1316hrs: Retinopathy of Prematurity (Khaled Tawansy)

/

1316_Tawansy

 

History: 3 week old hispanic male born 29.5wks gestation and seen 32.5 weeks post conception. VA LP, trace TVL, dilated post-pole vessels with some communication between the vascular arcades, ghost vessels, finger-like projections of retinal vessels.

Diagnosis: ROP? FEVR? Oxygen Toxic Retinopathy? Trauma? Something else?

Additional history: can’t really talk to mom as intubated in ICU. Has lupus and stopped all her lupus meds. Ultimately died 3 months after delivery. Found immune complexes in mom’s vessels. Feel therefore an immune related disease on top of ROP for this baby.

Treatment: did not know about this lupus vasculitis at first, otherwise might have treated for that. Based on BEAT-ROP study, did inject Avastin 0.6mg OS.

Three ROP variants: Typical ROP that responds to the study protocols, an aggressive posterior form, and a smouldering form. This last form never gets to threshold and the detachment can occur much later on, eg as a teenager. 

Biphasic retinal vascular development: vasculogenesis and angiogenesis both explained.

Compared risk factors between regular ROP and the smouldering form. Odds ratio favours smouldering form if some CNS abnormality. These patients need to be followed beyond the expected 45 weeks for late development of the ROP complications.

Now in our Anti-VEGF era, many of these cases may need close follow-up for injections.Talks about the BEAT-ROP study that used avastin as a treatment for ROP. 

Lessons from the BEAT-ROP study:

 

  • laser vs avastin stage III zone I and IIIp
  • prospective randomized
  • FDA approved with many site visits
  • primary outcome recurrence stage III plus
  • vascularity goes way down within 24hrs post injection
  • avastin not nearly as effective to salvage eyes that already had laser as it is primarily
  • neovascularization at the ridge resolves at 1-2wks with peripheral vessels crossing the ridge
  • growth of intrinsic vessels is delayed making follow-up more critical as wait for peripheral perfusion
  • rate of recurrence lower with avastin and occurs at two sites: leading edge and the original fibro-vascular ridge
  • advantage avastin vs laser far better zone I eyes than zone II eyes
  • some eyes will vascularize to ora
  • when detachments occurs after avastin, typically more dry and fibrotic which may be easier to operate
  • myopia and VF loss may be reduced in Zone I cases