Retinopathy Of Prematurity Screening Examinations Research Articles

Analgesia for retinopathy of prematurity screening: A systematic review.

Background and AimsPremature neonates require regular ophthalmological examination, generally indirect ophthalmoscopy, to screen for retinopathy of prematurity (ROP). Conventional analgesia is provided with topical anesthetic eyedrops and oral sugar solution, but neonates still experience significant pain. Here, the literature base was examined to evaluate the usefulness of other pharmacological analgesics.Materials and MethodsA systematic review was undertaken, adhering to a PROSPERO preregistered protocol in accordance with PRISMA guidelines (identifier CRD42022302459). Electronic databases were searched for primary research articles on pharmacological pain interventions used for ROP screening in neonates. The primary outcome measure was pain scores recorded using validated pain scoring tools, with and without pharmacological interventions in neonates during eye examination. For analysis, studies were separated into two categories: topical anesthesia and alternative pharmacological treatments.ResultsEleven studies met the inclusion criteria. Topical analgesia, oral paracetamol, and intranasal fentanyl were found to be effective in reducing the pain of eye examination. Oral morphine and inhaled nitrous oxide had no significant effect on premature infant pain profile (PIPP) scores during indirect ophthalmoscopy.DiscussionIn addition to topical anesthesia, premedication with oral paracetamol is recommended during screening examination for ROP. The routine use of fentanyl is not recommended due to the risk of potential side effects. Non‐pharmacological measures, such as sweet oral solutions and comfort techniques should also be employed. Further research is required to determine whether the use of nitrous oxide has a role, and to develop a safe and effective analgesic strategy to fully ameliorate the pain of ROP screening.

Real-World Visual Outcomes of Laser and Anti-VEGF Treatments for Retinopathy of Prematurity

To characterize visual outcomes in children screened for retinopathy of prematurity (ROP). Retrospective, interventional case series. Patients who received ROP screening examinations at UCLA Medical Centers and were followed with outpatient eye examinations at Stein Eye Institute and/or Doheny Eye Institute (Los Angeles, California) were included. Data were collected on birth characteristics, worst type of ROP, and ROP treatment. Adverse visual outcomes included myopia, strabismus, amblyopia, macular dragging, and optic atrophy. Snellen visual acuity was reported for children 4 years and older. A total of 175 infants (350 eyes) were included for analysis (mean gestational age=28.2 weeks and birth weight=1059 g) from a screening population of 539 infants (1078 eyes, 32.4% follow-up) over a 9-year period. Fifteen eyes received primary anti-vascular endothelial growth factor (anti-VEGF) therapy, whereas 59 eyes received primary laser therapy. Primary anti-VEGF therapy, as compared with primary laser treatment, was associated with a decreased incidence of amblyopia (adjusted odds ratio [aOR]=0.6-0.86, P < .0001) after controlling for gestational age and birth weight. The rates of optic atrophy (P=.79), strabismus (P=.98), and myopia (P=.93) were not different between anti-VEGF and laser treatment groups. Infants receiving anti-VEGF therapy had more posterior disease than laser-treated infants (P=.041). Infants receiving laser therapy were more likely to have severe myopia (aOR=1.02-1.3, P=.023), amblyopia (aOR=1.12-1.61, P=.002), and optic atrophy (aOR=1.01-1.32, P=.045) than infants not treated. These findings add to the advantages of anti-VEGF treatment compared with primary laser treatment, particularly in posterior ROP.

Retinopathy of Prematurity Screening Examination and Changes in Vital Signs.

Dilation and examination during retinopathy of prematurity (ROP) screening can cause systemic complications and even life-threatening adverse events (AEs). The main objective of this study is to assess the prevalence and significance of AEs and changes in vital signs during ROP screenings, and to correlate birth weight, gestational age, and length of exam as possible predictors of these changes. This is a prospective, observational study that includes 1,360 screening exams from 680 premature infants in two neonatal intensive care units. Systolic blood pressure, diastolic blood pressure, heart rate, respiratory rate, and oxygen saturation were monitored from the time that dilating drops were administered until 4 hours after the examination was completed. Any clinical deterioration or complication was documented. Of 1,360 infant screening exams, 153 (11%) screening exams resulted in at least one change in vital sign that alerted the monitor. There was one serious AE requiring bag valve mask resuscitation 30 minutes after dilating drops were placed. Gestational age, birth weight, and length of ROP exam were not significant predictors of AEs. There were statistically significant changes when comparing pre- and post-vital signs following dilation and funduscopy exam. Although ROP screening exams are essential for at-risk neonates, mydriatic drops and retinal exams can result in changes to vital signs and AEs. It is important to closely monitor neonates during these examinations. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:458-463.].

