Treatment of retinopathy of prematurity
Release time : 03/08/2025 09:30:02
Retinopathy of prematurity is a disease caused by the abnormal proliferation of retinal blood vessels in premature infants, and it is related to factors such as oxygen therapy.
The key to treatment is early detection, grasping the optimal treatment window, which lasts about one month, a term in medical terms known as the "window of opportunity."
The key to early treatment for neonatal retinopathy of prematurity lies in its early detection. Medical personnel such as obstetricians, neonatologists, and ophthalmologists must place great emphasis on it and maintain close cooperation. Additionally, establishing a comprehensive eye examination program for premature infants is essential.
If the iris is widely adherent, then a glaucoma surgery may be considered.
ROP is not invariably progressing from Stage I to Stage V. Many lesions develop to a certain stage and then regress without further progression, with only about 10% cases developing into full retinal detachment. Therefore, for lesions at Stages I and II, observation only is required; however, if the lesion reaches the threshold stage, treatment must be administered immediately. Thus, early detection and timely treatment of threshold ROP are the principles of management. Currently, surgical treatment remains the primary method, and in recent years, there have been developments in the use of pharmacotherapy based on possible mechanisms of the disease.
1. Surgical Treatment (1) Cryotherapy: Continuous cryotherapy on the non-vascularized peripheral retina of threshold ROP can prevent 50% of cases from developing severe consequences such as macular folds, posterior pole retinal detachment, and retrolental fibroplasia. Cryotherapy is generally performed under local anesthesia but may also be carried out under general anesthesia, which can cause bradycardia, apnea, and cyanosis. The complications of cryotherapy include conjunctival edema, hemorrhage, tearing, vitreous hemorrhage, central retinal artery occlusion, and retinal hemorrhage. Currently, the short-term efficacy of ROP cryotherapy has been confirmed, but its long-term effectiveness remains to be further determined.
Laser Photocoagulation Therapy: In recent years, with the development of indirect ophthalmoscopes equipped with laser devices, laser photocoagulation therapy has achieved excellent results in treating Retinopathy of Prematurity (ROP). Compared to cryotherapy, laser photocoagulation provides superior therapeutic outcomes for Zone I ROP and comparable efficacy for Zone II pathology. Additionally, it offers greater precision during the procedure, reduces the risk of vitreous hemorrhage, postoperative conjunctival edema, and intraocular inflammation. Currently, laser photocoagulation is regarded as the first-line treatment for threshold ROP internationally. Diode lasers are particularly recommended due to their strong penetration capability, which minimizes absorption by the refractive media and results in fewer complications. Some researchers have also explored the use of 810 nm lasers applied transsclerally as an alternative to cryotherapy, significantly reducing associated complications.
(3) Scleral Ring Binding: If the threshold ROP has not been controlled, and it progresses to stage IV or is still visible in stage V ROP with a clear fundus, then scleral ring binding may be effective. The purpose of scleral ring binding for ROP is to relieve retinal traction, promote the absorption of subretinal fluid, and facilitate retinal repositioning. It also aims to prevent progression to stage V. However, some scholars believe that some children may recover without surgery.
(4) Vitrectomy: For patients with vitrectomy failure and those in Stage V, only complex vitrectomy is required. The optimal surgical outcome for retinal detachment with a wide funnel-shaped retina is approximately 40% of the retina can be repositioned, while for a narrow funnel-shaped retina, it is only about 20%. After vitrectomy, the retina undergoes partial or complete anatomical repositioning. However, the ultimate restoration of visual function in children is extremely limited, rarely allowing for useful vision recovery.
2. Neonatal Treatment (1) Oxygen-induced Retinopathy of Prematurity (ROP): Oxygen therapy has been shown to induce ROP, and for a period, oxygen was withheld from preterm infants. However, this approach was not a definitive solution and also increased the mortality rate in preterm infants. With the establishment of the role of vascular growth factors in the development of ROP, it was found that hypoxia induces the synthesis of vascular growth factors. Thus, oxygen-supplemented treatment is proposed to inhibit neovascularization and the occurrence and progression of ROP, but further research is needed.
(2) New Vessel Inhibitors: Are still under development and animal testing.
