Prethreshold Retinopathy Of Prematurity Research Articles

Outcome of Eyes Developing Retinal Detachment During the Early Treatment for Retinopathy of Prematurity Study

To describe the structural and visual outcomes at age 6 years of retinal detachment (RD) from retinopathy of prematurity (ROP) in the Early Treatment for Retinopathy of Prematurity (ETROP) study. Prospective multicenter nonrandomized series of infants with high-risk prethreshold ROP who developed an RD by 6 months corrected age treated with observation or vitreoretinal surgery. Of 401 patients, 63 (89 eyes) experienced RD. Follow-up at age 6 years was available for 70 eyes (79%) of 49 surviving patients. The RDs were stage 4A in 28 eyes (40%), stage 4B in 14 (20%), stage 5 in 13 (19%), and not classified in 15 (21%). The macula was attached in 17 of 50 eyes (34%) after vitrectomy with or without scleral buckle, in 6 of 9 (67%) after scleral buckle only, and in 2 of 11 eyes (18%) observed. An attached macula at age 6 years after vitreoretinal surgery was present in 5 of 16 eyes (31%) with stage 4A, 6 of 10 (60%) with stage 4B, and 0 of 10 with stage 5. Favorable visual acuity (>20/200) was found in 6 of 70 eyes (9%); 5 had stage 4A, and 1 was not classified. Macular attachment was achieved in approximately one-third of eyes with RD and favorable visual acuity in some eyes with stage 4A.

Astigmatism Progression in the Early Treatment for Retinopathy of Prematurity Study to 6 Years of Age

To examine the prevalence of astigmatism (≥ 1.00 diopter [D]) and high astigmatism (≥ 2.00 D) from 6 months after term due date to 6 years of age in preterm children with birth weight of less than 1251 g in whom high-risk prethreshold retinopathy of prematurity (ROP) developed and who participated in the Early Treatment for ROP study. Observational cohort study. Four hundred one infants in whom high-risk prethreshold ROP developed in 1 or both eyes and were randomized to early treatment (ET) versus conventional management (CM). Refractive error was measured by cycloplegic retinoscopy. Eyes were excluded if they underwent additional retinal, glaucoma, or cataract surgery. Eyes were randomized to receive laser photocoagulation at high-risk prethreshold ROP or to receive treatment only if threshold ROP developed. Astigmatism and high astigmatism at each study visit. For both ET and CM eyes, there was a consistent increase in prevalence of astigmatism over time, increasing from 42% at 4 years to 52% by 6 years for the group of ET eyes and from 47% to 54%, respectively, in the CM eyes. There was no statistically significant difference between the slopes (rate of change per month) of the ET and CM eyes for both astigmatism and high astigmatism (P = 0.75). By 6 years of age, astigmatism of 1.00 D or more developed in more than 50% of eyes with high-risk prethreshold ROP, and nearly 25% of such eyes had high astigmatism (≥ 2.00 D). Presence of astigmatism was not influenced by timing of treatment, zone of acute-phase ROP, or presence of plus disease. However, there was a trend toward higher prevalence of astigmatism and high astigmatism in eyes with ROP residua. Most astigmatism was with-the-rule (75°-105°). More eyes with type 2 than type 1 ROP had astigmatism by 6 years. These findings reinforce the need for follow-up eye examinations through early grade school years in infants with high-risk prethreshold ROP. The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Grating Visual Acuity Results in the Early Treatment for Retinopathy of Prematurity Study

