|LETTER TO THE EDITOR
|Year : 2011 | Volume
| Issue : 5 | Page : 407-408
Treatment of acute retinopathy of prematurity
Atul T Ursekar
Ursekar Laser and Microsurgery Eye Clinic, Mumbai, India
|Date of Web Publication||9-Aug-2011|
Atul T Ursekar
Ursekar Laser and Microsurgery Eye Clinic, Krishna Niwas, 2nd floor, Junction of Karve Road and R. R. Roy Road, Mumbai - 400 004
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Ursekar AT. Treatment of acute retinopathy of prematurity. Indian J Ophthalmol 2011;59:407-8
My compliments to Jalali et al. for their excellent article on retinopathy of prematurity (ROP).  I would like to add that counseling and informed consent is an immensely critical issue which should be undertaken as part of the treatment protocol. The complexity of managing ROP is compounded by parents who are stressed by weeks of uncertainty related to a medically fragile neonate. This may lead to unrealistic expectations or poorly understood consequences of treatment.  Family dynamics, financial pressures, and the burden of a possibly disabled child puts the ophthalmologist at high medicolegal risk.  Parent-perceived unfavorable outcome can occur despite appropriate screening and skilled management. It is essential to spend extra counseling time with parents well beyond that used for other procedures.
For the novice, plus disease may not be easy to identify. The international classification for ROP has introduced the term pre-plus disease,  which represents a nebulous state of increased arterial tortuosity and venous dilatation but not sufficient to be categorized as plus disease. Inconsistency of agreement of plus disease diagnoses has been reported when retinal images were evaluated by ROP experts.  The exact point of onset of plus disease may be variably interpreted.
I wish to also highlight the following practical tips:
- Instead of higher level standard incubators, it is preferable to place the neonate on a shorter trolley which permits the more suitable vertical angle of treatment recommended in the article.  A portable warmer can prevent hypothermia.
- Using the laser involves numerous cables extending from the photocoagulator to the surgeon's headgear and footswitch. There is an inevitable jumbling of wires as the surgeon "walks" around to treat the entire circumferential peripheral zone. If the neonate is placed on a wheeled trolley, it is possible to rotate the neonate with the trolley to treat each quadrant, while the surgeon maintains a fixed position. This ensures that cables are never intertwined.
- Medically fragile neonates should be monitored by a pulse-oxymeter. The sensor should be taped with extra care as it can get displaced by a struggling neonate. The presence of a neonatologist is helpful to prevent interference in treatment due to erroneous alarms in an otherwise clinically stable child.
- Arrangements should be made for adjustable flow of oxygen as required during treatment.
- Topical 0.5% carboxymethylcellulose eye drops are useful to keep the cornea clear during treatment. Use of saline can result in earlier development of corneal haze, especially during prolonged treatments. Lubricant eye drops have reduced the incidence of corneal haze during my treatments.
- Neonates with zone 1 disease may have additional medical co-morbidities. Prolonged treatment session required to treat avascular retina in zone 1 disease often exhausts the child. In such situations, I have opted for planned treatment of each eye separated by a gap of 12 to 24 hours, to allow the neonate to recover from the stress of treatment. If staggered sessions are planned, the treatment strategy should be informed to the neonatologist as well as the parents in advance.
| References|| |
Jalali S, Azad R, Trehan HS, Dogra MR, Gopal L, Narendran V. Technical aspects of laser treatment for acute retinopathy of prematurity under topical anesthesia. Indian J Ophthalmol 2010;58:509-15.
Coats DK, Reddy AK. Retinopathy of Prematurity. In: Wilson ME, Saunders RA, Trivedi RH, editors. Pediatric Ophthalmology: Current Thought and A Practical Guide. Berlin Heidelberg: Springer-Verlag; 2009. p. 375-86.
Demorest BH. Retinopathy of prematurity requires diligent follow-up care. Surv Ophthalmol 1996;41:175-8.
The International Classification of Retinopathy of Prematurity revisited. Arch Ophthalmol 2005;123:991-9.
Chiang MF, Jiang L, Gelman R, Du YE, Flynn JT. Interexpert agreement of plus disease diagnosis in retinopathy of prematurity. Arch Ophthalmol 2007;125:875-80.