Stuti Astir, Shroff Eye Centre
Deependra V. Singh, Eye-Q Super-specialty Eye Hospitals
The ROP workshop at Delhi Retina Meet 2023 was designed to apprise the delegates about the latest developments in ROP classification, documentation, and management. The workshop was attended by 73 retina specialists from across the country and went on for nearly two hours with enlightening discussion amongst panelists, speakers, and delegates, and moderated by Dr. Deependra V Singh and Dr. Shashank Rai Gupta. The expert panelists were Dr. Mangat Dogra, Dr. Parveen Sen, Dr. Simar Rajan Singh, Dr. Anand Vinekar, and Dr. Yoshihiro Yonekawa.
The workshop opened with excellent deliberation by Dr. Anand Vinekar who spoke to us virtually on “Expanding boundaries of diagnosis and management.” He referred to new features in the ICROP-3 classification and touched on practical points from an Indian perspective. India has the highest number of preterm babies in the world which poses a significant challenge. Indian guidelines do account for higher gestational ages (GA) and birthweights (BW) that develop ROP in our country.
He also spoke about newer imaging devices and investigative techniques such as ultrawide field fluorescein angiography, OCT angiography for flat neovascularization and examination of the superficial capillary plexus, role of VEGF tear assays during screening, and integration of artificial intelligence with tele-screening to achieve better than 92% accuracy.
The discussion was focussed on extending tele-screening to other areas and encouraging ROP specialists to take up ROP treatment and surgery. Role of training institutes in preparing surgeons for these tough cases was emphasised by Prof. Mangat Dogra.
This was followed by an interesting case presentation by Dr. Manjari Tandon who shared an ROP case with a localized neovascular frond with hemorrhage which progressed very slowly in a relatively older neonate. Panelists were asked for their opinion. Dr. Praveen Sen stressed upon the importance of serial comparisons on follow ups and any progression to be considered as indication for treatment.
The second case was presented by Dr. Kirti Jai Singh who shared serial images of an ROP patient with pre-threshold ROP that finally progressed. Panel discussion focused on starting laser at the appropriate stage. Dr. Parijat felt that with plus disease now considered as a spectrum we do not need to wait for severe plus disease to initiate laser. Most panelists agreed upon consideration for early laser if the tempo of disease is worsening and especially if outpatient compliance is less reliable.
Next was Dr. Ajay Kapoor’s presentation who presented his ROP data from several districts of the Punjab State where he sees an extremely high rate of treatment-requiring ROP. He showed that the infants were still salvaged by timely screenings and treatments. Panelists including Dr. Yonekawa, added that NICUs need to be updated and informed if higher than normal rates of ROP are observed, so that oxygen treatment can be more fine-tuned.
The second talk was by Dr Parijat Chandra, from R P Centre for OS, AIIMS New Delhi on “AROP: How do Anti-VEGFs as monotherapy or adjuvant optimize my approach?” Anti-VEGF agents are now commonly the first line treatment in AROP, zone 1 / posterior zone 2 disease, in cases with extensive NVI, and severe plus disease with rapid ROP regression. Additional potential benefits include less refractive changes, more retinal revascularization, and better preservation of visual fields.
Management of peripheral avascular retina (PAR) is on ongoing debate, and his practice is to wait for 12- 14 weeks post anti-VEGF, and to apply laser if there is no re-vascularization.
Finally, he commented that he would avoid anti-VEGF agents in cases with stage 4A ROP showing progression despite treatment or severe reactivation with evidence of traction. Timely referral to ROP surgeons in cases showing progression and worsening traction was highlighted.
Discussion included collaborative approaches with the neonatologists in the NICU if there is a high incidence of A-ROP cases.
Also discussed was whether fluorescein angiography adds significant value in following these children treated by anti-VEGF injections. Dr. Simarranjan Singh cautioned that over referral to tertiary eye centers simply for documentation is neither warranted nor recommended.
Finally, several practical tips to minimize skip areas during ROP laser and the role of posterior barrage laser in special situations was also discussed.
The third talk was delivered by Dr. Yoshihiro Yonekawa from Wills Eye Hospital Philadelphia, USA. He spoke on “Stage 4A & 4B: Indications and Techniques of Lens Sparing Vitrectomy”
He demonstrated following steps
- Entering the eye
Anatomy is different from adults. Enter 1mm from limbus.
If lensectomy is needed for stage 4B/5, limbal/iris root incisions should be used. He prefers nasal infusions as it’s more stable and away from the anterior TRD, which tends to be temporal. This depends on individual eyes. It is important to cut tractional vectors between the ridge & lens and ridge & eyewall. In case of lensectomy and vitrectomy in stage 5 ROP, the capsule should also be carefully removed in its entirety. One can also use pediatric vitrectomy sets, if available, for these cases.
- Do not make iatrogenic breaks
He also reinforced the key principle of relying on the RPE to pump subretinal fluid out once traction is released. Iatrogenic breaks cannot be made in order for this surgery to be successful. Air fluid exchange is done at the end of surgery primarily to prevent vitreous incarceration.
- Think about the entire patient
Sharing interesting data, Dr. Yonekawa suggested that bilateral simultaneous surgery is preferred in some infants because the risk of death with a second session of general anesthesia in very ill preemies is potentially much higher than the risk of bilateral endophthalmitis, the main reason why bilateral surgery is typically avoided.
- Scleral Buckling
Dr. Yonekawa shared that utility of an encircling band is very limited for Stage 4 ROP in the modern vitrectomy area with wide-angle visualization, but a 240 encircling band can be applied in cases with very anterior TRDs or those harboring a rhegmatogenous component. This band can be cut after 3 – 4 months to minimize severe anisometropia.
The panelists had a great discussion and highlighted that surgery has better results if performed at the appropriate timing.