figure I The distribution ofROP vs gestational age. in 17 (20%) and 12 (25%) were normal. Seven had documented intraventricular haemorrhage 50- 49 a No ROP (IVH). Ten were excluded as two were blind E Stage 1 from ROP, three had uniocular cicatricial disease, one had cryotherapy to one eye only, 40- * Stage 2 U' three had optic nerve hypoplasia (ONH) and one a) M Stage 3 had optic atrophy. Primary strabismus was ') 30- |^A B~E Stage 4 therefore present in 19 (15%) children, 10 (11%) http://bjo.bmj.com/ 0 with ROP, and nine (21%) without ROP. 20- Seventeen (66%) had early onset, non- -EE accommodative strabismus. Two children, with z onset of strabismus after 2 years, did not have 10- ROP. Amblyopia developed in seven (5-3%) children. Three responded to occlusive therapy. 0- Four were unresponsive. This group included on September 23, 2021 by guest. Protected copyright. <7bU 75U-999 1000-1499 1500-2000 one child with nystagmus, one with aniso- Birth weight (g) (n = 232) metropia, and one microtropia. Corrective surgery was performed in nine (6-9%) cases. Figure 2 The distribution ofROIP vs birth weight. Four (3%) infants had bilateral OHN, three 120 - with ROP. This diagnosis was made clinically, 102 E Total by one observer (MOK), when a small optic 100 nerve head, associated with a double ring sign 5] Myopia was noted using a direct ophthalmoscope. Only one child has normal visual acuity. All weighed <, 80 75 less than 1000 g at birth. One (0-76%) child, a) a) without ROP, had optic atrophy associated with 0 hydrocephalus, secondary to IVH. One (0 76%) " 60- a) infant, with stage 4 retinopathy, had bilateral .0 E trabeculectomies for glaucoma. One child had a z 40- VI nerve palsy, secondary to IVH.
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