Taku Wakabayashi, MD, PhD
Wakabayashi Eye Clinic, Kanazawa, Japan
Aichi Medical University, Aichi, Japan
The pediatric session at FujiRetina 2024 moderated by Shunji Kusaka, MD and Aleksandra Rachitskaya, MD, covered important topics in the treatment of pediatric retinal diseases.
Dr. Shunji Kusaka from Kindai University presented the long-term visual outcomes following lens-sparing vitrectomy (LSV) for stage 4A retinopathy of prematurity (ROP). His study included 61 eyes from 42 patients with a minimum of 4 years of follow-up after successful LSV, where best-corrected visual acuity was measurable. The average age at the time of visual acuity measurement was 10.1 ± 3.3 years. Prior to LSV, all eyes had undergone laser photocoagulation, and 20 eyes (33%) received anti-VEGF treatment. The mean visual acuity was 20/87, with 23 eyes (54.1%) achieving a visual acuity of 20/50 or better. Of 49 phakic eyes, the mean refractive error was -10.1 ± 5.0 diopters, with 37 eyes (76%) experiencing high myopia of -6.0 diopters or more. No significant differences in visual acuity or refractive errors were observed between eyes treated with or without anti-VEGF therapy. Dr. Kusaka concluded that LSV for stage 4A ROP was associated with favorable visual outcomes, despite the presence of myopic refraction.
Dr. Eric Nudleman, from the Shiley Eye Institute, presented the long-term sequelae of ROP, with a focus on persistent avascular retina (PAR) and late onset retinal detachments. This is a hot topic in ROP currently. Dr. Nudleman first reviewed the evidence of cryotherapy (Cryo-ROP), laser photocoagulation (ET-ROP), and anti-VEGF therapy (BEAT-ROP) for treating ROP. Although anti-VEGF therapy for ROP offers several advantages, such as being performable at the bedside, quick administration, rapid response, preservation of a larger visual field, and reducing myopia, it also has disadvantages, particularly PAR, a condition increasingly recognized with the increased use of anti-VEGF therapy. PAR commonly occurs in eyes with type 2 ROP and may be a risk factor for delayed reactivation after anti-VEGF therapy and for late retinal detachments, which are challenging to treat with a single surgery. Dr. Nudleman then presented findings from his recent study on the risk factors for PAR after anti-VEGF therapy. In this study, eyes with PAR that underwent anti-VEGF therapy followed by laser photocoagulation were compared to eyes without PAR that fully vascularized without requiring laser photocoagulation. PAR was significantly associated with more posterior disease, a higher vascular severity score, and an earlier requirement for laser treatment. Although no definitive evidence exists regarding whether to perform laser for PAR, Dr. Nudleman mentioned he would perform laser for PAR based on its associated risks. The long-term visual and refractive outcomes of laser treatment on PAR remain to be explored in future studies.
Dr. Aleksandra Rachitskaya from the Cole Eye Institute presented the significance of multimodal retinal imaging in adults with a history of ROP. Dr. Rachitskaya began her presentation by showing that a significant number of preterm infants receiving modern neonatal care survive into adulthood. These patients are at increased risk of retinal pathologies, including retinal detachments that can be challenging to manage and may require multiple surgeries. This underscores the importance of multimodal imaging in understanding the retinal pathologies of these patients. Dr. Rachitskaya then shared findings from her recent study on foveal vascular changes using swept-source OCT angiography in adults with a history of prematurity. Compared to age-matched controls, these adults had a significantly smaller foveal avascular zone (FAZ) area, lower vessel density in 6×6 mm macular scans, and reduced foveal pit depth. These findings suggest that OCT angiography offers a non-invasive method to identify individuals born prematurely. Further, Dr. Rachitskaya presented peripheral OCT findings, including retinoschisis due to traction and asymptomatic retinal detachment with peripheral subretinal fluid, highlighting how multimodal imaging can assist in diagnosing and treating adult patients with a history of ROP.
Dr. Yoko Fukushima from Osaka University presented a study evaluating the relationship between continuous oxygen saturation (SpO2) measurements and the severity of ROP in premature infants. Oxygen supplementation is essential for low mortality in premature infants, but it is also known as a risk factor for ROP. Her study analyzed how minute-by-minute SpO2 levels during the first 20 days of life affected ROP severity. The study included 350 infants with a gestational age of less than 30 weeks, of which 83 (23.7%) required ROP treatment. Among four SpO2 variables (average, fluctuation, high, and low SpO2), average and low SpO2 were significantly lower, and SpO2 fluctuation and high SpO2 were significantly higher in infants requiring ROP treatment compared to those who did not. Average SpO2 and high SpO2 correlated positively with gestational age. These results indicate the association between SpO2 variables with severe ROP and gestational age. While a model combining birth data and SpO2 variables showed good ability to predict ROP treatment requirement (AUC=0.83), it did not outperform the model using birth weight and gestational age (AUC=0.82). However, defining high SpO2 < 0.6 as a high-risk threshold for ROP treatment could reduce the screening need to 25.1%, offering a potential cut-off value.
Finally, Dr. Hiroyuki Kondo from the University of Occupational and Environmental Health presented two cases where traction retinal detachment developed in patients with Coats disease during the course of treatment. Coats disease, an idiopathic congenital retinal vascular disorder, is characterized by telangiectasia, aneurysmal dilations, and peripheral nonperfusion. Leakage from these abnormal vessels can lead to exudative retinal detachment, but traction retinal detachment, as observed in cases presented by Dr. Kondo, is atypical. These cases showed contraction of the hyaloid leading to retinal traction, potentially due to early bevacizumab use. While anti-VEGF injections are sometimes employed to reduce exudation in Coats disease, he felt that they may also facilitate hyaloid contraction, similar to what is seen in ROP. Treating TRDs with vitrectomy was challenging, but both patients experienced resolution of retinal detachment without losing light perception. Dr. Kondo indicated that TRD might not be uncommon in patients with Coats disease and announced an ongoing international study with more cases.
