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Severe Retinopathy of Prematurity and Visual Outcomes in British Columbia: a 10-Year Analysis

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Severe Retinopathy of Prematurity and Visual Outcomes in British Columbia: a 10-Year Analysis Journal of Perinatology (2008) 28, 566–572 r 2008 Nature Publishing Group All rights reserved. 0743-8346/08 $30 www.nature.com/jp ORIGINAL ARTICLE Severe retinopathy of prematurity and visual outcomes in British Columbia: a 10-year analysis V Schiariti1, C Matsuba1, JS Hoube´1,2 and AR Synnes1,2 1Department of Pediatrics, Sunny Hill Health Centre, British Columbia Children’s Hospital, University of British Columbia, Vancouver, BC, Canada and 2Department of Pediatrics, Centre for Health Innovation and Improvement, University of British Columbia, Vancouver, BC, Canada Introduction Objective: To describe the incidence trend and long-term visual outcomes Over the past decade, there has been an increase in the survival of of infants diagnosed with stages 3 to 4 retinopathy of prematurity (ROP) or very low birth weight (BW) infants (BW <1250 g).1–5 This has laser-treated ROP born in British Columbia (Canada). raised concerns of an absolute increase in children with Study Design: Data from all (n ¼ 1384) neonates with birth weight neurosensory disabilities as severe neurosensory disorders occur in (BW) <1250 g, admitted to British Columbia Children’s Hospital between 10 to 25% of the survivors.6–10 Preterm infants are at risk for period 1 (January 1992 to December 1996) and period 2 (January 1997 to retinopathy of prematurity (ROP), a condition confined to the December 2001) were analyzed. Ophthalmologic records of infants with developing retinal vascular system of preterm babies. This stages 3 to 4 ROP or laser-treated ROP were abstracted. w2- and t-test were condition, if untreated, may result in retinal detachment. In used to compare neonatal characteristics between periods. Logistic developed countries, ROP accounts for 6 to 20% of childhood regression was used to identify risk factors associated with visual blindness.11,12 However, in developing countries, ROP is emerging impairment (defined as visual acuity p20/60 or visual field restriction of as a major cause of childhood blindness. 201 binocularly). Retinopathy of prematurity (ROP) is described by severity Result: Of 1159 surviving infants, 887 were examined for acute ROP (stages 1 to 5), location (zones I to III), extent by sector (clock 13 (473 in period 1, 414 in period 2). Stages 3 to 4 ROP or laser-treated ROP hours) and by the presence of ‘plus’ disease. Severity stages 1 and were present in 35 infants in period 1 (7%) and 59 in period 2 (14%), 2 are considered mild because, unless they progress to stage 3, they P 0001. Infants born in period 2 had lower mean BW and gestational resolve spontaneously without disabling sequelae. Stages 3 to 5 are p 14,15 age. Among infants who developed severe ROP or laser-treated ROP, considered severe. In stage 3, children with ROP are at binocular visual impairment was present in eight children in period significant risk of poor visual outcome. By stages 4 and 5 1 and seven in period 2. Refractive errors, including myopia and (conditions of retinal detachment), children have a dismal astigmatism, were increased in period 2. Children who developed prognosis for vision. A child with threshold ROP has a risk of 16 periventricular leucomalacia had the highest risk of visual impairment at blindness of about 50% if untreated. Thus, treatment by laser is 4 to 6 years of age. recommended. Recently, treatments at an even earlier stages have been considered, to reduce the number of adverse outcomes.17 To Conclusion: During the 10-year study period, a significant increase in date, ROP is still the most important ocular abnormality of the rates of stages 3 to 4 or laser-treated ROP was not associated with premature infant, with as many as 12.5% of infants born between increases in visual impairment rates. 23 and 26 weeks gestation requiring treatment for threshold Journal of Perinatology (2008) 28, 566–572; doi:10.1038/jp.2008.34; ROP.18,19 However, the incidence of severe ROP may be decreasing, published online 27 March 2008 possibly because of screening programs and early treatment with Keywords: retinopathy of prematurity; visual outcomes; visual laser therapy, or because of improvements in oxygen and ventilator impairment; prematurity; follow-up studies; neonatology management of respiratory diseases in the preterm.20 Population- based studies suggest that ophthalmic impairments remain 21–25 Correspondence: Dr V Schiariti, Department of Pediatrics, Sunny Hill Health Centre, British common in very low BW infants. In a prospective cohort 16 Columbia Children’s Hospital, University of British Columbia, Room S112C, 3644 Slocan study, O’Connor et al. showed that visual impairments Street, Vancouver, BC, Canada V5M 3E8. are associated with low BW and severe ROP. This study E-mail: [email protected] Received 29 October 2007; revised 11 February 2008; accepted 14 February 