Prophylactic laser versus continued surveillance after initial bevacizumab treatment for retinopathy of prematurity

Guidelines on managing infants after initial anti-vascular endothelial growth factor (VEGF) treatment (eg, bevacizumab) for retinopathy of prematurity (ROP) are limited. We found that following initial bevacizumab treatment for ROP, prophylactically lasering infant eyes before hospital discharge reduced the number and duration of outpatient ROP screening examinations compared with following infants, per current United States (US) ROP screening guidelines.

Foveal Differentiation and Inner Retinal Displacement Are Arrested in Extremely Premature Infants.

PurposeChildren with a history of prematurity often have poorly developed foveae but when during development foveal differences arise. We hypothesize that the course of foveal development is altered from the time of preterm birth.MethodsEyes of 102 preterm infants undergoing retinopathy of prematurity screening examinations in the STudy of Eye imaging in Premature infantS (BabySTEPS) (NCT02887157) were serially imaged between 30 and 42 weeks postmenstrual age (PMA) using handheld optical coherence tomography systems. Total retinal thickness, inner retinal layer (IRL) thickness, and outer retinal layer (ORL) thickness were measured at the foveal center and parafovea. Foveal put depth, IRL thickness, and ORL thickness were compared between infants born at different gestational ages using mixed effects models.ResultsFoveal pit depth and IRL thickness were inversely related to gestational age; on average, the most premature infants had the thickest IRL and shallowest pits at all PMAs. Differences were evident by 30 weeks PMA and persisted through 42 weeks PMA. The foveal pits of the most premature infants did not progressively deepen, and the IRLs did not continue to thin with increasing chronological age.ConclusionsFoveation in extremely preterm infants is arrested from the earliest observed ages and fails to progress through term equivalent age. The developmental displacement of the IRL from the foveal center into the parafovea does not occur normally after preterm birth. These observations suggest that foveal hypoplasia seen in children with history of prematurity is due to disturbances in foveal development that manifest within weeks of birth.

Early angiographic signs of retinopathy of prematurity requiring treatment.

Fluorescein angiography (FA) has been a pivotal tool to study the pathophysiology of retinopathy of prematurity (ROP) in vivo. We examined the course of ROP using FA in order to assess the predictive value of angiographic features. This is an observational retrospective cohort multi-center study of eyes screened for ROP with binocular indirect ophthalmoscope and with FA. All infants undergoing screening examination for ROP who had retinal vasculature limited to Zone I and posterior Zone II vascularization underwent FA between 31 and 34 weeks postmenstrual age. RetCam fundus imaging and video digital fluorescein angiography were performed in the neonatal intensive care units. Masked grading of the FA images was retrospectively conducted by two ROP expert ophthalmologists. Ten criteria that describe retinovascular and choroidal features on FA were used to assess their predictive value for development of treatment-requiring ROP. A total of 98 eyes of 56 patients were included for this study. FAs of eyes of premature infants show a wide range of features either at the junction between the vascular and avascular retina and posteriorly to that. Among the angiographic features evaluated, leakage, shunts and hyperfluorescent lesions at the junction between vascular and avascular zone were predictive of the development of treatment-requiring ROP (p < 0.05), but findings in the posterior vascularized retina were not. FA can add to our understanding of the evolution of vascular abnormalities in the course of ROP and can help predict which eyes will go on to treatment.

Should parents be present during screening examinations for retinopathy of prematurity?