To compare grating (resolution) visual acuity at 6 years of age in eyes that received early treatment (ET) for high-risk prethreshold retinopathy of prematurity (ROP) with that in eyes that underwent conventional management (CM). In a randomized clinical trial, infants with bilateral, high-risk prethreshold ROP (n = 317) had one eye undergo ET and the other eye undergo CM, with treatment only if ROP progressed to threshold severity. For asymmetric cases (n = 84), the high-risk prethreshold eye was randomized to ET or CM. Grating visual acuity measured at 6 years of age by masked testers using Teller acuity cards. Monocular grating acuity results were obtained from 317 of 370 surviving children (85.6%). Analysis of grating acuity results for all study participants with high-risk prethreshold ROP showed no statistically significant overall benefit of ET (18.1% vs 22.8% unfavorable outcomes; P = .08). When the 6-year grating acuity results were analyzed according to a clinical algorithm (high-risk types 1 and 2 prethreshold ROP), a benefit was seen in type 1 eyes (16.4% vs 25.2%; P = .004) undergoing ET, but not in type 2 eyes (21.3% vs 15.9%; P = .29). Early treatment of eyes with type 1 ROP improves grating acuity outcomes, but ET for eyes with type 2 ROP does not. APPLICATION TO CLINICAL MEDICINE: Type 1 eyes should be treated early; however, based on acuity results at 6 years of age, type 2 eyes should be cautiously monitored for progression to type 1 ROP. Trial Registration clinicaltrials.gov Identifier: NCT00027222.

Current update on retinopathy of prematurity: screening and treatment

Despite current treatments, retinopathy of prematurity (ROP) remains a major cause of blindness in premature infants and the incidence is increasing with increased survival of infants born at very early gestational ages. This review summarizes the recent literature on ROP with a special focus on recent advances in treatment options as well as newly developed methods for disease screening. Genetic studies find a genetic predisposition to ROP-linking genes in the Wnt pathway with development of severe ROP. With regard to diagnosis, a new screening method has been developed that allows prediction of ROP risk based on postnatal body weight gain alone. Formerly weight gain postnatally in combination with insulin-like growth factor levels was found to predict treatable ROP. New treatment options for severe cases of ROP have been proposed targeting vascular endothelial growth factor (VEGF). Whether anti-VEGF treatment is well tolerated in preterm infants, however, has to be further evaluated in controlled clinical trials. Finally, new reports from the early treatment ROP group suggest that early laser treatment for type 1 but not type 2 high-risk prethreshold ROP improves visual acuity outcomes at 6 years of age. With the increasing survival of premature infants and increased incidence of ROP, it is important to screen for ROP risk and treat at-risk patients in a timely manner to preserve their visual function and reduce complications.

Visual Field Extent at 6 Years of Age in Children Who Had High-Risk Prethreshold Retinopathy of Prematurity

To compare monocular visual field extent at 6 years of age in eyes with high-risk prethreshold retinopathy of prematurity (ROP) randomized to early treatment (ET) with eyes that underwent conventional management (CM) and were treated at threshold or regressed without treatment. Subjects were 370 surviving study participants who developed high-risk prethreshold ROP and were enrolled in the Early Treatment for Retinopathy of Prematurity Study between October 1, 2000, and September 30, 2002. When the participants were 6 years of age, vision testers unaware of ROP status used white-sphere kinetic perimetry to measure visual field extent along the superotemporal, inferotemporal, inferonasal, and superonasal meridians. The extent of the visual field was 0.1° to 3.7° larger in ET eyes when blind eyes were assigned a score of 0°. When data were examined from eyes of participants with 1 sighted ET eye and 1 sighted CM eye, ET eyes showed a small (1.3°-3.1°) reduction, which was statistically significant only along the superonasal meridian (P = .005). In bilaterally sighted children, visual field extent was not significantly reduced for high-risk type 1 ET eyes (-0.9° to 1.8°). However, in ET eyes with high-risk type 2 disease, visual field extent was significantly smaller compared with that of CM eyes (3.6°-8.7° superonasal field [P = .003]; inferonasal field [P < .001]). Early treatment preserves peripheral vision, with only a small reduction of visual field extent. Early treatment for high-risk prethreshold ROP does not adversely affect visual field extent clinically.

