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Indian Pediatr 2020;57:1020-1022 |
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Profile of Retinopathy
of Prematurity in Outborn and Inborn Babies at a Tertiary Eye
Care Hospital
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Anusha Sachan, 1 Parijat
Chandra,1 Ramesh Agarwal,2
Rajpal Vohra,1 Rohan Chawla,1
M Jeeva Sankar,2 Devesh Kumawat1
and Atul Kumar1
From 1Dr. Rajendra Prasad Centre for Ophthalmic Sciences
and 2Department of Pediatrics, All India Institute of Medical
Sciences, New Delhi, India.
Correspondence to: Dr Parijat Chandra, Professor, Department of
Ophthalmology, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All
India Institute of Medical Sciences, New Delhi 110 029, India.
Email:
[email protected]
Submitted: April 22, 2019;
Initial review: August 05, 2019;
Accepted: April 07, 2020.
Published Online: June 12, 2020;
PII: S097475591600196
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Objective: To study the
profile of retinopathy of prematurity (ROP) among outborn and inborn
babies at a tertiary-care centre. Methodology: In a prospective
observational study from 2015-2016, outborn and inborn babies eligible
for ROP screening were evaluated for ROP profile and treatment results.
Results: 532 outborns and 38 inborns had ROP. Respiratory
distress, sepsis and apnea were present in 81.3%, 51.5% and 36.2% of
outborns with ROP and 68.4%, 39.4% and 36.8% of inborns with ROP. Type 1
ROP was noted in 49.2% eyes of outborns with ROP and 36.8% eyes of
inborns with ROP. Type 1 ROP regressed with laser in 97.3% and 100% eyes
of outborn and inborn with ROP, respectively. Stage 4, 5 and sequelae
were noted in 5.2%, 22.8% and 4.6% eyes of outborns with ROP,
respectively, but none in inborns. Conclusions: Quality neonatal
care and timely screening ensured lesser ROP-related morbidity in
inborns as compared to outborns.
Keywords: Blindness, Referral, Screening, Surgery.
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I mproved neonatal care of preterm
babies has led to a reduction in mortality, but due to
unrestricted use of supplemental oxygen there is a significant
increase in retinopathy of prematurity (ROP), the so-called
third epidemic in middle income countries [1].
The quality of neonatal care,
neonatologist-ophthalmologist coordination, timely ROP screening
and management may prevent advanced ROP, with recent studies
showing lower rates of ROP ranging from 20% to 30% [2-4]. This
study was conducted to determine the difference in ROP profile
of inborn and outborn babies with respect to risk factors,
diagnosis at presentation, treatment given and outcomes.
METHODS
The study was conducted at our tertiary
eye-care centre and Neonatal intensive care unit (NICU)
associated with the same hospital, from May, 2015 to May, 2016.
The study was approved from the Institutional review board and
adhered to the Declaration of Helsinki guide-lines. Informed
written consent was taken from the parents to participate in the
study.
We studied the risk factors for ROP,
demographics and screening referrals of ROP from the discharge
summary or by interviewing the caregivers. Records were
requested from the NICU, if unavailable. Outborn babies
(referred from other health facilities to our centre) were
screened for ROP as per the National Neonatology Forum (NNF) of
India guidelines (<1750g; <34 week or 1750-2000 g or 34-36 week
in babies with co-morbidities) [5], and inborn babies (born at
level 3 nursery of our hospital) were screened as per our
hospital NICU protocol (<1500g; <32 week or 1500-2000 g or 32-34
week with co-morbidities).
The babies were examined with indirect
ophthalmo-scope and Retcam wide field imaging system. Diagnosis
at presentation was documented as per International
classification of ROP (ICROP), 2005 [6]. The treatment was given
as per early treatment of ROP (ETROP) guidelines [7]. As per
these guidelines, type 1 ROP includes (a) Zone 1 any
stage with plus disease; and (b) Zone 1 stage 3 without
plus disease and (c) Zone 2 stage 2/3 with plus disease;
and requires intervention. Type 2 ROP includes (a) Zone 1
stage 1/2 without plus disease, and (b) Zone 2 stage 3
without plus disease; and requires observation [7]. Advanced ROP
cases such as stage 4 and 5 ROP underwent surgical management.
The data were entered in a predesigned
proforma and analyzed using SPSS Version 23 (SPSS Inc. Chicago,
IL, USA). Due to variability in baseline characteristics, risk
factors were evaluated separately for ROP cases in outborns and
inborn babies. The categorical risk factors were subjected to
the Pearson chi-square test for comparison between the groups.
RESULTS
A total of 722 outborn babies were referred
among which 532 (73.6%) babies had ROP; 22.6% (n=38) of
168 inborn babies screened in NICU developed ROP.
The mean (SD) birthweight [1354.8 (376.3) g
vs 1122.2 (271.2) g; P=0.0002] and gestational age
[30.7 (2.7) week vs 29.6 (2) week; P=0.014] were
higher/similar between outborn and inborn babies with ROP,
respectively. Respiratory distress syndrome (RDS), sepsis, and
apnea of prematurity (AOP) were the most commonly associated
risk factors in both inborn and outborn ROP babies (Table
I).