Purpose:To investigate whether parents should be present during screening examinations for retinopathy of prematurity (ROP) by investigating the anxiety levels of parents using two different approaches.Methods:This cross-sectional and two-center study was carried out with the parents at the time of the first ROP screening examination of their premature infants. At one center, the parents accompanied the infants during the ROP examination (Group 1), and in the other center, they did not (Group 2). Anxiety levels were assessed with the State-Trait Anxiety Inventory (STAI), which consists of the State Anxiety (STAI-S) and Trait Anxiety (STAI-T) subscales and a visual analog scale (VAS).Results:A total of 147 parents of 127 infants were included in the study. STAI-T and -S levels were 40.5 ± 8 and 37.9 ± 7.5, respectively, in Group 1 and 39.6 ± 8.1 and 39.4 ± 9.1 in Group 2 before the examination. There were no statistically significant differences in terms of these values between the two groups (P > 0.05). The state anxiety levels increased by an average of 1.7 ± 8 in Group 1 and reached 39.6 ± 10.1 after the examination. In Group 2, these levels decreased by an average of − 2.7 ± 7.5 points to a score of 36.4 ± 10.3. This difference was found to be statistically significant (P = 0.001). A similar pattern was observed in the evaluation of the VAS data.Conclusion:As a preliminary opinion, it may be more appropriate for parents to not participate in screening examinations, but single-center controlled studies are required to confirm the results.

Prenatal intrauterine growth restriction and risk of retinopathy of prematurity

Low birthweight and decreased postnatal weight gain are known predictors of worse retinopathy of prematurity (ROP) but the role of prenatal growth patterns in ROP remains inconclusive. To distinguish small for gestational age (SGA) from intrauterine growth restriction (IUGR) as independent predictors of ROP, we performed a retrospective cohort study of patients who received ROP screening examinations at a level IV neonatal intensive care unit over a 7-year period. Data on IUGR and SGA status, worst stage of and need for treatment for ROP, and postnatal growth was obtained. 343 infants were included for analysis (mean gestational age = 28.6 weeks and birth weight = 1138.2 g). IUGR infants were more likely to have a worse stage of ROP and treatment-requiring ROP (both p < 0.0001) compared to non-IUGR infants. IUGR infants were more likely to be older at worst stage of ROP (p < 0.0001) and to develop postnatal growth failure (p = 0.01) than non-IUGR infants. Independent of postnatal growth failure status, IUGR infants had a 4–5 × increased risk of needing ROP treatment (p < 0.001) compared to non-IUGR infants. SGA versus appropriate for gestational age infants did not demonstrate differences in retinopathy outcomes, age at worst ROP stage, or postnatal growth failure. These findings emphasize the importance of prenatal growth on ROP development.

Retinopathy of prematurity in a tertiary facility: an initial report of a screening programme

Background: Retinopathy of prematurity (ROP) screening in Nigeria is at a nascent stage and at the moment there are no National guidelines for ROP screening in Nigeria. Thus it is desirable for screening programs to report findings amongst screened preterm infants in order to facilitate the development of national ROP screening criteria and guidelines. The aim of this report is to describe the frequency, severity and risk factors for retinopathy of prematurity (ROP) among preterm and very low-birth-weight babies screened within the first year of initiating an ROP screening program at a Nigerian tertiary facility.&#x0D; Methods: A cross-sectional study of infants born at less than 34 weeks gestational age; or with birth weight less than 1500g between May 2016 and May 2017. ROP screening examinations were performed by ophthalmologists with the use of an indirect ophthalmoscope, after pupillary dilation, in collaboration with the neonatology team. Information on gestational age at birth, birth weight, oxygen therapy and presence of other risk factors were recorded and analyzed.&#x0D; Results: A total of 74 infants were screened during the period. There were 36 (48.6%) males. Mean gestational age at birth was 29.6 (±2.35) weeks. Mean birth weight was 1.26 (±0.27) kg with a range of 800 to 1950g. ROP was detected in 9 (12.2%) infants. Two (22.2%) of these had Threshold ROP. There was no significant difference between the mean birth weight and mean gestational age of the infants who had ROP compared to those without ROP. The two infants with Threshold ROP were treated with intravitreal Bevazicumab and had regression of ROP.&#x0D; Conclusion: Retinopathy of prematurity was diagnosed in at risk infants in this facility. There is, therefore, a need to establish ROP screening programs in all neonatal units across the country. In addition, established programs need to evaluate their screening criteria with a view towards developing country-specific screening guidelines.&#x0D; Keywords: Retinopathy; Prematurity; Preterm; Neonates; Nigeria; Africa

Variability in Plus Disease Identified Using a Deep Learning-Based Retinopathy of Prematurity Severity Scale

