Lens-sparing surgery for retinopathy of prematurity

Abstract

Capone and Trese (Ophthalmology 2001;108:2068–70) suggested that the use of lens-sparing vitrectomy for stage 4A retinopathy of prematurity (ROP) reduces the progression of the disease and improves the patient's visual prognosis. After abandoning pars plana vitrectomy lensectomy for stage 5 ROP (due to the very poor rate of visual success at 4 years of follow-up), our group in Argentina has been performing three-port lens-sparing vitreous surgery with endophotocoagulation for stages 4A and 4B ROP. Of eight cases of stage 4A, 87.5% had good anatomic outcomes (unpublished data) and maintained central steady fixation. The other 12.5% (one eye) progressed to a worse stage of the disease, with both poor anatomic and poor functional results. Four of the stage 4A ROP eyes we treated had no peripheral retinal laser photoablation before surgery. With these eyes we obtained the best surgical outcome. At the time of the procedure, the organized vitreous was easier to cut and the retina was less rigid, so that when the traction was liberated we could observe the retina flattening smoothly. Conversely, in the eyes that had been treated with laser before surgery we found the organized vitreous more difficult to manipulate and the retina more rigid, thus increasing the risk of iatrogenic retinal tearing and detachment. Of course, we understand our experience is very limited, but the difference observed was remarkable; therefore, we thought it should be reported. We agree with Drs. Capone and Trese that the time of the surgical intervention is a key factor in achieving good results with this treatment. In our cases that were not treated with laser before surgery, the infants were brought to our institution with vascular activity (dilation and tortuosity). After releasing the traction a complete endophotocoagulation was carried out in the entire avascular zone to interrupt the pathogenic mechanism that leads to stages 4B and 5. As explained by Capone and Trese, timing is the most important issue in preventing blindness in any stage of the disease, and in remote places of our country where there is no ROP screening availability, early surgical treatment may be an alternative to consider.