Treatment of ROP-Related Retinal Detachment
Advanced ROP is Here to Stay: Although retinal ablation is effective in a majority of cases of threshold ROP, 12% of randomized eyes in the ETROP Study detached before 9 months corrected age despite timely peripheral ablation. Advanced ROP remains a significant problem in the United States as well as in developing countries.
Early Treatment for Retinopathy of Prematurity Cooperative Group: Revised Indications for the Treatment of Retinopathy of Prematurity: Results of the Early Treatment for Retinopathy of Prematurity Randomized Trial. Arch Ophthalmol 2003;121:1684–1694.
Natural History of RD in ROP: The advanced stages of ROP are poorly understood. Common misconceptions are that macula-sparing (stage 4A) partial retinal detachments are largely benign, that surgery should be deferred until the macula is detached, that scleral buckle is the preferred retinal reattachment procedure, and that useful vision cannot be obtained in eyes with total (stage 5) detachment.
ROP-related detachments may appear stable in the first few weeks or months after peripheral retinal ablation. Yet neither the stability of partial detachment nor visual acuity is predictable from retinal appearance in infants with ROP. This is particularly true for untreated eyes or those with incomplete peripheral retinal ablation. Visual outcome of eyes with even partial ROP-related retinal detachment is generally poor by 4.5 years of age.
Gilbert WS, Quinn GE, Dobson V, Reynolds J, Hardy RJ, Palmer EA. Partial retinal detachment at 3 months after threshold retinopathy of prematurity. Long-term structural and functional outcome. Multicenter Trial of Cryotherapy for Retinopathy of Prematurity Cooperative Group. Arch Ophthalmol 1996;114:1085-1091
Surgical Approaches: Scleral buckling and vitrectomy have been used to manage stage 4A ROP. Disadvantages of scleral buckling for stage 4A ROP are anisometropic myopia (up to 12 diopters) and the need for a second intervention to transect or remove the buckle so the eye may continue to grow. The tractional forces usually are not effectively addressed with scleral buckling alone. Vitrectomy interrupts the progression of ROP from stage 4A to stages 4B or 5 by directly interrupting transvitreal traction resulting from fibrous proliferation between the ridge and the periphery of the eye, the lens, and the optic nerve. Eyes with more advanced ROP are typically managed with lensectomy, vitrectomy and membrane peeling.
Trese MT. Scleral buckling for retinopathy of prematurity. Ophthalmology 1994;101:23-26
Recchia FM, Capone A Jr. Contemporary understanding and management of retinopathy of prematurity. Retina. 2004 Apr;24(2):283-92.
Goals of surgery: The goal of intervention for ROP-related retinal detachments varies with the severity of detachment.
Stage 4A: The goal for treatment of an extramacular retinal detachment is an undistorted/minimally distorted posterior pole, total retinal reattachment and preservation of the lens and central fixation vision. Data from several centers dedicated to surgery for advanced ROP has shown that, in experienced hands, lens-sparing vitrectomy allows primary retinal reattachment in ~ 90% of eyes with stage 4A ROP.
|Author||Year Published||N||Reattachment Rate|
|Capone, Trese||2001||40 eyes||90%|
|Hubbard et al||2004||25 eyes||84%|
|Moshfeghi et al||2004||32 eyes||94%|
|Lakhanpal et al||2005||32 eyes||85%|
Visual results following vitrectomy for stage 4A can be very rewarding, with mean visions on the order of 20/60 reported in two series.
|Author||Year Published||N||Mean VA|
|Prenner et al||2004||23 eyes||20/58|
|Lakhanpal et al||2006||30 eyes||20/62|
Capone A Jr, Trese MT. Lens-sparing vitreous surgery for tractional stage 4A retinopathy of prematurity retinal detachments. Ophthalmology 2001;108:2068-2070.
Hubbard GB 3rd, Cherwick DH, Burian G. Lens-sparing vitrectomy for stage 4 retinopathy of prematurity. Ophthalmology. 2004 Dec;111(12):2274-7.
Moshfeghi AA, Banach MJ, Salam GA, Ferrone PJ. Lens-sparing vitrectomy for progressive tractional retinal detachments associated with stage 4A retinopathy of prematurity. Arch Ophthalmol. 2004 Dec;122(12):1816-8.
Lakhanpal RR, Sun RL, Albini TA, Holz ER. Anatomic success rate after 3-port lens-sparing vitrectomy in stage 4A or 4B retinopathy of prematurity. Ophthalmology. 2005 Sep;112(9):1569-73.
Prenner JL, Capone A Jr, Trese MT. Visual outcomes after lens-sparing vitrectomy for stage 4A retinopathy of prematurity. Ophthalmology 2004;111:2271-2273.
Lakhanpal RR, Sun RL, Albini TA, Coffee R, Coats DK, Holz ER. Visual outcomes after 3-port lens-sparing vitrectomy in stage 4 retinopathy of prematurity. Arch Ophthalmol. 2006 May;124(5):675-9.
Stages 4B and 5 The functional goal of surgery for stages 4B and 5 is to minimize retinal distortion, prevent total detachment, and to provide ambulatory vision. Reported success rates vary widely, due in part to variability in peripheral retinal ablation status, vascular activity, severity of detachment (open-open vs. closed-closed, for example) and the presence of subretinal blood. Larger series report partial reattachment rates from 22% - 33%, although higher rates have been reported in smaller series.
Stage 5 ROP is a daunting disease. Though it is certainly possible to provide a superior anatomic outcome with surgical intervention (Figure 14A and 14B depict a stage 5 detachment pre-operatively and 3 months post-operatively, respectively), the surgical learning curve is long and steep. Initially successfully attached retinas can detach. Maximal recovery of vision following macula-off retinal detachment and interruption of visual development in infants may take years. A major vision-limiting feature in many such eyes is blood in the subretinal space that is toxic to the outer retina.
Cusick M, Charles MK, Agrón E, Sangiovanni JP, Ferris FL 3rd, Charles S. Anatomical and visual results of vitreoretinal surgery for stage 5 retinopathy of prematurity. Retina. 2006 Sep;26(7):729-35.
Gopal L, Sharma T, Shanmugam M, Badrinath SS, Sharma A, Agraharam SG, Choudhary A. Surgery for stage 5 retinopathy of prematurity: the learning curve and evolving technique. Indian J Ophthalmol. 2000 Jun;48(2):101-6.
Trese MT, Droste PJ. Long-term postoperative results of a consecutive series of stages 4 and 5 retinopathy of prematurity. Ophthalmology. 1998 Jun;105(6):992-7.
El Rayes EN, Vinekar A, Capone A Jr. Three-year anatomic and visual outcomes after vitrectomy for stage 4B retinopathy of prematurity. Retina. 2008 Apr;28(4):568-72.
Reoperation for Advanced ROP: Another consideration is whether eyes with more severe retinal detachment (4B and 5 ROP) merit reoperation in view of the limited visual potential. A common denominator among eyes that are candidates for reoperation is contraction of the posterior hyaloid. In a study employing plasmin enzyme to cleave the vitreoretinal juncture and facilitate posterior hyaloidal removal, 58% of eyes that had previous vitrectomy breaks could be reattached. This cohort had reduced visual results compared to eyes repaired after a single surgical procedure, yet many eyes demonstrated visual function, and progression to phthisis was rare. Reproliferation and glaucoma were the most common postoperative problems.
Wu W, Drenser KA, Lai M, Capone A, Trese MT. Plasmin enzyme-assisted vitrectomy for primary and reoperated eyes with stage 5 retinopathy of prematurity. RETINA 2008;28:S75-S80.