Retinopathy of prematurity is a leading cause of childhood blindness worldwide, but clinical diagnosis is subjective, which leads to treatment differences. Our goal was to determine objective differences in the diagnosis of plus disease between clinicians using an automated retinopathy of prematurity (ROP) vascular severity score. This retrospective cohort study used data from the Imaging and Informatics in ROP Consortium, which comprises 8 tertiary care centers in North America. Fundus photographs of all infants undergoing ROP screening examinations between July 1, 2011, and December 31, 2016, were obtained. Infants meeting ROP screening criteria who were diagnosed with plus disease and treatment initiated by an examining physician based on ophthalmoscopic examination results. An ROP severity score (1-9) was generated for each image using a deep learning (DL) algorithm. The mean, median, and range of ROP vascular severity scores overall and for each examiner when the diagnosis of plus disease was made. A total of 5255 clinical examinations in 871 babies were analyzed. Of these, 168 eyes were diagnosed with plus disease by 11 different examiners and were included in the study. The mean ± standard deviation vascular severity score for patients diagnosed with plus disease was 7.4 ± 1.9, median was 8.5 (interquartile range, 5.8-8.9), and range was 1.1 to 9.0. Within some examiners, variability in the level of vascular severity diagnosed as plus disease was present, and 1 examiner routinely diagnosed plus disease in patients with less severe disease than the other examiners (P < 0.01). We observed variability both between and within examiners in the diagnosis of plus disease using DL. Prospective evaluation of clinical trial data using an objective measurement of vascular severity may help to define better the minimum necessary level of vascular severity for the diagnosis of plus disease or how other clinical features such as zone, stage, and extent of peripheral disease ought to be incorporated in treatment decisions.

Assessment of the G-ROP study criteria for predicting retinopathy of prematurity: results from a tertiary centre in Turkey.

The postnatal growth and retinopathy of prematurity (G-ROP) study has proposed a new model for retinopathy of prematurity (ROP) prediction based on gestational age, birth weight and postnatal weight gain. The purpose of the current study is to assess the efficacy of the G-ROP modelfor predicting ROP among a Turkish cohort of premature infants. Records of infants who underwent ROP screening examinations between 2012 and 2019 were reviewed retrospectively. Infants with a documented ROP outcome and regular body weight measurements until day 40 of life were included. The G-ROP model was applied to the study group. The outcome measures were sensitivity and specificity of the model for detecting any stage ROP and treated ROP. A total of 242 infants were included. The G-ROP model identified 168 infants to be screened for ROP. The sensitivity was 88.3% for detecting any stage ROP and 91.2% for treated ROP. The specificity for any stage ROP and treated ROP was 51.7% and 34.1%, respectively. The incorporation of bronchopulmonary dysplasia to the model increased the sensitivity to 100% with 22.7% reduction in the number of screened infants. The G-ROP model is a simple and effective method for ROP prediction. However, in the current cohort, a small number of infants requiring treatment would be missed if G-ROP criteria were applied. The model may be modified with addition of bronchopulmonary dysplasia to detect all treatment requiring cases. Prospective studies among larger groups are necessary to assess the applicability of the modified model.

Retinal findings in neonates with congenital diaphragmatic hernia and extracorporeal membrane oxygenation

PurposeTo evaluate the prevalence of retinal pathologies in neonates with congenital diaphragmatic hernia (CDH) receiving extracorporeal membrane oxygenation (ECMO) therapy. MethodsThis retrospective study included consecutive infants that received ECMO therapy for CDH at our hospital between 2012 and 2018. Retinal changes were assessed by mydriatic indirect funduscopy. Recorded patient parameters include gestational age (GA), type of delivery, duration of ECMO therapy, duration of inhalative oxygen supplementation, and postmenstrual age at fundus examination. ResultsOf 54 infants that were treated by ECMO therapy for CDH during the study period, 27 were medically stable enough to receive funduscopic examination and were thus included in the study. Mean GA of these 27 children was 37.3 weeks (range 33.1–40.6) and mean duration of inhalative oxygen supplementation was 12.8 weeks (range 2.7–56.4). Retinal changes were observed in 3 neonates (11.1%). These included multiple midperipheral blot intraretinal hemorrhages in 5 eyes of 3 children and retinopathy of prematurity (ROP) in 2 eyes (stage 3 and stage 2, respectively, without plus disease) of 1 child (GA 35.0 weeks; duration of inhalative oxygen supplementation, 11.9 weeks). In all infants, retinal changes regressed without therapeutic intervention. ConclusionsNeonates treated with ECMO due to CDH may exhibit retinal hemorrhages, however usually without need for intervention. Prematurely born infants receiving ECMO may develop ROP and thus require ROP screening examinations. Type of studyPrognosis study. Level of evidenceLevel III.