Retinopathy of Prematurity in Infants Weighing Less Than 500 Grams at Birth Enrolled in the Early Treatment for Retinopathy of Prematurity Study

To describe patient characteristics, classification, and onset of prethreshold retinopathy of prematurity (ROP), and ocular findings at 6 months corrected age in infants with birth weights <500 g who were enrolled in the Early Treatment for Retinopathy of Prematurity (ETROP) Study. Multicenter randomized clinical trial. Sixty-three infants with birth weights <500 g who developed ROP and were enrolled in the ETROP Study. Infants <1251 g at birth were logged at 26 study centers from October 1, 2000, to September 30, 2002, and underwent examinations for ROP. Infants who developed ROP and whose parents/legal guardians consented were enrolled in the ETROP Study. Infants who developed high-risk prethreshold ROP were randomized; 1 eye was treated early with peripheral retinal ablation and the other eye was managed conventionally, or, in asymmetric cases, the high-risk eye was randomized to early peripheral retinal ablation or conventional management. All eyes reaching prethreshold ROP were examined when infants reached 6 months corrected age. Retinopathy of prematurity incidence, characteristics, and ocular findings among participants. Thirty-four infants reached prethreshold or worse severity in 1 or both eyes. Retinopathy of prematurity was located in zone I in 43.3% of all prethreshold eyes, and plus disease was present in 46.7%. Median postmenstrual age for diagnosis of all prethreshold ROP was 36.1 weeks, but earlier (35.1 weeks) for eyes that developed high-risk prethreshold ROP. In the 27 surviving infants with prethreshold ROP, ophthalmic examination at 6 months corrected age showed a normal posterior pole in 22 (81.5%), a favorable structural outcome with posterior pole abnormalities in 4 (14.8%), and an unfavorable structural outcome (stage 4B) in 1 (3.7%). One infant developed amblyopia, 4 infants developed nystagmus, 4 infants developed strabismus, and 8 infants developed myopia >-5.00 diopters. This is the first report on characteristics of prethreshold ROP in infants with birth weights <500 g. These infants are at high risk for developing prethreshold ROP, although many initially achieve a favorable structural outcome. They are at risk of developing strabismus, nystagmus, high myopia, and abnormal retinal structure and should therefore receive continued long-term follow-up. The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Structural sequelae and refractive outcome 1 year after laser treatment for type 1 prethreshold retinopathy of prematurity in Asian Indian eyes

Aim:The aim was to study the structural sequelae and refractive outcome after laser treatment for Type 1 prethreshold retinopathy of prematurity (ROP) in Asian Indian eyes.Materials and Methods:A retrospective chart review of infants with Type 1 prethreshold ROP (defined according to the Early Treatment for Retinopathy of Prematurity study) undergoing laser treatment at a tertiary center between January 2004 and December 2008 was done. The 1-year outcome of infants was analyzed.Results:Sixty-nine eyes of 36 infants were included. The mean birth weight was 1121.69 ± 254.81 g and the gestational age was 28.99 ± 2.03 weeks. Sixty-five eyes (94.2%) had zone 2 and 4 (5.8%) had zone 1 disease. Forty-four (63.77%) eyes had stage 2 ROP with plus disease and 25 (36.23%) eyes had prethreshold (fewer than five contiguous or eight cumulative clock hours) stage 3 ROP with plus disease. None of the eyes developed retinal structural sequelae. On cycloplegic retinoscopy, 59.4% eyes had nonsignificant hyperopia [spherical equivalent (SE) ≤ 4 D], 14.5% eyes had no refractive error (SE 0 D), 24.7% eyes had low myopia (SE < 5 D), and 1.4% eyes had high myopia (SE > 5.0 D). Eyes developing myopia were associated with a greater number of clock hours of ROP, greater number of laser spots used, and a longer time to disease regression. Two infants (5.6%) had esotropia and one (2.8%) had exotropia.Conclusion:Asian Indian infants treated for Type 1 prethreshold ROP did not develop retinal structural sequelae. Myopia was seen in nearly one-fourth of the eyes.The risk factors for myopia were a greater number of clock hours of ROP, greater number of laser spots, and a longer time to regression of ROP.

