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Fluorescein angiography is great but has limitations
Fluorescein angiography is a great way to look at the vasculature in retinopathy of prematurity, but it has its limitations: the expense of the machine, the necessity of having intravenous access on the infant, the systemic stability of the infant and the presence of a well-formed tunica vasculosa.
Despite these limitations, I obtain angiography on every child when I am concerned with the disease process or if I am going to treat the child. I also like to follow my treatment and the regression or recurrence of ROP after anti-VEGF or laser treatment with fluorescein angiography. To this day, I have never been unable to obtain an angiogram in a neonate.
Audina M. Berrocal, MD, is the medical director of pediatric retina and retinopathy of prematurity, vitreoretinal fellowship co-director, at the Bascom Palmer Eye Institute, Miami. Disclosure: Berrocal reports she is a consultant for Visunex and Phoenix.
It is possible to not use fluorescein angiography
It is certainly possible to perform thorough retinopathy of prematurity follow-up exams without the assistance of intravenous fluorescein angiography. For various reasons, including availability, these studies are not part of the routine evaluation in most cases of treated and recurrent ROP. With the increase in intravitreal anti-VEGF injections, weekly follow-up exams for months after treatment are performed. This is because of the relatively high recurrence rates of stage 3 ROP requiring re-injections or laser photocoagulation. The re-treatment criteria are usually based on the findings on indirect ophthalmoscopy. Pediatric ophthalmologists often follow these patients along with treating retina specialists. In addition to indirect ophthalmoscopy, they determine changes in refractive error over time, which is important in ROP management because myopia and anisometropia are so prevalent.
Ophthalmologists who follow these infants recognize that the vascularization of the retina following treatment does not proceed the same way in all patients. This is where the accumulation of fluorescein angiography data is particularly useful. For example, recurrent neovascularization has been shown to occur in both treated and untreated patients that may have not been detected on indirect ophthalmoscopy. In addition, posterior pole findings, including vessels encroaching on or crossing the fovea, have also been demonstrated on intravenous fluorescein angiography. This along with OCT findings may help to explain reduced vision in children who had significant but clinically resolved ROP.
The ability to describe the natural history of both treated and untreated ROP and combining clinical findings and fluorescein angiography and OCT all provide important information. In most cases, we are able to determine when intervention is indicated from indirect ophthalmoscopy, but to clarify the variations in peripheral vascularization and arrested vascular development as they occur in ROP is significant for understanding the pathogenesis.
Rudolph S. Wagner, MD, is an OSN Pediatrics/Strabismus Board Member. Disclosure: Wagner reports no relevant financial disclosures.