Skill needed for challenging staging, treatment of ROP

Retinopathy of prematurity occurs primarily in low birth weight premature infants who are admitted to a neonatal intensive care unit and require oxygen supplementation.

Current teaching is that either too much or too little oxygen can result in ROP. ROP, like other retinal vascular diseases, is in part mediated by the release of excess VEGF. Thus, the treatment is similar, including laser photocoagulation and/or anti-VEGF injections. A few thoughts by a non-expert for the comprehensive ophthalmologist.

At approximately 4 months of gestation, the fetal retina begins to vascularize. Retinal vascularization proceeds from the central retina to the periphery. The peripheral temporal retina vascularizes last, so this is a critical area for examination. A dilated indirect ophthalmoscopic examination with scleral depression is usually carried out by a fellowship-trained pediatric ophthalmologist or vitreoretinal specialist skilled in the art to diagnose and stage ROP. Most use the International Classification of Retinopathy of Prematurity system with five stages progressing from a temporal retinal demarcation line in stage 1 to a total retinal detachment in stage 5. There is also plus disease, which includes vitreous haze, iris vascularization and/or tunica vasculosa lentis. Proper staging is critical for planning personalized treatment and providing the patient’s family with a prognosis.

In metropolitan areas, every NICU has contracted with an ophthalmologist specialist to perform these examinations, and they are difficult and time-consuming and carry some medicolegal risk. In some U.S. rural areas and many emerging countries, widefield digital imaging and telemedicine are utilized. Recent evidence supports this approach, which has 90% sensitivity and specificity.

After a diagnosis is made and ROP severity is staged, appropriate treatment is required. Treatment requires significant skill, and in more severe cases in which there is a retinal detachment and vitreous haze, a fellowship-trained pediatric vitreoretinal specialist working together with a pediatric ophthalmologist is ideal. It is rare in the U.S. today that a comprehensive ophthalmologist is called to see these patients, and if so, special training is needed.

ROP often results in lifelong visual challenges including amblyopia, strabismus, progressive myopia, cataract, glaucoma, vitreous opacity or hemorrhage, and retinal detachment. Fortunately, most of these children are cared for by our pediatric and vitreoretinal specialist colleagues, but as they age, patients with ROP will be seen by other eye care professionals for optical correction and management of glaucoma, cataract or ocular surface disease. It is my hope that the accompanying Healio | OSN roundtable and my comments are helpful to those who participate in caring for these challenging patients.

• For more information:
• Richard L. Lindstrom, MD, can be reached at rllindstrom@mneye.com.

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Source:
Expert Submission

Disclosures:
Lindstrom reports having disclosures for Minnesota Eye Consultants, Unifeye Vision Partners and Zeiss.

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