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Review article of Prematurity: An Update Parveen Sen, Chetan Rao and Nishat Bansal

Sri Bhagwan Mahavir Introduction 1 ml of 10% phenylephrine (Drosyn) mixed in 3 ml Vitreoretinal Services, Retinopathy of prematurity (ROP) was originally of 1% tropicamide (after discarding 2 ml from 5 ml Sankara Nethralaya designated as retrolental fibroplasias by Terry in bottle) for pupillary dilatation. These combination 1952 who related it with premature birth.1 Term drops are used every 15 minutes for 3 times. 2 Correspondence to: ROP was coined by Heath in 1951. Punctum occlusion is mandatory after instilling the Parveen Sen, It is a disorder of development of retinal blood drops to reduce the systemic side effects of medica- Senior Consultant, vessels in premature babies. Normal retinal vascu- tion. Excess drops should also be wiped off to Sri Bhagwan Mahavir larization happens centrifugally from to prevent absorption through cheek skin. If the Vitreoretinal Services, ora. Vascularization up to nasal ora is completed does not dilate in spite of proper use of medication, Sankara Nethralaya. by 8 months (36 weeks) and temporal ora by 10 presence of plus disease should be suspected. E-mail: [email protected] months (39–41 weeks).3 Repeated installation of topical drops should be The incidence of ROP is increasing in India avoided to prevent systemic problems. Sterile because of improved neonatal survival rate. Out of Alfonso speculum is used to retract the lids and wire 26 million annual live births in India, approxi- vectis for gentle depression. mately 2 million are <2000 g in weight and are at High-quality retinal images obtained using risk of developing ROP.3 In India the incidence of commercially available wide-angle fundus camera ROP is between 38 and 51.9% in low-birth-weight like the Retcam followed by Telescreening by a infants.3,4 trained ophthalmologist can also be done. In developing countries like India where majority of Screening guidelines people live in remote areas which may not have American Academy of Pediatrics guidelines5 access to the tertiary-level care, telescreening may bring more children into the screening program. • Infants with birth weight of ≤1500 g. This model has been successfully used by Vinekar • Gestational age of 30 weeks or less. et al. in Karnataka Internet Assisted Diagnosis of Retinopathy of Prematurity (KIDROP).6 The follow • Infants with birth weight between 1500 and up schedule for these babies is given in Table 1. 2000 g or gestational age of >30 weeks with unstable clinical course. Role of laser Since the stimulus for abnormal vessels comes Indian scenario4 from the avascular therefore ablating the • Birth weight <1700 g peripheral avascular retina is believed to cause regression of the ROP. Earlier the CRYO-ROP • Gestational age at birth <34–35 weeks Study7 treatment guidelines were followed; with the results of Early treatment for retinopathy of • Exposed to oxygen >30 days prematurity (ETROP study)8 there has been a para- • Infants born at <28 weeks and weighing digm shift in treatment to laser therapy from <1200 g are particularly at high risk of devel- CRYO therapy. Laser therapy significantly allows oping severe form of ROP more precision of treatment as well as reduces the unfavorable side effects of the and • Presence of other factors such as respiratory has more than 90% successful results.8 Laser treat- distress syndrome, sepsis, multiple blood trans- ment protocol according to ETROP is given in fusions, multiple births (twins/triplets), apneic Table 2. episodes, intraventricular hemorrhage increase risk of ROP. In these cases screening should be Treatment guidelines considered even for babies>37 weeks gestation Laser is done using indirect laser ophthalmoscope or >1700 g birth weight. under topical anesthesia after pupillary dilatation The first screening should be done within 4 weeks under care of an anesthetist in the operation (30 days) of life in infants with age >28 weeks of theatre. The entire avascular retina up to the ora gestational age. Screening should be done earlier serrata should be ablated with near confluent (2–3 weeks after birth) if gestational age is <28 weeks burns (0.5–1 burn width apart) up to the ridge. or birth weight is <1200 g.4 Screening should be Heart rate and apnea spells should be monitored done by an ophthalmologist who is well versed throughout the laser.9 In severe forms of disease with indirect in ROP babies. Child not responding to this laser photocoagulation should be fed 1 hour prior to examination. We use further laser to the ridge as well as posterior to

Sci J Med & Vis Res Foun June 2015 | volume XXXIII | number 2 | 93 Review article

Fig. 1 (A) Stage 1: Demarcation line. (B) Stage 2: Ridge. (C) Stage 3: Ridge with extra retinal fibrovascular proliferation. (D) Stage 4A: extrafoveal . (E) Stage 4B: fovea involving retinal detachment. (F) Plus disease with dilated and tortuous retinal vessels

Table 1 Follow-up schedule for ROP babies4 Follow-up Immature vascularization, ROP ROP Regressing no ROP Stage 1 or 2 Stage 3 ROP 1 week or Zone I or immature retina Stage 1 or 2, Zone III, zone II less extends into posterior zone II zone I pre-threshold 1–2 weeks Posterior zone II Stage 2, zone II Unequivocally regressing ROP, Zone I 2 weeks Zone II Stage 1, zone II Unequivocally regressing ROP, Zone II 2–3 weeks Stage 1 or 2, Regressing ROP, Zone III zone III

ridge has also been shown to be effective in severe Follow-up visits after laser treatment are cases of ROP.10 This has caused regression of the usually weekly till the ROP regresses and involu- disease in some cases and avoided the progression tion of all tractional elements is seen and vascu- of tractional retinal detachment. larization reaches the temporal ora.

