RETINOPATHY OF PREMATURITY TREATMENT
Category: Child Health
Abstract : Medical Care: • Medical care consists of ophthalmologic screening of appropriate infants. • No specific medical therapies are available at this time. Surgical Care: • Ablative surgery o If threshold disease is present, perform ablative surgery. o Ablative therapy currently consists of cryotherapy or laser surgery to destroy the avascular areas of the retina.
Medical Care:
• Medical care consists of ophthalmologic screening of appropriate infants.
• No specific medical therapies are available at this time.
Surgical Care:
• Ablative surgery
o If threshold disease is present, perform ablative surgery.
o Ablative therapy currently consists of cryotherapy or laser surgery to destroy the avascular areas of the retina.
• Cryotherapy
o A randomized prospective trial of cryotherapy showed a 50% reduction in retinal detachment in treated eyes versus nontreated eyes.
o Beneficial effects were observed in infants with threshold disease, defined as 5 contiguous clock hours of stage 3 disease with plus disease or 8 noncontiguous clock hours of stage 3 disease with plus disease.
• Laser surgery
o Currently, laser surgery is preferred to cryotherapy because it may be more effective in treating zone 1 disease. Laser photocoagulation appears to be associated with outcomes in structure and function that are at least as good as those of cryotherapy 7 years after therapy. In addition, visual acuity and refractive error data suggest that laser surgery may have an advantage over cryotherapy, and evidence suggests that laser surgery is easier to perform and better tolerated by the infants.
o Laser surgery has been used more recently than cryotherapy, and whether the slightly improved outcomes with laser surgery are attributable to changes in the care of high-risk neonates (eg, antenatal glucocorticoid therapy, surfactant use) is unclear. However, cryotherapy has been rigorously evaluated in a multicenter prospective randomized fashion, and the 10-year follow-up data show long-term value in preserving visual acuity in eyes with threshold ROP (CRYO-ROP group, 2001).
Further Inpatient Care:
• Base follow-up examinations on previous examination results. The more immature the retinal vasculature or the more serious the disease, the shorter the follow-up interval must be to enable the detection of disease. These examinations allow the physician to offer treatment if threshold disease develops in the eye.
• After surgical intervention, an ophthalmologist should perform an examination to determine if additional surgery is indicated.
• Patients who are medically monitored must undergo examinations until the retinal vasculature is mature. Ensuring appropriate follow-up for infants is critical if they are discharged from the nursery before retinal vascular maturity is attained.
Further Outpatient Care:
• Patients require yearly ophthalmologic follow-up evaluations. More frequent evaluation may be necessary, depending on the severity of the disease.
• The long-term outcome for infants with ROP continues to be problematic. Patients with ROP are at significant risk for myopia. In addition, strabismus, amblyopia, and late retinal detachment continue to be problems for these infants. Long-term follow-up findings from the CRYO-ROP cooperative group indicate that refractive errors in eyes with mild ROP are associated with the same risk of myopia as that in eyes without ROP. In patients with moderate-to-severe ROP, the prevalence of severe myopia is increased. As previously stated, laser surgery offers some advantage over cryotherapy in treating zone 1 disease.
Deterrence/Prevention:
• The only known deterrent measure is to prevent preterm birth. The more mature a neonate is at birth, the less likely ROP is to occur.
• Recent studies regarding the effects of antenatal corticosteroids on ROP revealed that this treatment has a protective effect against severe ROP.
Complications:
• Late complications include myopia, amblyopia, strabismus, nystagmus, retinal breaks, and retinal detachment.
• Follow-up by an ophthalmologist is required on a long-term basis.
Medical/Legal Pitfalls:
• The timing of examination and follow-up are important factors in the diagnosis and treatment ROP. If a patient misses an examination, it should be rescheduled as soon as possible.
• Ensuring that parents are aware of the significance of ROP and appropriate follow-up is also important.
• Because of the risk of rush retinopathy, premature infants with immature retina and/or progressive ROP who come from a high-risk social environment should stay in the hospital and undergo retinal examinations every 1-2 weeks.
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