First Author: D.Sen INDIA
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Retinopathy of prematurity (ROP) is a leading cause of childhood blindness throughout the world. The disease mainly affects preterm infants of very low birth weight and occurs when abnormal blood vessels grow and spread throughout the retina. Aggressive Posterior ROP (APROP) is a rapidly progressive form that often results in retinal detachment without passing through the intervening stages. Intravitreal ranibizumab combined with laser therapy (gold standard) offers promising results especially in developing countries where high risks babies are aplenty and patient follow up is an issue.
Neonatal ICU in SSKM Hospital, a government tertiary care centre, Kolkata, India
This is a retrospective analysis of infants who were diagnosed with APROP with the help of binocular indirect ophthalmoscopy and subsequently treated with intravitreal injections of ranibizumab withing 24 hours of diagnosis. This was followed by laser photoablation of avascular retina after 5-7 days of injections irrespective of the response to ranibizumab. The infants were then followed up every 5-6 days until ROP regressed. Retreatment was given to recurrence of disease with laser therapy. The main outcome measures were recurrence rate and complication rate. Any treatment was conferred after obtaining a written informed consent from the parents of guardians. The statistical analysis was done using Microsoft Excel software and inbuilt statistical tools.
In total, 42 eyes (21 consecutive babies) with APROP were included in the study. The mean GA and BW at the time of initial treatment were 29.5 weeks and 1115 g respectively. One eye (2.4%) developed endophthalmitis following injection. None developed cataract. 1 infant developed RD (2.4%) for which surgical management was done. 4 cases developed recurrence (9.5%) for which a fill in laser was done and only 1 progressed to RD (as discussed earlier). 6 eyes (14.2%) developed a transient anterior uveitis and 2 (4.76%) developed macular ectopia. 3 babies (7.14%) had neurological delays which could be a coincidental finding. No systemic side effects were noticed.
Laser treatment is a cumbersome process and may be difficult in poorly dilating pupils. Also, most of the babies in developing countries present late with severe APROP and effect of laser may take some time before VEGF levels are brought down. Such complicated cases can be treated with ranibizumab injections first. However, ranibizumab therapy alone may leave the peripheral retina poorly vascularised and the patient needs to be followed up for a long time to ensure there is no recurrence of disease or RD. This is, more often than not, difficult in countries like India where patient compliance and follow up is a big uncertainty. Treating severe cases with a combined approach not only makes the laser easier, it also gives the ophthalmologist time to reassess the baby and decide on the course of therapy. Also, recurrence rates and rates of developing RD seem to be lower than single approach in severe cases of APROP. The cost of ranibizumab is a concern though and the Government of West Bengal has started providing it free of cost to aide in this regard. The future looks bright.