94 Sci J Med & Vis Res Foun June 2015 | volume XXXIII | number 2 | Review article

Table 2 Laser treatment protocol for ROP according 3 Failed laser treatment leading to persistent to ETROP8 neovascularization, tractional elements or trac- Zone 1 tional retinal detachment prior to surgery. No Plus Stage 1 Follow Stage 2 Follow Role of surgery Stage 3 Treat Surgery is done for tractional retinal detachment Plus Stage 1 Treat (TRD) repair as seen in Stages 4 and 5 ROP. The Stage 2 Treat aim for surgical intervention in Stage 4 ROP is to Stage 3 Treat prevent progression of retinal detachment. Scleral Zone 2 buckling (placing 240 band at the height of the No Plus Stage 1 Follow TRD by making tunnels in all quadrants) is Stage 2 Follow done for Stage 4A ROP with only peripheral trac- Stage 3 Follow tional retinal detachment. This surgery does not Plus Stage 1 Follow involve the removal of membranes formed on the Stage 2 Treat retina but by causing peripheral scleral indenta- Stage 3 Treat tion reduces the effective TRD. This procedure can be combined with cryotherapy or laser to any peripheral persistent new vessels. The encircling Role of anti-vascular endothelial growth band needs to be removed once the child is 1 year factor (VEGF) of age to allow normal growth of the eyeball and In recent times, anti-VEGF has also been used in to reduce the amount of induced by severe forms of ROP, especially those not respond- the buckle. ing to laser photocoagulation. Its role, however, is sparing (LSV) has shown very controversial. VEGF is needed in premature promising results in Stages 4A and 4B. Long-term babies for the normal organogenesis and vasculo- results with lens sparing vitrectomy were favor- genesis. Also systemic absorption may cause vas- able in the study by Trese et al.: 82.1% (Stage 4A), cular development delay in other organs in these 69.5% (Stage 4B) and 42.6% (Stage 5) showing premature babies. Therefore, it is not recom- successful anatomical reattachment of retina with 5 mended by many as the first-line therapy. lens being clear for at least the first decade of BEAT ROP study which compared life.14 Bhende et al. also reported 82% anatomical monotherapy with conventional laser therapy success in 4A stage ROP and 50% in Stage 4B showed promising results for stage 3+ ROP in ROP after single procedure.15 25-Gauge vitrectomy 11 zone 1 but not in zone 2. In this study, periph- is now commonly used for ROP surgery. Finer eral retinal vessels continued in normal fashion instrumentation and more effective microvit after treatment with intravitreal bevacizumab. This systems in small gauges are useful during mem- study was too small to assess the safety profile in brane dissection. However, modification of the 11 these babies. technique in the form of conjunctival dissection The follow-up period after mono therapy is as well as suturing of the sclerotomies at the end unpredictable as there can be a recurrence of neo- of surgery may be necessary.16 Modern vitreo- vascularization even beyond 54 weeks of post- retinal surgical tools like the infusion light pipe, gestational age. It is recommended that follow-up binocular indirect ophthalmoscopy (BIOM) which should be continued till there is no evidence of allows wide-angle viewing has reduced the risk of tractional elements and the vascularization creating iatrogenic retinal breaks and also sparing 5 reaches ora. In Zone 1 ROP, the Laser treatment of lens, allowing easy visual rehabilitation in outcomes are poorer. Treatment with anti-VEGF these children.17 followed by a 4–5 days later with laser treatment In Stage 5 ROP, the results of surgical interven- in these cases has improved the efficacy of laser tion are poor. It usually involves the removal of along with a reduced need for extensive laser the lens. Gopal et al. had anatomical success with 12 especially at the posterior pole. In a study by the attachment of posterior pole in 22.5% of cases Chen et al. both bevacizumab and with lens sacrificing vitrectomy though visual had similar efficacy at the end of 1 year in terms results were unsatisfactory with only two children 13 of ROP regression and . showing mobile vision out of 96 .18 Closed On the basis of available literature indication vitreoretinal surgery was done in all these for anti-VEGF therapy can be enumerated as: eyes with Stage 5 ROP. The aim of the surgery for Stage 5 ROP is to clear all preretinal tissue up to 1 Primary therapy for aggressive posterior zone the disc and open the peripheral trough all round. 1 disease (APROP). In most instances, bimanual surgery under visco- 2 Aggressive anterior ROP or media haze due to elastic is performed. Anterior chamber (AC) main- aggressive posterior disease to improve visual- tainer to keep the IOP under control during ization for laser treatment. surgery is also used. Fixation of infusion cannula

