MIAMI — A shortage of ophthalmologists willing or able to screen for retinopathy of prematurity is hampering implementation of updated guidelines released last year, Dr. Roberto Warman said at a pediatric update sponsored by Miami Children's Hospital.
“There is a major manpower crisis in management of retinopathy of prematurity. Because of liability concerns, very few ophthalmologists are interested in screening these babies and even fewer are willing to treat,” said Dr. Warman, director of the division of ophthalmology at the hospital.
The revised screening and treatment guidelines contain some “important changes,” Dr. Warman said. “The most important issue is gestational age.” All premature infants born at a gestation of 32 weeks or less or weighing 1,500 g or less should be screened. Select infants born with a birth weight from 1,500 g to 2,000 g and an unstable clinical course also should be screened.
Timing is important because retinopathy of prematurity (ROP) is a progressive condition if left unchecked. The guideline authors wrote, “Effective care now requires that at-risk infants receive carefully timed retinal examinations by an ophthalmologist who is experienced in the examination of preterm infants for ROP and that all pediatricians who care for these at-risk preterm infants be aware of this timing” (Pediatrics 2006;117:572–6; erratum Pediatrics 2006;118:1324).
Target the first exam for 4–6 weeks of age, Dr. Warman said. This will be approximately 31 weeks since last menstruation for infants born at 22–27 weeks of gestation. The guidelines recommend a topical anesthetic to reduce discomfort, pupil dilation, and then binocular indirect ophthalmoscopy to detect ROP.
“We have a small window of opportunity to treat,” Dr. Warman said. If the initial exam unequivocally demonstrates that the retina is fully vascularized in both eyes, then a second examination is not required.
Otherwise, the guidelines recommend close follow-up—the timing and frequency of which is determined by the degree and location of initial retinal findings. The guidelines were updated by the American Academy of Pediatrics, the American Academy of Ophthalmology, and the American Association for Pediatric Ophthalmology and Strabismus in February 2006.
ROP occurs only in immature retinal tissue. The condition can progress to tractional retinal detachment and functional or complete blindness. “We are trying to prevent a patient with scars in the retina. Although the retina is not detached, scars can cause serious visual impairment,” Dr. Warman said.
A marked decrease in the incidence of adverse outcomes is possible with advancements in peripheral retinal ablative therapy using laser photocoagulation, the authors noted.
Tight oxygen level monitoring in the hours after birth is another recommendation, Dr. Warman said.
“Still the best thing we can do is keep oxygen levels within guidelines in the neonatal intensive care unit and have great nursing to monitor well.”
Retinal detachment surgery is now performed during active disease, Dr. Warman said. “But this creates a problem because very few specialists are willing and able to do this surgery in these tiny patients.”
Direct injection of vascular endothelial growth factors is being performed in other countries “with great results,” Dr. Warman said. This area of research is “very exciting,” he added. A study sponsored by the National Institutes of Health to assess the safety and efficacy of this therapy is scheduled to start soon.
Timing is important because ROP is a progressive condition if left unchecked, as seen in this Stage 3 disease.
Here is an example of ROP with scarring in the posterior pole with cicatricial changes and with dragging vessels. PHOTOS COURTESY DR. ROBERTO WARMAN