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Original Investigation | Clinical Sciences

Visual Outcomes After Early Vitreous Surgery for Aggressive Posterior Retinopathy of Prematurity

Noriyuki Azuma, MD, PhD1; Makiko Ito, MD1; Tadashi Yokoi, MD, PhD1; Yuri Nakayama, MD1; Sachiko Nishina, MD, PhD1
[+] Author Affiliations
1Department of Ophthalmology and Laboratory of Cell Biology, National Center for Child Health and Development, Tokyo, Japan
JAMA Ophthalmol. 2013;131(10):1309-1313. doi:10.1001/jamaophthalmol.2013.4148.
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Importance  Aggressive posterior retinopathy of prematurity (AP-ROP) rapidly progresses to retinal detachment despite application of photocoagulation. Early vitreous surgery might achieve prompt regression of neovascular activity and a high incidence of retinal reattachment.

Objective  To evaluate visual outcomes in eyes with AP-ROP after early vitreous surgery.

Design  Retrospective nonrandomized study of patients who underwent early vitreous surgery with lensectomy when retinal detachment developed despite photocoagulation. Aphakic correction with spectacles or contact lenses and the use of orthoptics were continued postoperatively. The best-corrected visual acuity (VA) was measured in eyes with a total retinal reattachment using the preferential looking technique in patients ranging in age from 8 months to no more than 3 years and a VA chart with Landolt rings or pictures for older children. The VA findings were converted to Snellen lines.

Setting  Institutional ophthalmology practice.

Participants  Of the 103 eyes (57 patients) that underwent early vitreous surgery for AP-ROP, the VA was measured in 58 (32 patients) at a corrected age ranging from 8 months to 4 years.

Interventions  Early vitreous surgery and VA measurement using the preferential looking technique and a VA chart.

Main Outcomes and Measures  Postoperative VA, ROP stage, extent of fibrovascular tissue (FT) growth, and laterality of the eyes that underwent surgery.

Results  The VAs ranged from 20/2000 to 20/40. The VA may not be related to the preoperative ROP stage 4A or 4B but may depend on the preoperative extent of FT growth. In 39 of 58 eyes (67.2%), the FT had not reached the vitreous base preoperatively, and foveal formation occurred postoperatively with nearly age-appropriate VA (range, 20/250 to 20/40). In 17 of 58 eyes (29.3%), the FT had reached the vitreous base, and no fovea formed (VA range, 20/2000 to 20/250). Two of 58 eyes (3.4%) had deprivation amblyopia with a VA worse than 20/1600. The difference in VA between both eyes of patients who underwent bilateral vitreous surgery depended on ROP progression; patients who underwent a unilateral procedure in which the fellow eyes with ROP stabilized after photocoagulation tended to have poor vision because of deprivation amblyopia.

Conclusions and Relevance  Early vitreous surgery may be beneficial for AP-ROP and should be performed before the FT reaches the vitreous base to facilitate foveal formation and good VA outcomes. The roles of photocoagulation, vitreous surgery, and anti–vascular endothelial growth factor therapy in the treatment of AP-ROP should be investigated in randomized trials regarding efficacy, safety, convenience, and cost.

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Figure 1.
Preoperative and Postoperative Fundus Images of Aggressive Posterior Retinopathy of Prematurity (AP-ROP)

Early vitreous surgery was performed in the left eyes of patients 1 (top row) and 2 (bottom row) with different fibrovascular tissue (FT) growth. A and F, Preoperative drawings. B and G, Preoperative photographs. C and H, Preoperative fluorescein angiograms (FA). D and I, Postoperative photographs. E and J, Postoperative FA. The gestational age of patient 1 was 25 weeks, with a birth weight of 798 g; of patient 2, 26 weeks and 897 g, respectively. Preoperative images in patient 1 show minimal FT present in the photocoagulation scars; in patient 2, FT has grown extensively toward the vitreous base, under which a regional traction retinal detachment has developed. In both patients, vascular activity in the FT shown by fluorescein dye leakage has stabilized after vitrectomy. Patient 1 shows a reattached retina without retinal dragging and with the fovea; patient 2, retinal reattachment with retinal dragging resulting from contraction of residual FT and without the fovea.

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Figure 2.
Final Postoperative Visual Outcomes

The gray line with standard deviations (vertical bars) indicates normal visual development (visual acuity [VA]) in patients examined using the preferential looking technique from ages 0 to 3 years and using a Landolt ring chart or pictures from 3 to 5 years. Filled shapes indicate the preoperative findings of retinopathy of prematurity (ROP), stage 4A; open circles and triangles, ROP stage 4B; red, fibrovascular tissue (FT) that has not reached the posterior lens surface or vitreous base (Figure 1A); and blue, FT that is attached to the posterior lens surface or vitreous base (Figure 1F). The faint ovals pairing eyes indicate that both eyes are from the same patient. The 4 triangles at the VA level below 20/1600 indicate the worse eyes; their fellow eyes do not have a retinal detachment after successful photocoagulation. Of these 4, the 2 younger patients had retinal dragging, and the 2 older patients had deprivation amblyopia. The 2 triangles at the 20/100 VA level indicate the better eyes, the fellow eyes of which progressed to total retinal detachment (stage 5).

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