Ординатура / Офтальмология / Английские материалы / Handbook of Pediatric Retinal Disease_Wright, Spiegel, Thompson_2006
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FIGURE 10-16A–C. (A) Threshold ROP: ridge of active fibrovascular proliferation between vascular and avascular retina. (B) Dull white laser burns seen immediately after laser photocoagulation to avascular retina anterior to fibrovascular ridge. (C) Chorioretinal scarring 3 weeks following laser photocoagulation to avascular retina. Note regression of extraretinal fibrovascular proliferation. (Courtesy of Dr. R.R. Ober.)
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FIGURE 10-16A–C. (continued)
CRYO-ROP study and recent laser studies in the treatment of ROP. This idea is currently being tested in the Early Treatment for ROP study, sponsored by the National Eye Institute.
Several studies9,16,73,96,104,105 suggest that laser therapy is as effective as cryotherapy for ROP. The Laser ROP Study group,175 after conducting a meta-analysis of three published, randomized laser ROP trials and one unpublished, nonrandomized ROP trial, came to the same conclusion. The risks of laser versus cryotherapy must be weighed for each individual patient.
MANAGEMENT OF ADVANCED ROP
STOP-ROP Trial
The STOP-ROP multicenter trial studied the use of supplemental therapeutic oxygen late in the hospital course for the treatment of advanced ROP (pre-threshold ROP).78a,111 The hypothesis stated that increasing the oxygen in patients with Stage 3 ROP would down regulate VEGF and cause regression of the neovascularization. The results from the trial showed no significant decrease in poor outcomes. It is important to
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note that the supplemental oxygen therapy was given late in the infant’s hospital stay. Hyperoxia early in the premature infant’s course may be detrimental and increases the risk for
severe ROP.30a,57a,79a
Scleral Buckling
Despite the significant reduction in the incidence of an unfavorable anatomic outcome (posterior pole macular fold or retinal detachment) noted in the CRYO-ROP study, 31.1% of treated eyes progressed to this outcome.28 Reports before completion of the CRYO-ROP study utilizing encircling scleral buckling to reattach the retina in advanced ROP indicated encouraging results.106,107,161,168 However, the optimum timing and modality of surgical intervention for advanced ROP are unclear. A significant advantage of scleral buckling over vitrectomy is in maintaining phakia. Lens-sparing vitrectomy techniques have been developed and may be superior to buckling in some settings.102 Lens-sparing vitrectomy in stage 4 eyes may prevent progression to more advanced stages.16b
Eyes selected for scleral buckling usually are stage 4B eyes or stage 5 eyes with open funnels and minimal vitreous traction. Because the retinal detachment in stage 4A eyes, in particular, may remain stable or even undergo spontaneous reattachment, surgery may be withheld until progression of the detachment into the fovea.62 However, visual outcomes are generally poor despite successful macular reattachment, possibly because of retinal abnormalities as a result of detachment and amblyopia.19a,115 Thus, scleral buckling for stage 4A eyes, before macular detachment, may possibly yield better visual results.171
The technique of scleral buckling involves placement of a 2- to 2.5-mm-wide, 360°circumferential silicone band on episclera. Supplemental buckling elements can be placed to support the area of highest ridge elevation. Peripheral cryoablation may be applied to avascular attached retina if neovascular activity is still present and preoperative treatment is absent or inadequate. Subretinal fluid drainage is performed routinely by some surgeons,62 whereas others115,171 rarely drain, but instead perform anterior chamber paracentesis. The encircling band usually must be divided or removed several months following surgery to prevent retardation of eye growth and reduce the likelihood of extrusion of the band later in life.62,171 The retina usually
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remains attached after buckle removal, and myopia may decrease.19b
Scleral buckling for advanced ROP appears to play a role in reducing progression from stage 4 to stage 5 ROP. Greven and Tasman62 achieved anatomic attachment of the retina in 13 (59%) of 22 eyes with either stages 4B or 5. Of these patients achieving anatomic reattachment with follow-up of 18 months or more, 4 (40%) of 10 had 20/400 or better visual acuity. Noorily et al.115 used scleral buckling alone to successfully reattach 10 of 15 eyes (67%). However, of these cases only 2 (20%) of 10 were able to achieve fix-and-follow acuities. Trese171 reported anatomic retinal reattachment in 12 (70%) of 17 stage 4A eyes, 29 (67%) of 43 stage 4B eyes, and 4 (40%) of 10 stage 5 eyes. This study was not designed to tabulate visual results, but isolated cases yielded visual acuities as good as 20/30.171
As it was estimated in 1991 that 440 to 770 infants would be affected with low vision due to retinal detachments, the exact role of scleral buckling in the management of advanced ROP is a critical issue.111 Because spontaneous retinal reattachment in stage 4 ROP can occur (and rarely stage 5 ROP), it is critical to compare current data with the natural history of retinal detachment as it becomes available. Ideally, a randomized, prospective clinical trial of scleral buckling should be performed to define its role in the management of advanced ROP.
Vitreoretinal Surgery
If vitreous traction is severe, especially if the posterior pole is involved, scleral buckling may not be sufficient to reattach the retina, and vitrectomy may be indicated. Eyes considered for vitrectomy are usually stage 5 eyes, although stage 4B eyes with significant posterior vitreous traction may qualify. Refinements in vitrectomy instrumentation and techniques have been developed that allow meticulous removal of proliferative membranes and reattachment of the retina in some ROP eyes that previous were unsalvageable.
