While major advancements have occurred in the past decade regarding the treatment of retinopathy of prematurity (ROP), this potentially disabling disease continues to carry an enormous burden in our society.
Laser photocoagulation has largely replaced cryotherapy as the primary modality of obliterating ischemic retina. More recently, the introduction of anti-vascular endothelial growth factor (VEGF) agents such as bevacizumab have shown promising results.
One of the major challenges in ROP treatment is that in most neonatal intensive care units (NICU), the care of the infants is shared among two or more physicians. As a pediatric retina specialist, as in any other specialty, one’s experience expands in managing this difficult disease, as both treatment modalities and patterns of pathology often vary. Thus, different approaches and treatment protocols can be implemented to the same patient.
In this paper we describe the unique experience of one ophthalmologist managing ROP at a tertiary medical center over the span of 10 years.
Patients and Methods
A retrospective review of the medical records of 10,924 patients clinically screened for ROP at the Jackson Memorial Hospital neonatal intensive care unit between 2002 and 2012 was performed. The study was approved by the institutional review board at the University of Miami Miller School of Medicine, and all procedures were performed in accordance with the tenets of the Declaration of Helsinki.
Patients were screened for and clinically diagnosed with ROP via a dilated fundus examination by the same ophthalmologist (AMB) over the 10-year period. This study specifically investigated the use of laser photocoagulation as a treatment modality for ROP. Clinical data collected included birth weight, gestational age, age at treatment, and number of treatments. Exclusion criteria included patients who were transferred from outside facilities or had been administered anti-VEGF as an adjuvant therapy.
Only 235 of 10,924 patients (2.2%) screened for ROP were treated with laser photocoagulation. Of the 235 patients, 176 (74.9%) were included. Of the excluded patients, 55 infants were transferred from an outside institution, and four were administered off-label bevacizumab as an adjuvant treatment. Of the 176 treated patients, 89 (50.6%) were male and 87 (49.4%) were female. The average birth weight of treated patients was 687.3 grams, while the mean gestational age was 24.8 weeks. Retinal detachment occurred in two of 176 (1.1%) patients who eventually needed surgical repair (
SROP Patients Treated with Laser Photocoagulation
The mean time between birth and treatment was nearly 3 months. Of the 176 patients, 31 required re-treatment with laser photocoagulation (
). With time, a statistically significant downward trend was detected in the need for both treatment and retreatment (
). The results of the year 2012 were excluded in the re-treatment data because only one patient was treated with laser photocoagulation that year.
Bar graph representing by year the number of treatments and re-treatments with laser photocoagulation in patients with retinopathy of prematurity.
ROP screening criteria have evolved over time, with indications for treatment changing between 2002 and 2012, in favor of treating infants earlier. Due to the advanced neonatal care, the number of surviving premature infants has increased significantly.
This has created a higher demand for ROP screening, and an expected increase in more treated infants.
In this series, though the number of screenings increased in number, both the number and percentage of patients requiring treatment and re-treatment decreased significantly. This signifies that with increasing experience, a provider becomes more comfortable observing, rather than treating, pre-threshold disease.
Inadequate laser treatment could potentially result in progression to retinal detachment.
Within this cohort, retinal detachment only occurred in two patients, and the need for re-treatment decreased significantly as the provider became more efficient in delivering complete photocoagulation to an ischemic retina. This exemplifies how experience could help save and preserve neonatal vision, as well as relieving both the parents and the health care system from the stresses and economic burden of multiple treatments.
The average birth weight and age to treatment has not changed over the years. As a tertiary medical center, our institution may observe a greater prevalence of high-risk pregnancies, potentially skewing the data.
In conclusion, experience is essential in delivering optimal care in a complex disease such as ROP. Between 2002 and 2012, the rate of treatment and retreatment significantly decreased. Possible reasons include improvements in neonatal care, but it is more likely that the rate of treatment and re-treatment is inversely proportional to the ophthalmologist experience and comfort in the management of ROP. With the advent of new innovations in management of ROP such as anti-VGEF injections and telemedicine, the hurdle of experience in treating ROP could be minimized in the near future.
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SROP Patients Treated with Laser Photocoagulation
|Year||Average birth weight (mg)||Mean Gestational Age (weeks)||Mean Age at Treatment (months)||Months to Treatment||Male||Female||Both Eyes||One Eye||Number of Treated Patients||Number of Re-treated Patients||Percentage of Re-treated Patients|