Retinopathy of prematurity risk factors: Does human milk prevent retinopathy of prematurity?

Akyüz-Ünsal Aİ, Key Ö, Güler D, Bekmez S, Sagus M, Akcan AB, Kurt-Omurlu İ, Anık A, Oruç-Dündar S, Türkmen M. Retinopathy of prematurity risk factors: Does human milk prevent retinopathy of prematurity? Turk J Pediatr 2019; 61: 13-19. The aim of this study was to investigate the risk factors for Retinopathy of Prematurity (ROP) development and the potential effect of human breast milk among these factors. For this purpose, infants admitted to a tertiary referral clinic for ROP screening and treatment between April 2013 and May 2015, were included in this retrospective study. The demographic data, accompanying diseases, previous surgery, type of feeding and duration of human breast milk intake were recorded. According to the ROP screening examination results, infants were divided into two groups as those with ROP (infants at any stage of ROP) and those without ROP. Relationship between the risk factors and ROP were evaluated. The comparison of 221 infants without ROP and 99 infants with ROP; revealed that gestational age at birth, birth weight, mechanical ventilation support, bronchopulmonary and cardiac diseases, hydrocephaly, any previous surgery, infections, steroid treatment percentages were high and human breast milk intake percentage was low among infants with ROP. Mean breast feeding time for infants with ROP (3.81 ± 2.33 month) was shorter than the infants without ROP (5.51 ± 1.43 month) (p < 0.001). In logistic regression analysis, the duration of breast feeding was inversely related with ROP (OR 0.744; 95% CI 0.621-0.891; p < 0,001). These results suggest that gestational age at birth and accompanying diseases are the main risk factors for the development of ROP. As the duration of the breast feeding of the infants without ROP was longer than the infants with ROP; breast feeding may have a preventive effect on ROP development.

Analgesic efficacy and safety of morphine in the Procedural Pain in Premature Infants (Poppi) study: randomised placebo-controlled trial

SummaryBackgroundInfant pain has immediate and long-term effects but is undertreated because of a paucity of evidence-based analgesics. Although morphine is often used to sedate ventilated infants, its analgesic efficacy is unclear. We aimed to establish whether oral morphine could provide effective and safe analgesia in non-ventilated premature infants for acute procedural pain.MethodsIn this single-centre masked trial, 31 infants at the John Radcliffe Hospital, Oxford, UK, were randomly allocated using a web-based facility with a minimisation algorithm to either 100 μg/kg oral morphine sulphate or placebo 1 h before a clinically required heel lance and retinopathy of prematurity screening examination, on the same occasion. Eligible infants were born prematurely at less than 32 weeks' gestation or with a birthweight lower than 1501 g and had a gestational age of 34–42 weeks at the time of the study. The co-primary outcome measures were the Premature Infant Pain Profile–Revised (PIPP-R) score after retinopathy of prematurity screening and the magnitude of noxious-evoked brain activity after heel lancing. Secondary outcome measures assessed physiological stability and safety. This trial is registered with the European Clinical Trials Database (number 2014-003237-25).FindingsBetween Oct 30, 2016, and Nov 17, 2017, 15 infants were randomly allocated to morphine and 16 to placebo; one infant assigned placebo was withdrawn from the study before monitoring began. The predefined stopping boundary was crossed, and trial recruitment stopped because of profound respiratory adverse effects of morphine without suggestion of analgesic efficacy. None of the co-primary outcome measures differed significantly between groups. PIPP-R score after retinopathy of prematurity screening was mean 11·1 (SD 3·2) with morphine and 10·5 (3·4) with placebo (mean difference 0·5, 95% CI −2·0 to 3·0; p=0·66). Noxious-evoked brain activity after heel lancing was median 0·99 (IQR 0·40–1·56) with morphine and 0·75 (0·33–1·22) with placebo (median difference 0·25, 95% CI −0·16 to 0·80; p=0·25).InterpretationAdministration of oral morphine (100 μg/kg) to non-ventilated premature infants has the potential for harm without analgesic efficacy. We do not recommend oral morphine for retinopathy of prematurity screening and strongly advise caution if considering its use for other acute painful procedures in non-ventilated premature infants.FundingWellcome Trust and National Institute for Health Research.

