Since the ETROP (Early Treatment for Retinopathy of Prematurity) study was published in 2004, referrals for advanced retinopathy of prematurity (ROP) retinal detachments (RD) have decreased because treating ophthalmologists had hard data demonstrating that earlier treatment decreased poor outcomes. That study found that treatment for ROP resulted in a reduction in poor visual acuity outcomes (19.8% to 14.3%; P<.005) and a reduction in poor structural outcomes (15.6% to 9.0%; P<.001).1
Simultaneous to our increased understanding of when intervention should take place, improvements in neonatology have changed the types of ROP that clinicians see. Smaller babies present with more aggressive disease and at a slightly earlier age. This type of ROP is difficult to diagnose, the babies are extremely small and sick with multiple comorbidities, and the laser treatment itself is quite challenging. I have found that RetCam photography (Clarity Medical, Pleasonton, CA) is critical for the diagnosis and treatment of this type of aggressive ROP. The RDs referred most commonly today are zone 1 or posterior zone 2 RDs. Here we present a case of a child treated late who, despite dense laser pattern, progressed to bilateral RDs. In this case, RetCam photography was helpful in the documentation of the disease, in monitoring the response to treatment of this child after off-label, salvage use of intravitreal bevacizumab (IVB; Avastin, Genentech, Inc.), and in the decision process of when to intervene surgically. Most cases of progression to RD occur because laser is delayed or because laser is not applied in a complete fashion. In some of these cases off-label, salvage treatment with IVB seems to help in controlling the vascular component of the disease.
CASE PRESENTATION
A baby born at 24 weeks gestation and weighing 480
grams developed aggressive, posterior ROP (Figure 1).
This baby was treated at 37 weeks with very dense and
complete laser. A week after treatment, the baby exhibited
progression of the disease in both eyes. The left eye
presented with a complete retinal detachment with vitreous
hemorrhage and the right eye with a stage IVA
detachment in a circumferential fashion. The baby was
transferred to Jackson Memorial Hospital/Bascom Palmer
Eye Institute for treatment.
IMAGING AND TREATMENT
Upon the patient's arrival, photographs and ultrasonagraphy
were performed for documentation (Figure 2).
We treated the child with off-label, salvage IVB because
of the active vascular pattern. At the time of the injection,
it was known that we would intervene surgically
within 1 week. Three days later, we obtained RetCam (Clarity Medical, Pleasonton, CA) photographs that
showed progression of the vitreous traction, in a circumferential
fashion. At this time, it was decided to
intervene sooner. The baby underwent a lens-sparing
vitrectomy with no complications. The baby was transferred
back to the referring facility and has remained
stable. The last photographs were taken 6 months after
surgery, and the retina is flat with no tractional component
(Figures 3 and 4).
DISCUSSION
RetCam photography in this case was critical for the
documentation of the disease, the parents understanding
of the disease, for the decision of when to intervene
surgically, and for follow-up documentation. In the
comparison of the images one can appreciate it how
the circumferential traction starts closing in like a
purse string, after the intravitreal injection. Once we
observed the progression both clinically and objectively
in the photographs we made the decision to perform
surgery.
This case illustrates how we can use off-label, salvage treatment of bevacizumab as an adjunct in the surgical management of cases of retinal detachments, in where we see an active vascular component.
Audina M. Berrocal, MD, is an Associate Professor of Clinical Ophthalmology and Secondary Appointment in the Department of Pediatrics at the Bascom Palmer Eye Institute, University of Miami Miller School of Medicine. She reports that she is a paid consultant to Clarity Medical Systems. Dr. Berrocal can be reached at +1 305 326 6000; fax: +1 305 326 6417; or via email at aberrocal@med.miami.edu.
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