Ординатура / Офтальмология / Английские материалы / Textbook of Vitreoretinal Diseases and Surgery_Natarajan, Hussain_2008
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Textbook of Vitreoretinal Diseases and Surgery
FIGURE 18-7: Shows preand postoperative anatomical outcome in stage 4A (Top) and stage 4B (bottom)
SURGICAL MANAGEMENT
Although retinal ablation is effective in a majority of cases of threshold ROP, few cases still progress to retinal detachment. Detachment is often seen associated with areas of incomplete peripheral ablation or in eyes with inexorably progressive disease. Fibrous proliferation and contraction of neovacularization along the ridge and onto the overlying vitreous precede tractional retinal detachment. Condensation of vitreous into sheets and strands act as a scaffold for further extension of the fibrovascular tissue. Traction along the retinal surface and contraction of posterior hyaloid face contribute to distortion of the posterior pole architecture. The specific tasks of surgical intervention for ROP related retinal detachments vary depending on the tractional components causing retinal detachment. Lens sparing vitrectomy is the preferred treatment for posterior disease and most forms of tractional progressive stage 4 ROP, where as scleral buckle may be beneficial in rhegmatogenous detachments and those where the main tractional component is the sole tractional vector located near or anterior to the equator.
The goal for extramacular retinal detachment (stage 4A ROP) is an undistorted or minimally distorted posterior pole, total reattachment, and preservation of the lens and central fixation vision.
218 Lenssparingvitrectomy45 andscleralbuckle46 havebeenusedtomanagestage4AROP.Thedisadvantage of scleral buckle for stage 4A ROP are the dramatic anisometropic myopia 47 and the second intervention
Update on Retinopathy of Prematurity: Concept and Management
FIGURE 18-8: Shows preoperative (top) and postoperative (bottom) anatomical outcome after surgery for stage V ROP
required for removal of the buckle, so that the eye continues to grow. All tractional forces cannot be alleviated with scleral buckling alone. Lens sparing vitreous surgery can interrupt progression of ROP from stage 4A to stages 4B or 5 by directly addressing transvitreous traction resulting from fibrous proliferation. The functional goal for stage 4B eyes is ambulatory vision. The surgical goal for stage 5 ROP is to reattach as much as retina as possible. Form vision can be preserved following vitrectomy for stage 5 ROP. Figures 18-7 and 18-8 show preand postoperative anatomical outcome after Stage 5 ROP. Table 18-4 shows the surgical outcome results of ROP.
Nowadays anatomical and visual gain is possible with surgery even in advanced cases of ROP. Before contemplating surgery, a surgeon must remember the following:
• A good understanding of the patho-anatomy of ROP affected eyes (Figures 18-9A to D) |
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• USG is necessary delineating the funnel configuration in severely affected eyes |
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• The neonatologist’s description of the case and support is essential |
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Pre-anaesthetic consultation is a must |
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Extensive and careful counseling of the parents must be done. |
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Textbook of Vitreoretinal Diseases and Surgery
FIGURES 18-9A TO D: Demonstrate the surgical pathoanatomy. 1. Ridge to ora serrata; 2. Ridge to Ridge; 3. Ridge to ant. Hyaloid / equator of lens; 4a. Stalk to ant. Hyaloid; 4b.Stalk to posterior surface of lens; 4c.Stalk to retina laterally
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Update on Retinopathy of Prematurity: Concept and Management
TABLE 18-4: Surgical results of ROP
Authors |
Stage 4a |
Stage 4b |
Stage 5 |
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RV Azad et al |
(100%) 5/5 fully |
(50%) 3/6 posterior |
(38.5%) 15/39 posterior |
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attached |
pole attached |
pole attached |
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Lakhanpal et al1 |
100% |
92.1% |
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Hubbard G et al2 |
84% |
92% |
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Fuchino Y et al 3 |
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59% |
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Kono T et al 4 |
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47% |
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1Lakhanpal et al. Ophthalmology. 2005 Sep;112(9):1569-73;2Hubbard G et al. Ophthalmology. 2004 Dec;111(12):2274-7 ; 3Fuchino Y et al. Am J Ophthalmol. 1995 Sep;120(3):308-16; 4Kono T et al. Jpn J Ophthalmol 2000 Nov-Dec;44(6):661-7
COUNSELING
Counseling of parents is of utmost importance.
•Sympathetic approach should be maintained
•Anesthetic risks need to be explained
•Poor functional outcome
•Need for regular follow ups should be stressed
•Realistic expectations
New Considerations in ROP
•It needs to be understood that multiple factors cause ROP—the differential affliction of twin/ triplets/quadruplets is a good example of this. The genetic background of parents and the nature of prenatal, natal and postnatal injuries are highly relevant (Citations).
•Newer developments in management have taken place with the arrival of anti-VEGF drugs.
•Long term effect of ROP in premature infants needs to be considered and proper visual rehabilitation provided for refractive error, amblyopia, etc.