The symptoms of retinopathy of prematurity are common in the first 3 to 6 weeks after birth, and clinically divided into active phase and fibrous membrane formation phase.
1. The course of the disease is divided into five phases: (1) Vascular change stage: This is observed in the early stages of the disease course.
Both arterial and venous conduits are tortuously dilated.
The diameter of the vein sometimes exceeds 3-4 times normal.
Capillary ramifications of the peripheral retina are seen as brushlike structures.
(2) Stage of Retinopathy: As the condition progresses, the vitreous becomes cloudy, and the fundus appears more blurred than before.
Retinal neovascularization is increased, mostly located near the equator, but also present in the anterior or posterior poles of the equator. This area of the retina is prominent and has a surface covered by capillaries that crawl over it, often accompanied by varying degrees of retinal hemorrhage.
(3) Early Proliferative Stage: The previously described localized retinal protrusion develops into proliferating blood vessel cords, which extend into the vitreous and cause a small area of retinal detachment at the peripheral (mostly) or posterior pole (rarely) of the fundus.
(4) Moderate proliferative stage: The separation area extends to more than half of the retina.
(5) Extremely Proliferative Stage: Retinal Total Detachment.
At times, it is also possible to observe extensive blood accumulation within the glass cavity.
The disease's active phase lasts 3 to 5 months.
Not all cases go through these five stages. Approximately 1 / 3 of the cases are in stage 1, 1 / 4 in stage 2, and the rest in stages 3, 4 and 5 before entering the fibrous capsule formation phase.
2. In the fibrotic stage, cases that fail to resolve spontaneously during the active phase eventually form a fibrous membrane, which, depending on its severity, is categorized from mild to severe as grades 1 to 5.
Grade I: The retinal vessels are narrow, the periphery of the retina appears grayish-white and opacified with small irregular pigment spots, accompanied by a few scattered patches in the vitreous body. This condition is often associated with myopia.
II. Disc margins are involved with organic masses, disc and retinal vessels are pulled to one side by the mass, the temporal edge of the other disc is pigmented, and the disc is pale.
III degree: Fibrous scar formation, which pulls the retina into a single or multiple folds.
Each wrinkle is connected with a membranous castoid mass of the retina's peripheral part.
905 is located on the lateral side of the temporal region and 105 is located on the nasal side.
Those located on the lateral sides of the temporal bone, particularly above and below the temporal region, are quite rare.
The retinal vessels are not distributed along this fold, unlike congenital retinal folds.
IVth degree: The crystalline lens can be seen with a fibrous membrane or a portion of the retina that has detached and is covered by scar tissue, obscuring the pupil.
Upon examination, the fundus with red light reflection was visible through the eyeglasses.
V: The crystalline lens is covered by the retina, which has either fused to the fibrous capsule or has undergone calcification.
Mydriasis examination reveals a radiating, serrated-shaped scleral spur extending from the periphery of the pupil.
Anterior chamber is very shallow, often with the anterior and posterior iris adherents.
It may also result from secondary glaucoma or extensive anterior synechiae, leading to corneal opacification and a smaller, inverted eyeball.
The etiology of retinopathy of prematurity (ROP) remains unclear. Risk factors include low birth weight, preterm delivery, and oxygen therapy.
1. Primary reasons for prematurity and low birth weight: Retinal development is not mature, with a grayish-white blood vessel that cannot cross over as a boundary line, preventing normal growth of the blood vessels.
The incidence of ROP is higher and the severity of the condition is greater when a newborn has a lower birth weight and smaller gestational age.
2. Oxygen therapy currently has two theories regarding its causative factors: (1) The longer the duration of oxygen therapy, the higher the inhaled oxygen concentration, the higher the arterial blood oxygen partial pressure, and the higher the risk of Respiratory Organ Failure (ROP), leading to more severe conditions.
ROP incidence was higher in patients with CPAP or mechanical ventilation than those with face mask oxygen.
Patients generally have a history of excessive oxygenation in incubators during birth.
(2) After the concentration of oxygen is given, it is quickly stopped to cause the relative hypoxia of the tissue, thereby promoting ROP production. This is unrelated to the duration of oxygen administration.