Table I Neonatal Systemic Risk Factors in Babies Diagnosed With Retinopathy of Prematurity (N=570)
| Risk factors |
Outborn babies
with ROP (n=532) |
Inborn babies
with ROP (n=38) |
| RDS |
433 (81.3) |
26 (68.4) |
| Sepsis |
274 (51.5) |
14 (36.8) |
| AOP |
193 (36.2) |
15 (39.4) |
| PDA |
40 (7.5) |
8 (21) |
| NEC |
39 (7.3) |
5 (13.1) |
| HIE |
22 (4.1) |
4 (10.5) |
| Seizures |
20 (3.7) |
3 (7.8) |
| TTN |
11 (2.0) |
14 (36.8) |
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All values in no. (%). RDS: Respiratory distress
syndrome, TTN: Transient tachypnea of newborn, AOP:
Apnea of prematurity, PDA: Patent ductus arteriosus,
HIE: Hypoxic ischemic encephalopathy, NEC: Necrotizing
enterocolitis. |
Among the outborn group, type 2 ROP or less
was seen in 192 (18%) eyes which spontaneously regressed on
follow up. All the eyes with type 1 ROP (524 eyes, 49.2%)
regressed following interventions like laser and anti-VEGF
therapy. Out of 76 inborn eyes, 48 eyes (63.1%) were type 2 ROP
or less and 28 eyes (36.8%) were type 1 ROP, which required only
laser therapy and regressed (Table II).
Table II Profile of Retinopathy of Prematurity in Outborn and Inborn Babies (N=570)
| Outcomes/treatment |
Outborn babies
|
Inborn babies |
|
(n=1064 eyes) |
(n =76 eyes) |
| Type 2 ROP/Follow up |
192 (18) |
48 (63.1) |
| Type I ROP |
| Laser |
510 (47.9) |
28 (36.8) |
| Laser plus anti-VEGF |
14 (1.3) |
0 |
| Stage 4 ROP/Surgery |
56 (5.2) |
0 |
| Stage 5 ROP |
| Surgery attempted |
88 (8.2) |
0 |
| Surgery not attempted |
155 (14.5) |
0 |
|
ROP sequalae
|
49 (4.6) |
0 |
| All values in no. (%);
ROP: Retinopathy of prematurity; VEGF: Vascular
endothelial growth factor. |
Median age for referral of outborns was 39
(range 29 to 316) weeks. Only 66.9% (n=483/722) babies
had been advised ROP screening among outborns, out of which 219
(30.3%) were screened late. All inborn babies were advised
timely ROP screening within 4 weeks by the pediatricians and
were screened timely by the ophthalmologists.
DISCUSSION
The proportion of ROP was 22.6% with no case
of severe/advanced ROP amongst the inborn babies. However, a
much higher prevalence of ROP was found among outborn babies
with a high proportion of advanced ROP due to the large number
of referrals to our center.
Respiratory distress syndrome (RDS), sepsis
and apnea of prematurity (AOP) were the main risk factors found
in both the groups. These risk factors likely increase the
chances of neonatal mortality, long NICU stay and high oxygen
exposure, which increases the risk for severe ROP [8]. Although,
a safe level of oxygen supplementation has not yet been defined,
in our NICU we target a arterial oxygen saturation between
90-95% to avoid hyperoxia.
In our study, we saw a spectrum of ROP from
milder forms to severe/advanced forms like type 1 ROP and stage
4 requiring immediate intervention (laser or anti-VEGF drugs or
surgery). In our study, most outborn (97.3%) and inborn (100%)
babies who underwent laser therapy as per ETROP guidelines had
regressed ROP after the procedure. Anti-VEGF drug (Bevacizumab)
was used in selected cases of zone I disease with informed
parental consent. Though multiple studies have been done on
efficacy of anti-VEGF agents in ROP, its safety profile has
still not been fully established [9]. Operated stage 4 cases had
good anatomical outcome while the outcomes were poor in stage 5
cases wherever surgery was attempted. Cases with sequalae were
not operated in view of limited further visual potential. Though
advanced ROP and its sequelae were not seen among the inborn
babies due to timely treatment, a large number (32.7%) of
outborn babies had advanced ROP or its sequelae. This clearly
shows the importance of pediatrician-ophthalmologist
coordination, early ROP screening and appropriate treatment to
halt the progression of the disease to severe forms. Sicker
babies who are not able to be screened and treated in peripheral
cities are referred to tertiary eye care centres at a later
stage and hence the ratio of severe cases among outborn and
inborn babies is more [10].