Conclusions
The critical factor to ensure better outcomes are to screen early, follow-up weekly or more closely, watch out for Plus and/or new vessels and treat such eyes vigorously for full retinal ablation of avascular retina . ROP is a continuous race against time with a very small window of opportunity of 7-10 days where optimum treatment outcomes with least complications can be achieved.
ROP affects a large number of preterm babies in our country who will become blind if the disease is not treated. Around 1.68 million babies are at risk of developing ROP and 7% will eventually become blind without treatment. ROP is not a blinding disease if detected early and treated promptly with laser. Spontaneous regression is the rule in 80-90% cases and only 7-10% of cases develop blinding ROP. ROP does not occur at birth. It is good to follow 30 days rule after birth when first screening should be done. Surgical interventions offer the potential for preservation of vision for eyes with ROP related retinal detachment; especially if it is directed prior to macular distortion. Even in advanced stages surgery is possible and can provide useful vision. In selected cases of stage
V useful navigation vision is possible. In future pharmacological stabilization of aberrant angiogenesis 221 may be one approach.
Textbook of Vitreoretinal Diseases and Surgery
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Seiberth V, Iinderakamo O. Risk factors in retinopathy of prematurity. A multivariate stastical analysis. |
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Early Treatment for Retinopathy of Prematurity Cooperative Group. Revised indications for the treatment of |
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retinopathy of prematurity: results of the early Treatment for Retinopathy of Prematurity Randomised trial. Arch |
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Ng YK, Fielder AR, Shaw D, et al. Epidemiology of retinopathy of prematurity. Lancet 1988; 2:1235-8. |
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Schaffer DB, Palmer EA, Plotsky DF, et al. Prognostic factors in the natural course of retinopathy of prematurity. |
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Ophthalmology 1993; 100:230-7. |
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Cryotherapy for Retinopathy of Prematurity Cooperative Group. Multicenter trial of cryotherapy for retinopathy |
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of prematurity: natural history ROP: at 5 years in premature infants with birth weight less than1251 grams. Arch |
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Ophthalmol 2002; 120:595-9. |
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Kivlin JD, Biglan AW, Gordan Ra, et al. Early retinal vessel development and iris vessel dilatation as factors in |
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retinopathy of prematurity. Arch Ophthalmol 1996; 114:150-4. |
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The STOP-ROP Multicenter Study Group. Supplemental therapeutic oxygen for prethreshold retinopathy of |
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prematurity (STOP ROP), a randomized, controlled trial I : Pediatrics 2000;105(2):295-310. |
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Higgins RD, Mendelson AL, DeFeo Mj, et al. Antenatal dexamethasoneand decreased severity of retinopathy of |
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prematurity. Arch Ophthalmol 1998;116:659-671. |
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Halliday HL, Ehrenkranz RA. Delayed (> 3 weeks) postnatal corticosteroid for chronic lung disease in preterm |
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infants (Cochrane review).cochrane database Syst Rev 2003;1:CD001146. |
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Cuculich PS, Delozier KA, Mellen BG, et al. Postnatal dexamethasone treatmentand retinopathy of prematurity in |
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very low-birth weight neonates. Biol Neonate 2001; 79:9-14. |
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Jalali S, Anand R, Kumar H, et al. Programme planning and screening Strategy in Retinopathy of Prematurity. |
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Update on Retinopathy of Prematurity: Concept and Management
31.Reynolds JD, Dobson V, Quinn GE, et al. Cryo-ROP and Light ROP Cooperative Study Groups. Evidence-based screening criteria for retinopathy of prematurity: Natural history data from the Cryo-ROP and Light-ROP studies. Arch Ophthalmol 2002; 120: 1470-6.
32.Report of a Joint Working Party of the Royal College of Ophthalmologists and British Association of Perinatal Medicine. Retinopathy of Prematurity: Guidelines for Screening and Treatment. Early Hum Dev 1996; 46:239-58.
33.American Academy of Pediatrics, American association for Pediatric Ophthalmology and Strabismus, American Academy of ophthalmology. Screening examination of premature infants for retinopathy of prematurity. Pediatrics 2001;108:809-11.
34.Cryotherapy for Retinopathy of Prematurity Co-operative Group. Multicentre trial of cryotherapy for retinopathy of prematurity. Three and a half-year outcome-structure and function.Arch Ophthalmol 1993; 111: 339-44.
35.White JE, Repka MX. Randomised comparison of diode laser photocoagulation versus cryotherapy for threshold retinopathy of prematurity: 3-year outcome. J Paediatr Ophthalmol Strabismus 1997; 34:83-7.
36.Hunter DO, Repka MX. Diode laser photocoagulation for threshold ROP. Ophthalmology 1993; 100:238-44.
37.Cryotherapy for Retinopathy of Prematurity Co-operative Group. Multicentre trial of cryotherapy for retinopathy of prematurity. Snellen visual acuity and structural outcome at five and a half years after randomisation. Arch Ophthalmol 1996; 114: 417-24.
38.Seiberth V, Linderkamp O, Vardarli I. Transscleral Vs transpupillary diode laser photocoagulation for the treatment of Threshold retinopathy of prematurity. Arch Ophthalmol 1997;115:1270-5.