2008; published demonstrates that preterm birth alone has an impact on the online 27 March 2008 immature visual system from the eye to the cortex. However, Retinopathy of prematurity and visual outcomes V Schiariti et al 567 severe ROP is associated with the highest rate of visual were involved in the ROP diagnosis and follow-up assessments in impairments. our center; one of them worked throughout the study period and Long-term visual outcomes of premature infants born in British the other one started working in 1994. Columbia (BC) and admitted to British Columbia Children’s Hospital (BCCH) neonatal intensive care unit (NICU) have not Long-term visual outcomes been fully studied. BCCH is a tertiary-care hospital that services Newborns with severe ROP (stages 3 to 4 or laser-treated ROP) children throughout the province. Unlike other communities, diagnosed and/or treated at BCCH were linked with their long-term BCCH has unique characteristics to allow investigation into the visual outcomes using the seven-digit personal identification visual outcome of children with ROP. First, the majority of numbers. Searches were made directly at the departments of children with ‘threshold’ ROP are screened and treated in BCCH’s ophthalmology and the VIP. nursery. Further, two subspecialty programs, the Visual Impairment At 4 to 6 years of age, children with severe ROP had the Program (VIP) and Ophthalmology Clinic provide the intervention following tests of visual functions measured: VA charts for distal and follow-up for all children with ROP in the province. and near vision (Snellen) and for younger children matching The purposes of this retrospective study were to describe charts (HOTV) or force-choice acuity cards (Teller Acuity Cards), incidence trend and visual outcomes of infants, born in the years perimetry (Damato campimeter) to measure the visual field and 1992 to 2001, diagnosed with severe ROP or laser-treated ROP and for younger children (kinetic perimetry was used). Tests of to study the relationship between perinatal characteristics and later strabismus (cover test and prism tests) and refractive state by visual outcomes. cycloplegic refraction were also conducted. Spherical equivalents were calculated in patients with astigmatic refractive errors. Anterior and posterior segments of the eye were assessed by slit Methods lamp. Stereopsis was tested with the Titmus test. This descriptive study is a retrospective review of a sample of very Patients were considered visually impaired if they met at least low BW infants. The study population consists of all babies one of the following criteria: VA of 20/60 or worse for children older admitted to BCCH with BW <1250 g from 1 January 1992 to 31 than four and half years, or VA below the fifth percentile for age for December 2001. The 10-year period was divided in period 1 children based on a force-choice preferential acuity or a visual field (1 January 1992 to 31 December 1996) and period 2 (1 January restriction of 201 or narrower binocularly. Blindness was defined as 1997 to 31 December 2001). The time period was selected, as laser VA of <20/400 in the better eye, which is in accord with the 26 treatment first became available at BCCH in 1992. The 2001 end definition by the World Health Organization. Strabismus was point was selected in order to gather information on defined as the presence of a manifest deviation in the primary ophthalmologic assessments at 4 to 6 years of age for all patients. position at any distance, with or without glasses. BCCH was the sole site of the research project. Ethical approval was obtained from the Universities of BC The primary outcome of interest was visual impairment. Other and BCCH. visual function and ophthalmologic outcomes including best binocular visual acuity (VA), strabismus, myopia, astigmatism and Analysis nystagmus were also analyzed. Additionally, comparison of severe All data were investigated for normality to determine whether ROP rates between the two time periods, together with the perinatal parametric or nonparametric methods should be used. The trends characteristics, were made. in incidence of stages 3 to 4 or laser-treated ROP and perinatal characteristics were assessed by comparing the first 5-year period Neonatal ophthalmologic assessment with the latter 5-year period. The w2, Mann–Whitney and t-test During NICU admission, infants with BW <1250 g were examined were used to assess differences between periods. Incidence of ROP by an ophthalmologist skilled in indirect ophthalmoscopy at 6 was defined as the rate of new ROP cases present in infants who weeks of age, and had further review if ROP was detected or the eye had an ophthalmology exam. When different stages of ROP were not fully vascularized. The criteria for laser treatment were ROP found in both eyes, the maximum stage of ROP in either eye was stage 2 in zone I, and ROP stage 3 in at least four contiguous clock used. Descriptive statistics on visual outcomes were assessed for hours in zone II, even in the absence of plus disease.
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