We found that 33.1% babies were never advised
screening and 30.3% were screened late for ROP, showing the lack
of awareness and structured protocol for ROP screening and
referral in many centers. A pilot survey in Northern India
showed that 34% of pedia-tricians never referred babies for ROP
screening from their NICU and only 14.5% of pediatricians were
following international guidelines for ROP [11]. Similar results
were shown in another study conducted in stage 5 ROP where none
of the babies were referred by their pediatricians for ROP
screening [12]. Another study showed that the lack of awareness
and compromise in screening and management leads to large
number of stage 5 ROP cases being referred to tertiary eye care
centres [13].
The major limitation of this study is the
study design, which makes comparison between inborn and outborn
cases difficult due to the missing information in outborn babies
and their selective referral with higher stages of ROP. Since
our center is a tertiary care referral facility, a larger number
of babies are referred for advanced management which could
account for a higher number of advanced ROP seen in the outborn
group. A large multi-centre country wide study may be able to
better estimate the true incidence and causal relationship
between the risk factors leading to advanced ROP.
Superior NICU care and management practices
can prevent development of ROP and reduce disease severity [14].
Health planners need to address the urgent need to establish
effective ROP screening and treatment services as well as
develop good neonatal services across the country.
Ethical clearance: Institutional
Ethical Committee, AIIMS, New Delhi; No. IESC/T-01/21.01.2015,
RT-18, dated April 1, 2015.
Contributors: PC, RA, MJS, RC, RV, AK:
substantial contri-butions to the conception or design of the
work; AS, DK, MJS, PC: acquisition, analysis, or interpretation
of data for the work; AS, DK, PC, RA, MJS, RC: drafting the work
or revising it critically for important intellectual content.
All authors approved the final manuscript.
Funding: None; Competing interest:
None stated.
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What This Study Adds?
Inborn babies with appropriate neonatal care and
timely screening/management of ROP did not develop or
progress to severe/advanced stages of ROP, unlike
outborn babies.
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REFERENCES
1. Zin A, Gole GA. Retinopathy of
prematurity-incidence today. Clin Perinatol. 2013; 40: 185-200.
2. Aggarwal R, Deorari AK, Azad RV, et al.
Changing profile of retinopathy of prematurity. J Trop
Pediatr. 2002; 48: 239-242.
3. Kumar P, Sankar MJ, Deorari A, et al.
Risk factors for severe retinopathy of prematurity in preterm
low birth weight neonates. Indian J Pediatr. 2011; 78: 812-816.
4. Blencowe H, Lawn JE, Vazquez T, et al.
Preterm-associated visual impairment and estimates of
retinopathy of prematurity at regional and global levels for
2010. Pediatr Res. 2013; 74 Suppl 1: 35-49.
5. Pjaver RK, Bilagi AP, Vinekar A, Deorari
AK, Jalali S. Evidence based ROP guidelines in the NNF Evidence
based guidelines. 2010. 253-63. Available from: http:
aimaonline.org/iap-neochap-2013/uploads/acd-corner/nnf_guidelines-2011.pdf.
Accessed April 8, 2020.
6. International Committee for the
Classification of Retino-pathy of Prematurity. The International
Classification of Retinopathy of Prematurity revisited. Arch
Ophthalmol. 1960 2005; 123: 991-999.
7. Early Treatment for Retinopathy of
Prematurity Cooperative Group. Revised indications for the
treatment of retinopathy of prematurity: results of the early
treatment for retinopathy of prematurity randomized trial. Arch
Ophthalmol Chic Ill 1960 2003; 121: 1684-1694.
8. Chaudhari S, Patwardhan V, Vaidya U, et
al. Retinopathy of prematurity in a tertiary care center–incidence,
risk factors and outcome. Indian Pediatr. 2009; 46: 219-224.
9. Mintz-Hittner HA, Kennedy KA, Chuang AZ,
et al. Efficacy of intravitreal bevacizumab for stage 3+
retino-pathy of prematurity. N Engl J Med. 2011; 364: 603-615.
10. Jalali S, Anand R, Rani PK, et al.
Impact of the day-30 screening strategy on the disease
presentation and outcome of retinopathy of prematurity. The
Indian twin cities retinopathy of prematurity report number 3.
Indian J Ophthalmol. 2014; 62: 610-614.
11. Patwardhan SD, Azad R, Gogia V, et al.
Prevailing clinical practices regarding screening for
retinopathy of pre-maturity among pediatricians in India: A
pilot survey. Indian J Ophthalmol. 2011; 59: 427-430.
12. Sanghi G, Dogra MR, Katoch D, et al.
Demographic profile of infants with stage 5 retinopathy of
prematurity in North India: Implications for screening.
Ophthalmic Epidemiol. 2011; 18: 72-74.
13. Azad R, Chandra P, Gangwe A, et al.
Lack of screening underlies most stage-5 retinopathy of
prematurity among cases presenting to a tertiary eye center in
India. Indian Pediatr. 2016; 53: 4.
14. Sivanandan S, Chandra P, Deorari AK,
et al. Retinopathy of prematurity: AIIMS, New Delhi
experience. Indian Pediatr. 2016; 53 Suppl 2: S123-S128.
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