The authors report the correlation between chest physiotherapy and increased risk of vitreous hemorrhage after laser photocoagulation therapy in patients with retinopathy of prematurity (ROP). Two premature neonates, the first born at 26 weeks and the second at 31 weeks gestational age, both underwent chest physiotherapy, the first for congenital cystic fibrosis and bronchopulmonary dysplasia and the second for premature alveolar atelectasis. Both were diagnosed as having ROP that necessitated laser photocoagulation treatment at 34 and 37 weeks, respectively. The first patient developed bilateral vitreous hemorrhage and bilateral cataracts. The second patient developed vitreous hemorrhage in one eye. Chest physiotherapy in neonates with ROP significantly increases the risk of hemorrhage after laser photocoagulation in an otherwise fragile retinal vasculature.
From the Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida (HAA, SC, AMB); and Jackson Memorial Hospital, Miami, Florida (MD-B).
The authors have no financial or proprietary interest in the materials presented herein.
Correspondence: Hassan A. Aziz, MD, Bascom Palmer Eye Institute, 900 N.W. 17th Street, Miami, FL 33136. E-mail: email@example.com
Received: April 14, 2012
Accepted: November 26, 2012
Posted Online: February 19, 2013
Retinopathy of prematurity (ROP) is a leading cause of potentially avoidable blindness worldwide, accounting for 8% of blind children in developed countries and 40% in developing countries.1,2 Diode laser photocoagulation is now considered the preferred modality of treatment in ROP.3 Laser photocoagulation results in a favorable anatomical outcome in 86% to 95% of cases.2 The complications of the procedure are listed in Table 1.4
Table 1: Rate of Complications After Laser Photocoagulation in Neonates With Retinopathy of Prematurity
Chest physiotherapy (CPT) is thought to assist infants in the clearance of airway secretions and decreasing the ventilatory effort.5 Various CPT techniques have been developed, including chest percussion, vibration in postural drainage positions, chest shaking, directed coughing, and slow passive forced exhalation.6 Its use varies among institutions, with vibration and chest percussion being the most widely used techniques.6
We present two patients with ROP who had CPT treatment for pulmonary disorders and developed vitreous hemorrhage after laser photocoagulation therapy.
Two premature neonates were referred to the Jackson Memorial Hospital/Bascom Palmer Eye Institute for the evaluation and management of ROP. They were born at 26 and 31 weeks gestational age and their birth weight was 1,065 and 2,720 g, respectively. The first was diagnosed as having cystic fibrosis and bronchopulmonary dysplasia and the second as having premature alveolar atelectasis. CPT was performed on both patients to help alleviate the respiratory airway obstruction. The two patients were also diagnosed as having ROP that necessitated laser photocoagulation treatment performed by the referring physician at 34 and 37 weeks, respectively.
The ophthalmic examination of the first patient revealed persistent plus disease in both eyes and vitreous hemorrhage in the right eye. Salvage treatment with off-label intravitreal bevacizumab was given to the right eye due to poor vision, poor dilation, and persistent plus disease. The vision in the left eye was clear and laser photocoagulation was performed. One month follow-up examination showed resolved plus disease in both eyes with attached and vascularized retina.
The ophthalmic examination of the second patient revealed bilateral vitreous hemorrhage and a white cataract in the right eye with a milder cataract in the left eye. Pars plana vitrectomy and pars plana lensectomy with intravitreal triamcinolone was performed in the right eye at 42 weeks. The left eye received an off-label bevacizumab injection. At the 6-month follow-up examination, the patient was aphakic in the right eye with sensory amblyopia treated with alternating patching. The left cataract had become increasingly worse but the vitreous hemorrhage had cleared. The patient underwent cataract exchange to the left eye. The retina was attached and vascularized in both eyes.
These two cases illustrate the possible consequences of CPT on patients with ROP. CPT imparts a significant physical and physiological stress on neonates. In vulnerable newborns and premature neonates, it prompts an increase in mean arterial pressure and intracranial pressures.7 CPT for premature neonates has also been implicated in a specific form of brain damage (encephaloclastic porencephaly).8
In patients with ROP, the neovascular networks formed in the ischemic retina are tenuous and susceptible to damage.9 Laser photocoagulation may result in vessel damage and vitreous hemorrhage in up to 7.9% of treated patients with ROP.4 We believe that the cumulative effect of CPT and laser photocoagulation on an otherwise friable vasculature increases the risk of vitreous hemorrhage significantly.
Chest physiotherapy on a patient with ROP who might undergo laser photocoagulation should be considered a relative contraindication due to the considerable risk of vitreous hemorrhage and development of secondary complications.
- Gilbert C, Rahi J, Eckstein M, O’Sullivan J, Foster A. Retinopathy of prematurity in middle-income countries. Lancet. 1997;350:12–14. doi:10.1016/S0140-6736(97)01107-0 [CrossRef]
- Axer-Siegel R, Maharshak I, Snir M, et al. Diode laser treatment of retinopathy of prematurity: anatomical and refractive outcomes. Retina. 2008;28:839–846. doi:10.1097/IAE.0b013e318169faee [CrossRef]
- O’Keefe M, Kirwan C. Diode laser versus cryotherapy in treatment of ROP. Br J Ophthalmol. 2006;90:402–403. doi:10.1136/bjo.2005.086330 [CrossRef]
- Fallaha N, Lynn MJ, Aaberg TM Jr, Lambert SR. Clinical outcome of confluent laser photoablation for retinopathy of prematurity. J AAPOS. 2002;6:81–85. doi:10.1067/mpa.2002.121452 [CrossRef]
- Oberwaldner B. Physiotherapy for airway clearance in paediatrics. Eur Respir J. 2000;15:196–204. doi:10.1183/09031936.00.15119600 [CrossRef]
- Perrotta C, Ortiz Z, Roque M. Chest physiotherapy for acute bronhiolitis in paediatric patients between 0 and 24 months old. Cochrane Database Syst Rev. 2007;24:CD004873.
- Perlman JM, Volpe JJ. Suctioning in the preterm infant: effects on cerebral blood- flow velocity, intracranial pressure, and arterial blood pressure. Pediatrics. 1983;72:329–334.
- Harding JE, Miles FK, Becroft DM, Allen BC, Knight DB. Chest physiotherapy may be associated with brain damage in extremely premature infants. J Pediatr. 1998;132:440–444. doi:10.1016/S0022-3476(98)70017-4 [CrossRef]
- Flynn JT, Chan-Ling T. Retinopathy of prematurity: two distinct mechanisms that underlie zone 1 and zone 2 disease. Am J Ophthalmol. 2006;142:46–59. doi:10.1016/j.ajo.2006.02.018 [CrossRef]
Rate of Complications After Laser Photocoagulation in Neonates With Retinopathy of Prematurity
||Rate of Occurrence
|Anterior segment ischemia