The two major surgical approaches to vitrectomy for advanced ROP are the closedand open-sky techniques. Both techniques offer advantages and disadvantages. Charles18 and others20,37,169,170,176 helped to pioneer the closed technique, which is now the technique used most commonly. Charles18 utilized a two-port technique; one port for right-angle 20-gauge scissors and the other for an infusion needle. He advocated a pars plicata
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entry site because of the usual marked anterior displacement of the retina and the underdeveloped pars plana in the premature infant eye. After lensectomy, the retrolental tissue and epiretinal membranes are removed by scissors delamination. Air is injected at the completion of the dissection, but subretinal fluid is usually not drained because of the risk of retinal break with forceful posterior expansion of the retina. deJuan and Machemer37 use a similar technique, but advocate using a limbal entry site and a three-port technique with suturing of the infusion cannula to the globe. This technique allows both true bimanual membrane removal (forceps and scissors) and posterior dissection with the use of an intraocular fiberoptic light pipe. Trese169,170 reported a two-port system combined with sodium hyaluronate infusion; this allows for a true bimanual technique and the use of a fiberoptic light pipe for posterior dissection.
Hirose et al.72 advocated an open-sky technique, because of some of the inherent difficulties with closed vitrectomy. With this technique, the cornea is removed and stored in tissue culture fluid during surgery. The lens is then extracted intracapsularly with a cryoprobe. The retrolental membranes are then dissected with a microspatula and Vannas scissors and removed from the detached retina in one piece. Hyaluronic acid is used to expand the funnel detachment to facilitate removal of membranes and fibrous tissue. The corneal button is then replaced and sutured with 10-0 running nylon sutures. The open-sky technique allows direct access to the retrolental membranes, affords an excellent view, and allows a true bimanual technique. The potential disadvantages of the open-sky technique include prolonged hypotony, prolonged operating time, limiting posterior dissection, and induced astigmation.
Indications for surgical intervention are not established, but most surgeons recommend operating when vascular activity is regressing or regressed. In general, surgery is performed between 6 and 12 months of age. However, ambulatory vision has been reported in patients operated between 2 and 3 years of age.72 Better results have been attained if the configuration of the retinal detachment funnel was wide anteriorly and wide posteriorly.72,169,170
The anatomic results following either closed-sky or opensky vitrectomy are variable. Hirose et al.72 reported reattachment in 205 (39.2%) of 524 eyes in 338 infants with the open-sky technique during the period 1974 through 1989. Trese170 achieved anatomic retinal attachment in 48% of eyes with stage
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5 ROP. Zilis et al.176 achieved partial attachment in 9 (64%) of 14 eyes with stage 4 ROP and in 38 (31%) of 121 eyes with stage 5 ROP; complete attachment in stage 5 eyes was achieved in 11 eyes (9%). Quinn et al.140 reported a reattachment rate of 28% in 20 of 71 eyes (defined as retinal reattachment of some degree). Charles18 reported a 46% anatomic success rate in 580 patients.
Unfortunately, despite anatomic reattachment following vitrectomy, visual outcome is extremely disappointing.79 These poor visual outcomes are probably a result of ocular and neurological (amblyopia) causes.19a,79,170,176 Hirose et al.72 reported visual results among 82 eyes with attached retinas; vision was 20/200 in 3 eyes, 20/400 in 4 eyes, 20/800 in 9 eyes, 20/1600 in 11 eyes, and 20/3200 in 24 eyes. In 26 eyes, vision was limited to light perception. Trese170 reported 26 of 85 eyes (31%) exhibiting visual behavior (light reaction, follow objects, identify shapes). Zilis et al.176 reported final visual acuity of fix and follow or greater in 6 (43%) of 14 eyes with stage 4 and in 13 eyes (11%) with stage 5 ROP. Quinn et al.140 reported pattern vision (response to low-vision acuity card with 2.2-cm-wide stripes39) in only 2 of 20 eyes with retinal reattachment following vitrectomy. A study by Cherry et al. demonstrated that in 5 eyes with reattached retinas after stage 5 ROP, the ERG was nonrecordable. Thus, persistent retinal dysfunction limits vision even after retinal surgery for severe ROP.19a
In selected cases, lens-sparing vitreous surgery may be performed in stage 4B or stage 5 eyes16b,102; this offers several potential advantages over standard vitrectomy methods, in which lensectomy is performed, regarding development of the visual system following surgery, such as better optical rehabilitation and shorter periods of postoperative visual deprivation. Finally, vitreous surgery may be beneficial in selected eyes of older patients with advanced ROP in eliminating media opacities and for uncovering areas of functional, attached retina.11 The visualevoked potential and contact B-scan ultrasound of the globe may be useful in predicting which older patients may benefit from vitreous surgery. A randomized clinical trial is needed.
FUTURE DIRECTIONS IN CLINICAL RESEARCH FOR ROP
Although great strides have been made in treating the active stages of ROP, the cicatricial sequelae, for example, retinal detachment, retinal folds, and retrolental membranes, are best
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prevented rather than managed after they occur because of severe limitations in successful anatomic and visual outcomes. Therefore, clinical research regarding any of the aspects of prenatal, perinatal, or neonatal care that could result in lower rates of premature birth is vital. In addition, knowledge gained about the basic mechanisms of control of neovascular retinopathies and vitreoretinal disorders may be applied clinically to aid in the reduction or elimination of the cicatricial sequelae of ROP. Some day, perhaps control can be achieved pharmacologically.
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