Large spot transpupillary thermotherapy: A quicker laser for treatment of high risk prethreshold retinopathy of prematurity - A randomized study

To compare structural and functional outcome and time efficiency between standard spot sized conventional pulsed mode diode laser and continuous mode large spot transpupillary thermotherapy (LS TTT) for treatment of high risk prethreshold retinopathy of prematurity (ROP). Ten eyes of five preterm babies having bilateral symmetrical high risk prethreshold ROP were included in this study. One eye of each baby was randomized to get either standard spot sized conventional pulsed mode diode laser or continuous mode LS TTT. There was no significant difference between structural or functional outcome in either group. The mean time taken for conventional diode laser was 20.07 minutes, while that for LS TTT was 12.3 minutes. LS TTT was 40% more time efficient than the conventional laser. It may be better suited for the very small fragile premature infants as it is quicker than the conventional laser.

Retinopathy of prematurity: Recommendations for screening

Retinopathy of prematurity (ROP) is a disorder of the developing retinal blood vessels of the preterm infant. New recommendations for screening and treatment of ROP have been published in the past few years. Current evidence suggests that screening infants with gestational ages of 30 6/7 weeks or less (regardless of birth weight) and birth weights of 1250 g or less is a strategy with a very small likelihood that an unscreened baby would have treatable ROP. Individual centres may choose to extend birth weight screening criteria to 1500 g. Initial screening should be performed at 31 weeks' postmenstrual age in infants with gestational ages of 26 6/7 weeks or less at birth, and at four weeks' chronological age in infants with gestational ages of 27 weeks or more at birth by an ophthalmologist skilled in the detection of ROP. Follow-up examinations are conducted according to the ophthalmologist's recommendation. Infants with high-risk prethreshold ROP and threshold ROP are referred for retinal ablative therapy. Developing processes for ROP screening, documenting results and communicating results to parents as well as health professionals involved in the infant's care are important responsibilities for all nurseries providing care for preterm infants.

Kein Anstieg von Inzidenz, Therapie- und Erblindungsrate der Retinopathia praematurorum in einem universitären Perinatalzentrum Level 1 - eine prospektive Beobachtungsstudie von 1978 - 2007

There is a controversy over whether the improved survival rate of extremely low birth weight (ELBW; birth weight < 1000 g) and of extremely low gestational age (ELGA; gestational age < 28 weeks) infants has resulted in a higher incidence of severe retinopathy of prematurity (ROP) and induced blindness. We studied the incidence, treatment and the structural outcome of ROP in a Perinatal Centre Level III over a 30-year period in infants < 1500 g birth weight (VLBW = very low birth weight). 1473 VLBW infants, who survived the first 28 days, had ocular examinations from 1978 to 2007. Neonatal and ROP data were collected prospectively. Proliferative ROP, threshold disease and high-risk prethreshold ROP indicated treatment for peripheral retinal ablation in respect to the CRYO-ROP and ETROP studies. Incidence, treatment and structural outcome of ROP were analysed for the periods 1978 - 1992 (P1) and 1993 - 2007 (P2) and for children with BW < 1000 g and > 1000 g. In P 1 43.1 % (n = 87) ELBW infants survived and 82.3 % (n = 372) in P 2, whereas the survival rates of the infants with a BW of 1000 - 1499 g were 74.6 % (n = 453) and 95.1 % (561), respectively. The ROP incidence was decreased from 27.6 % (n = 149) in P 1 to 15.1 % (n = 141) in P 2 significantly (p < 0.003) as well the mean BW 1136.6 ± 211.3 g to a mean BW 822.3 ± 215.3 g and the mean gestational age (GA) 29.3 ± 2.2 weeks and to a mean GA 26.4 ± 2 weeks, respectively (both differences p < 0.001). Also the coagulation rate was significantly decreased from 13 % (n = 70) in P 1 to 6.8 % (n = 63) in P 2 (p = 0.043). The blindness rates (structurally unfavourable outcome of both eyes) of 1.5 % in P 1 and 1.0 % in P 2 were not significantly reduced (p = 0.543). Among the ELBW the number of ROP infants was increased from 39 in P 1 to 117 in P 2 while the ROP incidence decreased from 44.8 % to 31.5 % (p = 0.053) and the ROP-OP rate from 19.5 % to 14.8 % (p = 0.029). Also among the ELGA the number ROP infants was increased from 66 in P 1 to 121 in P 2 but the ROP incidence was reduced from 70.2 % to 27.6 % and the ROP-OP rate from 30.9 % to 13.2 % (both p < 0.001). Inspite of an increase of the number of ELBW/ELGA infants and their survival rate in 1978 - 2007 there is no increase in the incidence of ROP, operations and blindness among the VLBW and VLGA infants.