The fluctuation of arterial oxygen partial pressure plays a significant role in the progression of ROP.
The above text is already in English. Here is the translation of the provided Chinese text into English: "Other causes include hypoxia, acidosis (pH < 7.25), anemia, transfusion, hyperbilirubinemia, hypernatremia, hypoglycemia, hypothermia < 35.6°C, patent ductus arteriosus, intracranial hemorrhage, sepsis, exposure to light, and the use of xanthines." If you need further assistance or clarification, feel free to ask!
(2) Beta-blocker: Enters the fetal body through the placenta, increasing vascular tension in the retinal capillaries, and promoting the progression of ROP.
(3) PaCO2: A low PaCO2 can cause retinal vascular constriction, leading to retinal ischemia and ultimately the development of ROP.
Maternal anemia and polyhydramnios.
(5) Race: White individuals have a higher incidence and more severe conditions.
How to prevent retinopathy of prematurity? The only effective prevention is the strict restriction of oxygen use in premature infants. Except for cases of severe cyanosis and life-threatening situations, 40% oxygen concentration can be administered for a short time.
In addition, early and high-dose administration of vitamins may also play a certain preventive role. Timely implementation of cryotherapy or laser photocoagulation can prevent the further deterioration of the lesion, with successful reports.
Additionally, to prevent the occurrence of secondary glaucoma in premature infants with retinopathy of prematurity, patients in active stages and severe cases must be regularly mydriaticized to avoid posterior synechiae.
In summary, complications of retinal lesions must also be given attention. Active prevention and control measures should be taken.
What to Eat for Premature Infants with Retinopathy of Prematurity Is there a special diet required for premature infants with retinopathy of prematurity? Are there any foods that should be avoided, and what are the benefits of correct dietary habits for this condition? What is beneficial for premature infants with retinopathy of prematurity? These are important considerations.
I. Feeding 1. Advocate for early feeding. For those with low body weight or poor general condition, such as those who have experienced cyanosis, respiratory distress, or have undergone a surgical delivery, appropriate delays in feeding may be considered, with intravenous fluid replenishment.
Actions: Shorten the time to achieve physiological weight loss, or reduce its degree, and decrease the incidence of hypoglycemia, and relative reduction in serum bilirubin concentration.
The baby is usually given sugar water at 6-12 hours after birth, and breast milk is introduced at 24 hours.
2. Breastfeeding Method: For infants with heavier birth weight and good sucking reflex, breastfeed directly; otherwise, feed using a syringe or gastric tube.
3. Maximum Intake: The daily breastfeeding volume (ml) for the first 10 days after birth is calculated as follows: (the actual number of days the baby has been born + 10) × the weight of the baby (in grams per 100).
10 days after birth: the daily amount of breastfeeding (ml) = 1/5 - 1/4 of the infant's weight (g). Premature infants may not be able to finish the required amount and can be supplemented by intravenous injection.
4. Feeding Interval: For infants weighing less than 1000g: one feeding every hour.
For those weighing between 100 to 1500 g: feed once every 1.5 hours.
Weight 150-2000g: Feed once every 2 hours.
Weight ranges from 2001 to 2500 grams, with one dose every three hours.
II. Nutritional Needs: 1. Caloric needs: Daily caloric intake per kilogram of body weight should be between 110 to 150 kcal.
Supply should be started at a slightly lower level and gradually increased as needed.
2. Amino Acids: Premature infants lack the necessary enzymes for transamination, which means that they cannot convert methionine into cysteine or tryptophan into tyrosine. Consequently, cysteine and tyrosine become essential amino acids that must be obtained from food.
3. Protein: The protein intake of preterm infants is higher than that of term infants.
4. Vitamins: Premature infants are prone to hemolytic anemia due to vitamin E deficiency.
Premature infants have a lower absorption rate of fat than mature infants and may lack fat-soluble vitamins and other nutrients.
5. Inorganic salts: More than what mature infants need.
The medical information provided in this article is for reference only.
In case of discomfort, it is recommended to seek medical attention immediately. The diagnosis and treatment should be based on the medical advice provided by a face-to-face consultation.