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through pars plicata is impossible in these cases prematurity: results of early treatment of retinopathy of because the retina is pulled up to the lens. prematurity randomized trial. Arch Ophthalmol. – Open sky vitrectomy (through a trephined 2003;121:1684 96. 9. Jalali S, Azad R, Trehan HS, Dogra MR, Gopal L, Narendran V. corneal opening) has also been advocated by some Technical aspects of laser treatment for acute retinopathy of 19 especially in cases with . It has prematurity under topical anesthesia. Indian J Ophthalmol. the advantage of allowing two hand dissection 2010;58(6):509–15. from a large anterior incision but maintenance of 10. Uparkar M, Sen P, Rawal A, Agarwal S, Khan B, Gopal L. Laser is difficult. photocoagulation (810 nm diode) for threshold retinopathy of prematurity: a prospective randomized pilot study of treatment Conclusion to ridge and avascular retina versus avascular retina alone. Int Ophthalmol. 2011;31(1):3–8. Considering the poor outcome of surgery in end- 11. Mintz-Hittner HA, Kennedy KA, Chuang AZ; BEAT-ROP stage ROP timely intervention in the form of laser Cooperative Group. Efficacy of intravitreal bevacizumab for treatment is the best treatment option. There is stage 3+ retinopathy of prematurity. N Engl J Med. 2011;364 need to increase the awareness of the disease to (7):603–15. make sure these babies can be treated on time. 12. Mota A, Carneiro A, Breda J, Rosas V, Magalhaes A, Silva R, Also there is a need of more numbers of special- Falcao-Reis F. Combination of intravitreal ranibizumab and ized vitreoretinal surgeons who can handle these laser photocoagulation for aggressive posterior retinopathy of prematurity. Case Rep Ophthalmol. 2012;3(1):136–41. babies. 13. Chen SN, Lian I, Hwang YC, Chen YH, Chang YC, Lee KH, Chuang CC, Wu WC. Intravitreal anti-vascular endothelial References growth factor treatment for retinopathy of prematurity: 1. Terry TL. Extreme prematurity and fibroblastic overgrowth of comparison between ranibizumab and bevacizumab. Retina. persistent vascular sheath behind each crystalline 2015;35(4):667–74. lens. I. Preliminary report. Am J Ophthalmol. 1942;25:203–4 14. Nudleman E, Robinson J, Rao P, Drenser KA, Capone A, 2. Heath P. Pathology of retinopathy of prematurity, RLF. Am J Trese MT. Long-term outcomes on lens clarity after lens-sparing Ophthalmol. 1951;34:1249–68. vitrectomy for retinopathy of prematurity. . 3. Pejawar R, Vinekar A, Bilagi A. National Neonatology 2015;122(4):755–9. Foundation’s Evidence-based Clinical Practise Guidelines 15. Bhende P, Gopal L, Sharma T, Verma A, Biswas RK. Functional (2010), Retinopathy of Prematurity, NNF India, New Delhi and anatomical outcomes after primary lens-sparing pars plana 2010:253–62. vitrectomy for Stage 4 retinopathy of prematurity. Indian J 4. Jalali S, Anand R, Kumar H, Dogra MR, Azad R, Gopal L. Ophthalmol. 2009;57(4):267–71. Programme planning and screening strategy in retinopathy of 16. Gonzales CR, Boshra J, Schwartz SD. 25-Gauge pars plicata prematurity. Indian J Ophthalmol. 2003;51(1):89–99. vitrectomy for stage 4 and 5 retinopathy of prematurity. Retina. 5. Fierson WM. Screening examination of premature infants for 2006;26(7 Suppl):S42–6. retinopathy of prematurity. Pediatrics. 2013;131:189–95. 17. Trese MT, Capone A Jr. Surgical approach to infant and 6. Vinekar A, Gilbert C, Dogra M, Kurian M, Shainesh G, Shetty B, childhood retinal diseases: invasive methods. In Hartnett ME, Bauer N. The KIDROP model of combining strategies for Tresse MT, Capone A Jr, et al, eds. Pedatric Retina. Philadelphia: providing retinopathy of prematurity screening in underserved Lipponcott Williams& Williams; 2005, pp. 359–64. areas in India using wide-field imaging, tele-medicine, 18. Gopal L, Sharma T, Shanmugam M, Badrinath SS, Sharma A, non-physician graders and smart phone reporting. Indian J Agraharam SG, Choudhary A. Surgery for stage 5 retinopathy of Ophthalmol. 2014;62(1):41–9. prematurity: the learning curve and evolving technique. Indian 7. Cryotherapy for retinopathy of prematurity cooperative J Ophthalmol. 2000;48(2):101–6. group. Multicentric trial of retinopathy of prematurity: 3 19. Tasman W, Borrone RN, Bolling J. Open sky vitrectomy for months outcome. Arch Ophthalmol. 1990;108:195–204. total retinal detachment in retinopathy of prematurity. 8. Early Treatment of Retinopathy of Prematurity Cooperative Ophthalmology. 1987;94(4):449–52. Group. Revised indications for treatment of retinopathy of

How to cite this article Parveen S, Chetan R, Nishant B. Retinopathy of Prematurity: An Update, Sci J Med & Vis Res Foun 2015;XXXIII:93–96.

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