Final Visual Acuity Results in the Early Treatment for Retinopathy of Prematurity Study

To compare visual acuity at 6 years of age in eyes that received early treatment for high-risk prethreshold retinopathy of prematurity (ROP) with conventionally managed eyes. Infants with symmetrical, high-risk prethreshold ROP (n = 317) had one eye randomized to earlier treatment at high-risk prethreshold disease and the other eye managed conventionally, treated if ROP progressed to threshold severity. For asymmetric cases (n = 84), the high-risk prethreshold eye was randomized to either early treatment or conventional management. The main outcome measure was ETDRS visual acuity measured at 6 years of age by masked testers. Retinal structure was assessed as a secondary outcome. Analysis of all subjects with high-risk prethreshold ROP showed no statistically significant benefit for early treatment (24.3% vs 28.6% [corrected] unfavorable outcome; P = .15). Analysis of 6-year visual acuity results according to the Type 1 and 2 clinical algorithm showed a benefit for Type 1 eyes (25.1% vs 32.8%; P = .02) treated early but not Type 2 eyes (23.6% vs 19.4%; P = .37). Early-treated eyes showed a significantly better structural outcome compared with conventionally managed eyes (8.9% vs 15.2% unfavorable outcome; P < .001), with no greater risk of ocular complications. Early treatment for Type 1 high-risk prethreshold eyes improved visual acuity outcomes at 6 years of age. Early treatment for Type 2 high-risk prethreshold eyes did not. Application to Clinical Practice Type 1 eyes, not Type 2 eyes, should be treated early. These results are particularly important considering that 52% of Type 2 high-risk prethreshold eyes underwent regression of ROP without requiring treatment. Trial Registration clinicaltrials.gov Identifier: NCT00027222.

Progression of Type 2 to Type 1 Retinopathy of Prematurity in the Early Treatment for Retinopathy of Prematurity Study

To examine the frequency and timing of progression from type 2 to type 1 retinopathy of prematurity (ROP) in the Early Treatment for Retinopathy of Prematurity Study. Infants with prethreshold ROP that was no worse than low risk in 1 or both eyes, based on the RM-ROP2 model, were examined every 2 to 4 days for at least 2 weeks. Using the Early Treatment for Retinopathy of Prematurity Study-defined classification of eyes as having type 1 or type 2 prethreshold ROP, we analyzed the time to conversion from type 2 to type 1. Data were analyzed for 1 randomly selected eye for each child. Of 294 eyes at first diagnosis of type 2 ROP, 65 (22.1%) progressed to type 1 (mean [SD] interval, 9.0 [6.6] days; median, 7.0 days). Of 217 eyes with type 2 ROP that had an examination in less than 7 days, 25 (11.5%) were diagnosed with type 1 ROP in less than 7 days. Of 200 eyes that continued to have type 2 disease at the first follow-up examination and underwent a subsequent examination, 24 (15.7% of the 153 eyes that had an examination in <7 days) developed type 1 ROP in less than 7 days. The risk of progression from type 2 to type 1 in less than 7 days was greatest between 33 and 36 weeks' postmenstrual age, regardless of zone of retinopathy. Type 1 ROP can be identified with weekly examinations in most eyes with initial diagnosis of type 2 ROP; a small subset progresses to type 1 in less than 7 days. clinicaltrials.gov Identifier: NCT00027222.