Systemic Effects of Optos versus Indirect Ophthalmoscopy for Retinopathy of Prematurity Screening

Many regions of the world have a relative shortage of ophthalmologists trained and willing to screen for retinopathy of prematurity (ROP).1 As a result, many regions have turned to retinal imaging and telemedicine.2 Optos ultrawide-field retinal imaging (Optos PLC, Dunfermline, UK) has recently been used as a screening tool for ROP.3,4 However, there are no data available regarding the systemic effects or stress induced by a ROP screening examination with the Optos. In this prospective, randomized, crossover study, we determined the effects of Optos ultrawide-field screening examination on cardiorespiratory indices, as a measure of stress, and compared the stress response with that of conventional binocular indirect ophthalmoscopy (BIO) examination.

Vitreous Bands Identified by Handheld Spectral-Domain Optical Coherence Tomography Among Premature Infants

Handheld spectral-domain optical coherence tomography (SD-OCT) can provide insights into the complex interactions occurring at the vitreoretinal interface in retinopathy of prematurity (ROP) to enhance our understanding of ROP pathology. To characterize vitreous bands in premature infants with use of handheld SD-OCT. Prospective cohort study conducted from July 7, 2015, to February 28, 2017, at 2 university-based neonatal intensive care units. Seventy-three premature infants who required routine ROP screening examination were recruited. Informed consent was obtained from all legal guardians. Trained graders who were masked to the clinical assessment analyzed each SD-OCT scan of the right eye for vitreoretinal findings. A third trained grader mediated disagreements. Associations between the presence of vitreous bands in premature infants with ROP diagnoses and the presence of other vitreoretinal SD-OCT findings were investigated. Of the 73 infants recruited, 6 infants' parents withdrew their children from the study, and 2 infants were too hemodynamically unstable for imaging, leaving a total of 65 participants. Of these, 32 (49%) were female, 36 (55%) were white, 10 (15%) were Hispanic, 3 (5%) were Native American, 4 (6%) were African American, 4 (7%) were Asian/Pacific Islander, and 8 (12%) were other. The mean (SD) gestational age was 28 (2.7) weeks, the mean (SD) birth weight was 997 g (286 g), and the mean (SD) postmenstrual age at imaging was 34 (3) weeks (mean [SD] total of 3 [2] imaging sessions). Comparing the 24 infants (37%) who had a right eye vitreous band at any time with the 41 (63%) who did not, no difference in mean birth weight, gestational age, postmenstrual age at imaging, sex, or race/ethnicity was identified. No associations with ROP stage (eg, in 6 [25%] infants with vitreous bands vs 4 [9.8%] in those without; P = .23), presence of plus disease (2 [8%] vs 2 [5%]; P = .84), or type 1 ROP (3 [12%] vs 3 [7%]; P = .66) were identified. Vitreous bands were associated with epiretinal membrane detected on SD-OCT (P = .001) with an odds ratio of 9.4 (95% CI, 2.8-31.3) in 15 [62%] infants with vitreous bands vs 6 [15%] in those without. Vitreous bands were also associated with cystoid macular edema (in 15 [62%] infants with vitreous bands vs 1 [27%] in those without; P = .005) with an odds ratio of 4.5 (95% CI, 1.5-13.3). In this study, the development of vitreous bands was associated with both cystoid macular edema and epiretinal membrane. These findings suggest a tractional pathogenesis to these entities among premature infants. This study did not find a direct association between vitreous bands and severe ROP. Additional study is needed to determine whether vitreous bands represent subclinical hyaloidal organization leading to retinal detachment in advanced ROP.