39.Davis AR, Jackson H, Trew D, et al. Transscleral diode laser in the treatment of retinopathy of prematurity. Eye 1999;13:571-6.
40.Dobson V, Quinn GE, Summers CG, et al. Effect of acute-phase retinopathy of prematurity on grating acuity development in the very low birth infants. The cryotherapy for retinopathy of prematurity Co-operative Group. Invest Ophthalmal Vis Sci 1994; 35:4236-44.
41.Cryotherapy for retinopathy of prematurity. Co-operative group. 15 years outcomes following threshold retinopathy of prematurity. Arch Ophthalmal 2005; 123: 311–8.
42.Ling C S, Fleck B W, Wright E, et al. Diode laser treatment for retinopathy of prematurity: structural and functional outcome. Br J Ophthalmol 1995; 79: 637-41.
43.Clark DI, Hero M. Indirect diode laser treatment for stage 3 retinopathy of prematurity. Eye 1994; 8: 423-6.
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Textbook of Vitreoretinal Diseases and Surgery
Introduction
Rhegmatogenous retinal detachment (RRD) is an uncommon entity in pediatric population. Though uncommon, it is important to identify and treat these children with retinal detachment as early as possible because of few important reasons. First, though the prognosis is not as good as in adult rhegmatogenous retinal detachment, almost 40% of treated children show some degree of visual improvement.1 This definitely has a profound long term effect on future development of the child in all aspects—physical, mental, social and economical.
Although the incidence is low, there is a high chance of bilateral involvement. In some cases, RRD can be part of a syndrome complex which may have serious systemic involvement. All this makes early diagnosis and prompt management of pediatric RRD cases very important.
Because of inability of children to exactly assess their own vision, difficulty in examination and relatively poor prognosis, identification and management of these young patients presents a formidable challengetovitreoretinalsurgeon.Italsodemandsagreatdealofparentaldeterminationanddedication.
Epidemiology
Because of low incidence, there are very few reported case series of RRD in children. In general, RRD has an annual incidence of 12.4 cases per 1,00,000 population.2 RRD in paediatric population (birth to 18 years) has been estimated to be only 3.2% to 5.6% of total RRD patients—it means approximately 0.38 to 0.69 cases per 1,00,000 population3 and retinal detachment (RD) surgeries performed in children constitute approximately 3.1% of total RD surgeries.4
AGE AND SEX DISTRIBUTION
Most childhood RRD present at and around 10 years of age.3, 5-7 Boys out number girls by approximately 4 times in pediatric RRD population. In a consecutive series of 111 eyes of juvenile RRD in Indian population, Nagpal et al found 77.47% cases belonged to boys.8 The high incidence of trauma in boys correlates well to overall high incidence of RRD in boys—trauma being one of the commonest etiological factors in childhood RRD.
PECULIAR FEATURES OF PEDIATRIC RRD
It is difficult for children to exactly express the nature and duration of their symptoms .Hence, children with RRD often present late and hence with more advanced disease (Figure 19-1). Because most of them are not very cooperative, examiner has to rely more upon physical findings than history. Also visual assessment in children—both preand postoperative is a challenging job. Examination has to be very thorough and yet quick enough, so the child does not lose cooperation. Examination also demands great deal of patience as well as clinical acumen on examiners part. Many a times, surgeon has to consider examination under general anesthesia for complete evaluation and confirmation of diagnosis. Because of frequent need of multiple surgeries and relatively poor prognosis, management of these children demands a great deal of financial and emotional investment from the society as well as the parents.
Etiopathogenesis
226 Rhegmatogenous retinal detachment is characterized by presence of full thickness retinal break (‘Rhegma’ in Greek means break). The precursors for this are liquefied vitreous and tractional forces
Pediatric Retinal Detachment
FIGURE 19-1: RRD in 8-year-old boy. Thin retina and extensive subretinal gliosis indicates long standing RD
that can produce and maintain a retinal break through which fluid gains access to sub retinal space.5 The most common predisposing factors for retinal detachment in children include abnormal vitreoretinal adhesions in association with posterior vitreous detachment (PVD), conditions like high myopia and retinoschisis, previous history of ocular (most commonly cataract) surgery, trauma and various vitreoretinopathies like Stickler’s syndrome and Marfan’s syndrome. These conditions predispose an eye for development of RRD due to very high incidence of associated vitreous detachment and retinal breaks.5
Weinberg et al6 found that, each case of pediatric RRD can be categorized into any of the following four broad groups.
1.Structural ocular abnormalities—56%
2.Trauma—63%
3.Previous ophthalmic surgery—51%
4.Preceeding uveitis—13%
They found that every childhood RRD has at least one of the above risk factors while more than
50% cases had 2 or more risk factors.
Fivgas et al1 has found high myopia (> 4D) and previous ocular surgery (34% incidence for each) as the two most important risk factors of RRD development in children.
In general, there are four most important risk factors which alone or in combination are present in majority cases of RRD in children.
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High myopia |
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Previous history of ocular surgery |
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3. |
Previous history of trauma |
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Congenital or developmental eye anomalies. |
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