Eyeworld

EW INTERNATIONAL 54 December 2015 by Matt Young and Gloria D. Gamat EyeWorld Contributing Writers Operating successfully in stage 4A looks promising, stage 4B looks possible, and stage 5 begins to be addressed O ne of the most common causes of blindness in children, retinopathy of prematurity (ROP), contin- ues to challenge ophthal- mologists, especially in developing countries. Scientific literature is fortunate- ly strengthening the path to success, especially in India. In Western India, a team of vitreoretinal surgeons from PBMA'S H.V. Desai Eye Hospital, Pune, India (a tertiary care eye hospital in the state of Maharashtra), recently made headlines for their work on the successful surgical management of stage 4B ROP and have published the results in various international peer-reviewed journals. Their latest findings were published in the May 2015 issue of Graefe's Archive for Clin- ical and Experimental Ophthalmology. "Timely successful vitreoretinal surgery followed up by periodic visual assessment with best possi- ble refraction showed significant improvement in vision in the long term at or beyond 80 weeks," the team reported. "The role of gradual restoration of retinal architecture and malleability of the infant's brain are the probable causes of this long- term development in vision." ROP status in India According to various studies report- ed in the literature, the incidence of ROP in the population at risk in India varies between 22.3% and 44.7%. However, ROP affects bigger babies (heavier and more mature) in India. Therefore, the country's cut-off criteria for ROP screening are gestational age (GA) ≤34 weeks and/ or birth weight (BW) ≤2,000 grams. "In a clinical audit of the 1,174 babies screened by our hospital a few years ago, the incidence of ROP was 29.8% while 9.10% had severe ROP; most of the babies coming to us for surgery are those who do not have access to screening, hence are typically treatment naive," said Salil S. Gadkari, FRCS, head of vitreoret- ina surgery and director of research, PBMA'S H.V. Desai Eye Hospital. Lens sparing vitrectomy (LSV) as described by Michael Trese, MD, re- mains the standard of care for stage 4 ROP, Dr. Gadkari noted. "However, the introduction of better vitrectomy platforms with immaculately controlled fluidics and small gauge cutters introduced through trocar cannula systems have improved the surgical outcomes and reduced the morbidity," he added. In terms of performing LSV, Dr. Gadkari and his colleagues had a great experience recently work- ing on the 27-gauge system on the Constellation platform (Alcon, Fort Worth, Texas). "Good maneuverability despite the small gauge, valved cannulae, and very controlled cutting of the membranes while working in close proximity to the detached retina improved the ease and safety of surgery," he said. While stage 4A is a more grat- ifying stage in ROP to intervene in, with better postoperative visual outcomes, according to Dr. Gadkari, most of the studies published from the center in Pune, India, pertain to patients with stage 4B disease. "It's important to realize that ROP is not a static disease but one in a state of progression," he said. "Hence, the decision to intervene surgically is decided by not only the stage but by the direction we see [ROP] going." There is no substitute for surgery once vitreoretinal traction begins to distort retinal anatomy, Dr. Gadkari said. "While the traction is typically described in the temporal periph- ery, it can occur in any clock hour, especially when you deal with smaller babies with immature retina all around at birth; treatment too makes a difference in the presen- tation of vitreoretinal traction, bringing it more posterior due to peripheral laser," he said. Critical factors for ROP management success In clinical practice worldwide, screening infants at risk of ROP within the first two weeks of birth can result in early detection and treatment of this condition; this is the keystone in the management of ROP. On top of that, Dr. Gadkari said, the strict monitoring of oxygen in the NICU is the key to preven- tion of the disease itself. However, both are challenges in developing countries. In India's case, according to Dr. Gadkari, a wide variation exists between the best centers located in cities and declining standards of care as one moves into the countryside, a situation common among most developing countries worldwide. "Timely administration of laser and/or anti-VEGF agents can prevent progression of the disease; needless to say that systemic status of the patient can swing the same ophthalmic situation differently," Dr. Gadkari said. PBMA'S H.V. Desai Eye Hospital runs an ROP screening outreach program visiting 48 NICUs in and around the district in addition to of- fering training to ophthalmologists for screening, Dr. Gadkari said. "It is important here to stress the role of RetCam-based [Clarity Medical Systems, Pleasanton, Calif.] screening to ensure quality control; image acquisition is done by techni- cians and reporting by trained retina specialists using telemedicine," he added. Karnataka is the only state in India to be engaged in supporting such a program at a government level, through KIDROP (Karnataka Internet Assisted Diagnosis of Successful surgical management of advanced stage ROP in India A dvanced retinopathy of prematurity is a devastating complication that haunts fragile preterm newborns. The groundbreaking work by the skilled surgeons at PBMA's H.V. Desai Eye Hospital is a ray of hope for the future of infants with otherwise blinding ROP. Using the latest technology in vitrectomy, this incredibly delicate surgery was shown to restore visual potential and importantly change the lives of individuals. John A. Vukich, MD, international editor The May 2015 cover of Graefe's Archive for Clinical and Experimental Ophthalmology showed the surgical recovery of one of the eyes included in the article. Source: Salil S. Gadkari, FRCS International outlook

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