Spectral-Domain OCT Findings of Retinal Vascular–Avascular Junction in Infants with Retinopathy of Prematurity

Bedside examination of premature infants at risk for retinopathy of prematurity (ROP) is predominantly performed with ophthalmoscopic en face viewing of the retina. While postmortem retinal microstructures have been studied at the vascular-avascular junction, a critical location for pathogenesis of ROP, to date this has not been possible in vivo. Here we present bedside, non-sedated in vivo cross-sectional imaging and analysis of retinal microstructures at the vascular-avascular junction in infants with ROP using handheld spectral-domain optical coherence tomography (SDOCT). Prospective observational study. Eleven preterm infants consented for research imaging during ROP screening examinations. We imaged the vascular-avascular junction in the temporal retina using a SDOCT system (Envisu, Bioptigen Inc., NC) in 18 eyes from 11 preterm infants with zone I or II, stage 0 through 4 ROP. B-scan and en face images were analyzed and compared to historical light micrographs. SDOCT morphology at the vascular-avascular junction. Multiple bedside SDOCT findings at the vascular-avascular junction were comparable to historic light micrographs: thickened inner retinal ridge structure in stage 2 ROP was comparable to thickened vanguard and rear guard cells in micrographs; vascular tufts on the posterior retinal surface in stage 2 ROP, broad arcs of neovascularization above the retina in stage 3 ROP, and splitting of inner retinal layers into clefts on either side of neovascularization mimicked findings of historic light micrographs. A unique findings was thickening of the avascular inner retinal band adjacent to neovascularization. On SDOCT imaging over several weeks, neovascularization and retinal clefts diminished after intravitreal bevacizumab therapy. Retinal morphology at the vascular-avascular junction imaged with handheld SDOCT is consistent with known histopathology, and provide the advantage of monitoring change in vivo over time. These unique findings provide new insights into preterm retinal neurovascular development in ROP.

Screening for retinopathy of prematurity: Trends over the past 5 years in two German university hospitals

The number of preterm births in Germany has been increasing continuously over the past decades. Retinopathy of prematurity (ROP) is amajor complication of preterm birth and one of the leading causes of blindness in children. This study analyzes the development of the incidence of ROP over the past 5 years at two German university hospitals, utilizing data from ROP screening examinations. We assessed all children born in the years 2012-2016 who were included in the ROP screening program at two German university hospitals according to the criteria of the German ROP screening guidelines. Parameters such as gestational age, birth weight, ROP stage and zone, and need for therapeutic intervention were assessed. We analyzed the data of 863 children who had undergone atotal of 4117 screening examinations. The number of children included in the screening program per study year increased continuously over the study period by atotal of 43.1% (137 in 2012, 196 in 2016). Likewise, the number of screening examinations per year increased by 58.4% (608 in 2012, 963 in 2016). Overall, 27.5% of screened infants were diagnosed with ROP of any stage and 2.5% required treatment for ROP. The number of children diagnosed with ROP of any stage per year increased by 100.0% (32 in 2012, 64 in 2016). Mean gestational age (29.0 ± 3.0weeks) and mean birth weight (1192 ± 513 g) remained stable over the study period. Screening data for ROP from two German university hospitals demonstrates asignificant increase in both the number of screened infants and the number of infants affected by ROP over the past 5 years.

Evaluating a Portable, Noncontact Fundus Camera for Retinopathy of Prematurity Screening by Nonophthalmologist Health Care Workers

To evaluate (1) the feasibility of non-ophthalmologist healthcare workers (HCWs) to obtain images of sufficient quality for retinopathy of prematurity (ROP) screening using a FDA-approved portable, non-contact, narrow-field fundus camera (i.e., Pictor™), and (2) the accuracy of grading these images to identify infants who developed treatment-warranted (type 1) ROP. Prospective cohort study. Infants undergoing routine ROP screening examinations (i.e. birth weight ≤1500 grams and/or gestational age ≤30 weeks or selected infants with a birth weight of 1500-2000g or gestational age >30 weeks and an unstable clinical course). We prospectively recruited infants undergoing ROP screening examinations at a community hospital. On the same day an ophthalmologist examined them, a trained HCW imaged their retinas using the non-contact camera. Two masked ROP experts graded these images remotely. We calculated both the percentage of gradable images (i.e. having at least 3 quadrants with sufficient image quality), as well as the accuracy of identifying infants who developed type 1 ROP. Percentage of gradable images and the sensitivity and specificity of each grader for identifying infants with type 1 ROP by grading for the presence of pre-plus or plus disease. Ninety-nine infants were included. Overall, 92.4% and 94.2% of all infant imaging sessions were considered gradable by graders 1 and 2, respectively. Amongst gradable images, the sensitivity of both graders for identifying type 1 ROP by grading for the presence of pre-plus or plus disease was 100% (95% confidence interval (CI): 95-100%) and the specificity 91% (95% CI: 83-95%) for grader 1 and 93% (95% CI: 86-96%) for grader 2. It was highly feasible for trained HCWs to obtain digital retinal images of sufficient quality for ROP screening using a non-contact fundus camera. By grading for the presence of pre-plus or plus disease, graders identified infants who developed type 1 ROP with high sensitivity and specificity. The use of portable, non-contact retinal cameras by trained HCWs could increase our workforce in ROP screening and identify infants needing an indirect ophthalmoscopy examination by an ophthalmologist.