Anterior Segment Complications After Diode Laser Photocoagulation for Prethreshold Retinopathy of Prematurity

To evaluate anterior segment complication rates in eyes treated for prethreshold versus threshold retinopathy of prematurity (ROP) and look for potential risk factors. Retrospective, observational case series study. All patients treated with diode laser for ROP between 1995 and 2007 were identified. A total of 259 eyes of 184 patients were studied, 120 eyes in the pretheshold group and 139 eyes in the threshold group. We compare baseline characteristics, treatment parameters, ocular complications, and structural outcomes after treatment. The main outcome measured was anterior segment complication rates in eyes treated for prethreshold versus threshold ROP and we looked for potential risk factors. Thirteen of 120 eyes treated at prethreshold had anterior segment complications versus 0 of 139 treated at threshold (P < .01). All eyes developed post-laser hyphema, 3 with elevated intraocular pressure. Three eyes developed cataract (2 requiring cataract extraction); 1 required treatment for band keratopathy. The mean postmenstrual age at treatment was significantly different between the prethreshold and threshold groups (36.6 vs 37.9 weeks, P = .03); eyes with anterior segment complications were treated at mean postmenstrual age of 35.7 weeks. No difference was found based on gestationtal age at birth, birth weight, zone, stage, or number of laser spots for eyes with anterior segment complications. Most anterior segment complications (77%) resolved without long-term sequelae. Younger postmenstrual age at laser treatment may be related to an increased risk of anterior segment complications, which should be recognized and managed appropriately.

Technical aspects of laser treatment for acute retinopathy of prematurity under topical anesthesia

Retinopathy of prematurity (ROP) is a significant cause of childhood blindness. The criteria for laser therapy have been revised from threshold ROP to include the earlier stage of high-risk prethreshold ROP. Laser photocoagulation is an established technique for the treatment of ROP. However, the detailed procedure and techniques for laser photocoagulation have not yet been published. Adequate and appropriate laser photocoagulation for ROP is different from the application of lasers in adult retinal vascular diseases, and many ophthalmologists need to be trained in this technique if the outreach of ROP treatment programs is to improve. Laser under topical anesthesia has been practiced in India as a preferred modality especially due to logistics and risks of general anesthesia in these pre-term babies. We discuss the details of the technique as practiced at tertiary care ophthalmic hospitals in India, so that the nuances in treatment parameters and clinical decision-making can be usefully applied to ophthalmic practice. This will ultimately lead to safe and effective treatment delivery in ROP.

Telemedical diagnosis of retinopathy of prematurity: accuracy of expert versus non-expert graders

Background/aimsTo assess accuracy of telemedical retinopathy of prematurity (ROP) diagnosis by trained non-expert graders compared with expert graders.MethodsEye examinations (n=248) from 67 consecutive infants were captured using wide-angle retinal photography...

Severe retinopathy of prematurity in big babies in India: History repeating itself?

To describe the characteristics of babies with severe retinopathy of prematurity (ROP) attending a tertiary referral eye hospital in South India. Data on consecutive preterm infants with severe ROP presenting between July 2002 and October 2007 were retrieved from medical records. Severe ROP was defined as high risk prethreshold disease or worse. 144 babies with severe ROP were divided into two groups: group 1 had high risk prethreshold or threshold ROP while group 2 had stages 4 or 5 ROP. The overall mean gestational age was 30.7 weeks (range 25-35 weeks) and the mean birth weight was 1410 g (range 650-2310 g). Most babies had received unmonitored supplemental oxygen (ascertained through discussion with the treating pediatricians). More bigger and mature babies are developing severe ROP in South India than in industrialized countries. The characteristics of babies affected are similar to those seen during the first epidemic of ROP which occurred during the 1950s in Europe and North America. Guidelines on oxygenation and screening policies should be jointly developed by pediatricians and ophthalmologists to end this epidemic of avoidable blindness in India.

