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Long-Term Functional Results Following Vitrectomy for Advanced Retinopathy of Prematurity Murat Karacorlu, Mumin Hocaoglu, Isil Sayman Muslubas, Serra Arf

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Long-Term Functional Results Following Vitrectomy for Advanced Retinopathy of Prematurity Murat Karacorlu, Mumin Hocaoglu, Isil Sayman Muslubas, Serra Arf Downloaded from http://bjo.bmj.com/ on August 21, 2017 - Published by group.bmj.com Clinical science Long-term functional results following vitrectomy for advanced retinopathy of prematurity Murat Karacorlu, Mumin Hocaoglu, Isil Sayman Muslubas, Serra Arf Istanbul Retina Institute, ABSTRACT treated in a consistent manner, and were Istanbul, Turkey Purpose To assess long-term functional results after followed-up closely postoperatively to enable early vitrectomy for stages 4 and 5 retinopathy of prematurity intervention. We aimed to perform a meticulous Correspondence to (ROP). assessment of visual function by using a standard Professor Murat Karacorlu, İstanbul RETINA Enstitüsü, Methods Retrospective analysis of data from eyes that protocol and to investigate whether such an orga- Hakkı Yeten Cad. Unimed underwent lens-sparing vitrectomy (LSV) or combined nised attempt at appropriate diagnosis, a current Center No: 19/7, Fulya—Şişli, lensectomy and vitrectomy (LV) and had a follow-up of surgical approach, and postoperative management Istanbul 34349, Turkey; at least 5 years. could yield visual results in the long-term. [email protected] Results Eighty-eight eyes of 65 infants who underwent Received 16 June 2016 LSV or LV for stage 4 or 5 ROP were included in the METHODS Revised 13 July 2016 study. The mean follow-up was 6.9 years. The anatomic We retrospectively reviewed the records of infants Accepted 24 August 2016 success rate was 89% (17/19) for stage 4A, 63% (24/38) with stage 4 and 5 ROP who underwent vitrectomy Published Online First for stage 4B, and 42% (13/31) for stage 5. Forty-five eyes 15 September 2016 between January 1996 and December 2010 per- (51%) had measurable visual acuity (VA). The formed by a single surgeon (MK) at a tertiary refer- approximate Snellen VA equivalent was 20/550 for stage ral centre. Detailed informed consent was taken 4A, 20/1600 for stage 4B, and 20/4000 for stage 5. The from the parents before each surgical procedure. The remaining 39% (34/88) had light perception or no light study protocol was approved by the Institutional perception. Owing to neurological conditions, VA in nine Review Board of Sisli Memorial Hospital, Istanbul. eyes (10%) could not be measured. Anatomic and visual The study was in accordance with the principles of outcomes were not associated with surgical technique. the Declaration of Helsinki. Conclusions Surgery for stage 4A ROP has better visual The clinical charts were retrospectively reviewed success. Acceptable vision for stage 4B and poor for to collect the following data: birth weight, gesta- stage 5 ROP, despite retinal reattachment, is thought to tional age, sex, clinical characteristics of the ROP, be secondary to irreversible injury to either the retina or timing of surgery, intraoperative procedures, post- visual nervous pathways, or both. operative complications, follow-up duration, ana- tomic status, and visual acuity (VA) at the final visit. Patients who had been lost to follow-up and those INTRODUCTION with insufficient medical records were excluded. Retinopathy of prematurity (ROP) is a complex All the infants were examined preoperatively condition characterised by onset of vascular abnor- with indirect ophthalmoscopy, and B-mode orbital malities in the developing retina, a major cause of ultrasonography was performed by an experienced visual impairment and blindness in premature radiologist if indicated. neonates. Screening and treatment guidelines established Surgical procedures by the Cryotherapy for ROP and Early Treatment All patients underwent 3-port vitrectomy through a for Retinopathy (ETROP) studies have reduced the pars plicata approach, with or without lensect- rates of stage 4 and 5 ROP and its resultant visual omy.815After lateral canthotomy and a standard loss.12Despite early treatment of high-risk cases, conjunctival opening, a 2.5 mm, 20-gauge infusion unfortunately 12% of the eyes progress to stage 4 cannula was placed 1 mm posterior to the limbus or 5 ROP and need surgical repair.2 Open-sky (ie, through the pars plicata) in the inferotemporal vitrectomy,3 scleral buckling,45lensectomy and quadrant. Additional sclerotomies were made at the vitrectomy (LV) with or without scleral buckling,67 10 and 2 o’clock positions, either limbal or 1 mm and lens-sparing vitrectomy (LSV)8 are the surgical posterior to the limbus. A lensectomy was per- techniques that have been used for the management formed if the lens was found to impede adequate of retinal detachments associated with ROP. management of anterior-posterior traction, or if Some studies have reported anatomic outcomes there was limiting intraoperative