RETINOPATHY OF PREMATURITY PRACTICES: A NATIONAL SURVEY OF CANADIAN NEONATAL INTENSIVE CARE UNITS

BACKGROUND: Retinopathy of prematurity (ROP) accounts for significant morbidity in preterm infants. Early detection and treatment helps prevent adverse sequelae. The objective of this study was to survey the current screening inclusion criteria, treatment options, supportive care and post screening events for ROP in tertiary level Neonatal Intensive Care Units (NICU’s) in Canada. OBJECTIVES: The objective of this study was to survey the current screening inclusion criteria, treatment options, supportive care and post screening events for ROP in tertiary level Neonatal Intensive Care Units (NICUs) in Canada. DESIGN/METHODS: The study was designed as a prospective observational study where a survey was sent out to all 29 level three NICU’s across Canada. Following ethics exemption from the local research ethics board, a cross sectional survey was distributed across all level three NICU’s in Canada from September 1 to December 30, 2015. The tool was designed to elicit information on the screening practices for detection of ROP in tertiary NICU’s. In addition, information on the ROP screening processes, including the timing of screening and grounds for screening infants outside the criteria were collected. The survey also explored the screening process from an organizational standpoint in terms of the person responsible for initiating the screening processes, choice of mydriatics as well as organizing follow up. The practice and use of supportive measures during ROP screening and treatment options provided were also captured.The primary outcome was defined as adherence to the current CPS/COS or AAP guidelines. Specifically, guideline adherence was assessed for the following criteria: inclusion of an infant for ROP screening, age at which first ROP exam was initiated, circumstances where infants outside the screening criteria were deemed eligible for inclusion in the screening process and appropriate follow up processes. Secondary outcomes were defined as the supportive practices in use during the ROP screening examination. This includes the type and dose of mydriatics used, and measures to reduce photophobia and discomfort after ROP related therapeutic interventions. We also assessed healthcare system perspectives related to ROP screening and treatment. This was determined by the availability of dedicated personnel to coordinate the exam, pre-printed order sheets for medication and equipment required, measures to ensure appropriate follow up, use of RetCam (Clarity Medical Systems INC.), ROP treatment options (Anti vascular endothelial growth factor [anti-VEGF] and/or Laser) and treatment location. RESULTS: Twenty two level three nurseries responded to the survey (76 % response rate). Ten different ROP screening inclusion criteria were found to be in use with significant variation in gestational age and birth weight criteria. Reasons for screening babies outside any given unit’s inclusion criteria included unstable clinical course or high oxygen demand as decided by the attending neonatologist. Many other national variations also exist regarding the supportive, procedural and treatment protocols surrounding ROP screening such as Ret Cam use, use of mydriatics and preprinted order sheets. From a treatment standpoint, 50 percent of the centers preferred laser while the remaing 50 percent prefereed Anti VEGF(Vascular Endothelial Growth factor) CONCLUSION: Despite national guidelines, there exists significant variation in ROP screening inclusion criteria practices among neonatal units in Canada. For the many other aspects of ROP screening and treatment, for which there are no national guidelines there also exists significant variations in practice patterns. There is therefore an urgent need for better evidence based screening guidelines as well as a need to standardize supportive measures surrounding ROP screening and treatment, followed by efforts to encourage national uptake of these recommendations.