Wide-field digital imaging based telemedicine for screening for acute retinopathy of prematurity (ROP). Six-year results of a multicentre field study

ObjectiveTo report on a 6-year experience with wide-field digital imaging based telemedicine (WFDI telemedicine) to reduce the risk for blindness from retinopathy of prematurity (ROP).MethodsWide-angle digital fundus cameras (RetCam 120, Massie Lab, Pleasanton, CA, USA) were installed in five neonatal intensive care units (NICUs) in Germany. All prematures at risk were screened with WFDI, and the local ophthalmologists were asked to continue binocular indirect ophthalmoscopy (BIO) according to the German guidelines. Image data were coded and transferred to the Reading Centre in Regensburg. Image evaluation and additional BIO of infants with suspected treatment-requiring ROP (STR-ROP i.e. threshold ROP zone II, prethreshold ROP zone I (type-1 ROP according to ETROP), and ROP possibly requiring treatment but not reliably classifiable from the images) were performed by paediatric ophthalmologists at the Reading Centre. ROP was classified following ICROP, ETROP, and revised ICROP criteria. Outcome measures were incidence of clinically relevant ROP (CR-ROP, i.e. any ROP up to mid-peripheral zone III, ≤ stage 3+), sensitivity to detect STR-ROP, and positive predictive value to detect treatment-requiring ROP (TR-ROP).ResultsIn total, 1,222 prematures at risk were screened (mean BW 1395 g, SD ±507 g; mean GA 30 wks, SD ±3 wks). The overall incidence of CR-ROP was 27.6% (71.8% mild = stage 1 to 3 without plus disease, 15.7% prethreshold = type-1 ROP according to ETROP, 12.5% threshold according to ICROP). Zone I disease was present in 3.3%, zone II disease in 76.5%, and zone III disease in 20.2%. According to ETROP, 95 infants were type-1 or type-2 ROP; 67.4% type-1 ROP, and 32.6% type-2 ROP. Of all 1,222 infants, 3.5% received treatment. Following ETROP (not applied in the study), 5.3% would have been treated. The sensitivity for detecting STR-ROP was 100%, and the positive predictive value for TR-ROP 82.4% (28/34) at the time of the first referral (28 infants, ≤ stage 3+ in zone I or II).ConclusionAll TR-ROP was detected in time, showing the potential of our telemedical screening program. The overall incidence of CR-ROP was comparable to ROP incidences reported in other West European countries.

Astigmatism in the Early Treatment for Retinopathy of Prematurity Study: Findings to 3 Years of Age

To examine the prevalence of astigmatism (> or =1.00 diopter [D]) and high astigmatism (> or =2.00 D) at 6 and 9 months corrected age and 2 and 3 years postnatal age, in preterm children with birth weight of less than 1251 g in whom high-risk prethreshold retinopathy of prematurity (ROP) developed and who participated in the Early Treatment for Retinopathy of Prematurity (ETROP) Study. Randomized, controlled clinical trial. Four hundred one infants in whom prethreshold ROP developed in one or both eyes and who were randomized after they were determined to have a high risk (> or =15%) of poor structural outcome without treatment using the Risk Management of Retinopathy of Prematurity (RM-ROP2) program. Refractive error was measured by cycloplegic retinoscopy. Eyes with additional retinal, glaucoma, or cataract surgery were excluded. Eyes were randomized to receive laser photocoagulation at high-risk prethreshold ROP (early treated [ET]) or to be conventionally managed (CM), receiving treatment only if threshold ROP developed. Astigmatism and high astigmatism at each visit. Astigmatism was classified as with-the-rule (WTR; 75 degrees -105 degrees ), against-the-rule (ATR; 0 degrees -15 degrees and 165 degrees -180 degrees ), or oblique (OBL; 16 degrees -74 degrees and 106 degrees -164 degrees ). The prevalence of astigmatism in ET and CM eyes was similar at each test age. For both groups, there was an increase in prevalence of astigmatism from approximately 32% at 6 months to approximately 42% by 3 years, mostly occurring between 6 and 9 months. Among eyes that could be refracted, astigmatism was not influenced by zone of acute-phase ROP, presence of plus disease, or retinal residua of ROP. Eyes with astigmatism and high astigmatism most often had WTR astigmatism. By age 3 years, nearly 43% of eyes treated at high-risk prethreshold ROP developed astigmatism of > or =1.00 D and nearly 20% had astigmatism of > or =2.00 D. Presence of astigmatism was not influenced by timing of treatment of acute-phase ROP or by characteristics of acute-phase or cicatricial ROP. These findings reinforce the need for follow-up eye examinations in infants with high-risk prethreshold ROP. The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Risk factors and prevention of retinopathy of prematurity