visualisation. after vitreoretinal surgery for stage 4 and stage 5 Vitreous and membranes were removed, and – ROP.3 8 However, anatomic success may not equate anterior-posterior and circumferential tractions to functional success, and few studies have focused were released using the Associate 2500 vitrectomy – on assessing functional outcomes.9 17 Most of system (DORC, Zuidland, Netherlands). For visual- these publications are limited by small sample size, isation of the residual vitreous and posterior surgery performed by multiple surgeons, a short hyaloid membrane, after removal of the anterior To cite: Karacorlu M, – Hocaoglu M, Sayman follow-up period, and reporting bias. and core vitreous, 0.2 0.3 mL (40 mg/mL) triamci- Muslubas I, et al. This study describes a retrospectively analysed nolone acetonide aqueous suspension was injected Br J Ophthalmol series of patients with stages 4 and 5 ROP treated into the mid-vitreous cavity, followed by partial or 2017;101:730–734. by single surgeon in Turkey. All the children were complete removal of the posterior hyaloid. Other 730 Karacorlu M, et al. Br J Ophthalmol 2017;101:730–734. doi:10.1136/bjophthalmol-2016-309198 Downloaded from http://bjo.bmj.com/ on August 21, 2017 - Published by group.bmj.com Clinical science surgical procedures included retrolental membrane dissection, between initial laser and surgery was 6.5±4.8 weeks. The mean epiretinal membrane delamination, forceps membrane peeling, follow-up period was 6.9±1.9 years. Of the 88 eyes, 51 (58%) fluid-air exchange, and fluid-gas exchange. No intravitreal anti- had received prior retinal ablative treatment. vascular endothelial growth factor (anti-VEGF) was given pre- LSV was performed on 39 eyes (44%) and combined LV was operatively or intraoperatively. The parents were advised to use performed on 49 eyes (56%) (table 2). Six eyes after LSV (4 a topical antibiotic and corticosteroid drops four times a day for stage 4A and 2 stage 4B) and one after LV (stage 5) required 1 month during the postoperative period. reoperation (mean 9 weeks later) due to vitreous haemorrhage or reproliferation. Favourable anatomic and visual outcomes Follow-up examination were achieved in only two (stage 4A) of these seven eyes despite All the infants were routinely examined on day 1 after surgery, the second surgical procedure. There were no significant differ- then 1 week, 1 month, and every 3 months for a year, and then ences in anatomic success between LSV and LV for stage 4A yearly. All the patients were closely followed up in our institu- (93% vs 75%, p=0.39) or for stage 4B (67% vs 57%, p=0.35). tion and were referred to a paediatric ophthalmologist for com- Forty-five eyes (51%) had measurable VA at the final visit and prehensive postoperative visual rehabilitation. Ametropic and 34 (39%) had vision of LP or no LP (NLP). Owing to various anisometropic amblyopia were managed by correction with neurological conditions, VA could not be measured in nine eyes contact lenses or spectacles and subsequent eye patching. (10%) that had the ability to fix and follow. Table 3 summarises VA measurements were performed using the Tumbling E or the long-term visual results after vitrectomy for stages 4 and 5 Early Treatment Diabetic Retinopathy Study (ETDRS) charts. ROP. Following a standardised protocol, the ETDRS charts were used Of the 11 eyes (58% of all stage 4A eyes) for which a VA with a maximum distance of 4 m, but the distance was reduced could be measured, 42% (8/19) had VA of 20/200 or better, and to 1 m or to 0.5 m if needed to permit letter identification in an 16% (3/19) had ambulatory VA of 20/2000 or better. Of the 22 eye with poor vision.18 In some patients, VA testing was not per- eyes (58% of all stage 4B eyes) for which a VA could be mea- formed because of developmental limitations (the chart-measured sured, seven (32%) had VA of 20/400 or better. The mean vision as ‘fixes and follows’ or ‘central-steady-maintained’)orif approximate Snellen VA equivalent of the 11 eyes that under- both eyes had vision of light perception (LP) or worse. went surgery for stage 5 ROP and had measurable VA (35% of Anatomic success was defined as complete retinal attachment all stage 5 eyes) was 20/4000 (range 20/2000–20/20 000). for stage 4A ROP,partial retinal detachment for stage 4B, and at The visual outcomes of stage 4A were better than those of least posterior pole attachment for stage 5. stage 5 ROP (p=0.001). Earlier retinal ablation was associated Data were analysed using the Kruskal-Wallis test, Pearson with better visual results for stage 4B ROP (p=0.04). There was χ2 test, Fisher’s exact test, Mann-Whitney test, and Spearman’s no statistically significant difference in the visual results between rank correlation depending on the variables. A value of p<0.05 LSV and LV for stage 4B (p=0.39), but numbers were too small was considered statistically significant. Statistical analyses used to allow statistical comparison for stage 4A. SPSS V.20.0(SPSS, Inc, Chicago, Illinois, USA).
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