A review of treatment for retinopathy of prematurity

Abstract

Introduction: Retinopathy of prematurity (ROP) is a leading cause of childhood blindness worldwide.

Areas covered: Recent methods to identify and manage treatment-warranted vascularly active ROP are recognized and being compared to standard care by laser treatment in prospective large-scale clinical studies. Pharmacologic anti-angiogenic (anti-VEGF) treatment has changed the natural history of vascularly active ROP by reducing stage 3 intravitreal neovascularization and extending physiologic retinal vascularization in many infants. Tractional retinal detachments in stage 4 ROP after treatment with anti-VEGF agents show additional fibrovascular complexity compared to eyes treated with laser only. We review current management and outcomes for vascularly active and fibrovascular retinal detachment in ROP (stages 3, 4, 5 ROP), highlighting the evidence from recent clinical studies. Included are technical details important in surgery for retinal detachment in ROP. Literature searches were employed through PubMed.

Expert opinion: Methods in pediatric imaging, safer pharmacologic treatments, and surgical techniques continue to advance to improve future ROP outcomes.

Keywords: angiogenesis; laser; lens-sparing; retinal detachment; retinopathy of prematurity (ROP); scleral buckle; stage 4 or 5 ROP; surgical outcomes; vascular endothelial growth factor inhibitors (anti-VEGF); vitrectomy.

Figure 1.

Treatment-Warranted and Retinal Detachment in ROP Retcam images of A. Type 1 ROP in zone II, stage 3+. B. Type 1 ROP in zone I- posterior zone II, stage 3+. C. Stage 4 ROP with a combination of exudative and tractional elements. Images by Melissa Chandler, CRA, OCT-C

Figure 2.

Infant and Adult Eye Artist drawing depicting estimated differences in A. Infant eye – Safe entry into the vitreous is through pars plicata, which is less than 1 mm wide; lens is more spherical; vitreous is about 1 mL, and B. Adult eye – Safe entry into vitreous is through pars plana – 3.5–4.0 mm posterior to the limbus; vitreous is ~4 mL. Drawn by James Gilman, CRA, FOPS

Figure 3.

Tractional Forces in Stage 4 ROP Addressed in Lens-sparing Vitrectomy A. Artist drawing of lens-sparing vitrectomy demonstrating vitreoretinal contractile forces from (1) ridge to ora serrata and anterior retina, (2) ridge and lens, (3) circumferentially from ridge to ridge, (4) ridge to the optic nerve, and (5) over the optic nerve. After anti-VEGF treatment, additional tractional components occur over the optic nerve and in the mid peripheral retina where previous ridge occurred. Drawn by James Gilman, CRA, FOPS B. Optical coherence tomogram (OCT) through ridge of stage 4 ROP showing retinal detachment and vitreoretinal tractional components. Image obtained by Glen Jenkins, CRA, OCT-C

Figure 4.

Fibrovascular Contraction after Anti-VEGF in Former APROP A. Montage of mid-peripheral vitreoretinal traction in region of previous stage 3 ROP at posterior vascular/avascular junction prior to extension of physiologic vascularization after anti-VEGF treatment. Laser marks noted in periphery. B. OCT through superotemporal ridge shows evidence of tractional retinal detachment and retinoschisis. Images by Glen Jenkins, CRA, OCT-C.

Figure 4.

Meridional External Element Artist drawing of an external element to support peripheral traction causing a localized retinal fold and reduce further macula dragging. Drawn by James Gilman, CRA, FOPS