The history of retinopathy of prematurity (ROP) gives a prime example of how dangerous the uncontrolled introduction of a new medical treatment--particularly in the field of neonatology--may be. The most important risk factors for the development of ROP are the immaturity of premature infants as well as uncontrolled and/or inadequate treatment with oxygen. In comparison to the fetus, the premature infant is exposed to a nonphysiologically high oxygen concentration. This hyperoxia leads to formation of aggressive oxygen radicals on the one hand and, on the other hand, to temporarily reduced production of growth factors such as vascular endothelial growth factor and erythropoietin, which both play an important role in the pathogenesis of ROP. The most important measure to prevent ROP is restrictive and carefully monitored oxygen treatment. Medical treatment to prevent ROP includes injection of D-penicillamine and retinol, but the available data are still limited, particularly with regard to the long-term effects of this treatment. A higher oxygenation in prethreshold ROP does not lead to recovery of ocular findings, but it increases the incidence of pulmonary complications. A reduction of light intensity in neonatal intensive care units proved not to be efficient for preventing ROP. To avoid blindness, standardized screening of the risk group is needed.

Telemedical Diagnosis of Retinopathy of Prematurity: Intraphysician Agreement between Ophthalmoscopic Examination and Image-Based Interpretation

To evaluate the intraphysician agreement between ophthalmoscopic examination and image-based telemedical interpretation for retinopathy of prematurity (ROP) diagnosis, when performed by the same expert physician grader.Prospective, nonrandomized, comparative study.Sixty-seven consecutive premature infants who underwent ROP examination at a major university medical center whose parents consented for participation.Infants underwent standard dilated ophthalmoscopy by one of two pediatric ophthalmologists, followed by retinal imaging with a commercially available wide-angle fundus camera by a trained neonatal nurse. Study examinations were performed at 31 to 33 weeks postmenstrual age (PMA) and/or 35 to 37 weeks PMA. Images were uploaded to a Web-based telemedicine system developed by the authors. After a 4- to 12-month period, telemedical interpretations were performed in which each physician graded images from infants upon whom he had initially performed ophthalmoscopic examinations. Diagnoses were classified using an ordinal scale: no ROP, mild ROP, type 2 prethreshold ROP, and treatment-requiring ROP.Absolute intraphysician agreement and kappa statistic between ophthalmoscopic examination and telemedical interpretation were calculated by eye. All intraphysician discrepancies were reviewed, and underlying causes were classified by eye as no ROP identified by ophthalmoscopic examination, no ROP identified by telemedical interpretation, discrepancy about presence of zone 1 ROP, discrepancy about presence of plus disease, or other discrepancy in classification of ROP stage.Absolute intraphysician agreement between ophthalmoscopic examination and telemedical interpretation was 86.3%. The kappa statistic for intraphysician agreement between examinations ranged from 0.657 (substantial agreement) for diagnosis of treatment-requiring ROP to 0.854 (near-perfect agreement) for diagnosis of mild or worse ROP. Among 206 eye examinations (103 infant examinations), there were 28 (13.6%) intraphysician discrepancies in diagnosis, 8 of which resulted from uncertainty about presence of zone 1 disease and 4 from uncertainty about presence of plus disease.Intraphysician agreement between ophthalmoscopic examination and telemedical interpretation for ROP was very high. Neither examination modality appeared to have a systematic tendency to overdiagnose or underdiagnose ROP. Diagnosis of zone 1 disease and plus disease were major sources of clinically significant discrepancies.