José Alfonso Gutiérrez-Padilla

Prediction of Retinopathy of Prematurity Using the Screening Algorithm WINROP in a Mexican Population of Preterm Infants

OBJECTIVE To retrospectively validate the WINROP (weight, insulin-like growth factor I, neonatal, retinopathy of prematurity [ROP]) algorithm in identification of type 1 ROP in a Mexican population of preterm infants. METHODS In infants admitted to the neonatal intensive care unit at Hospital Civil de Guadalajara from 2005 to 2010, weight measurements had been recorded once weekly for 192 very preterm infants (gestational age [GA] <32 weeks) and for 160 moderately preterm infants (GA ≥32 weeks). Repeated eye examinations had been performed and maximal ROP stage had been recorded. Data are part of a case-control database for severe ROP risk factors. RESULTS Type 1 ROP was found in 51.0% of very preterm and 35.6% of moderately preterm infants. The WINROP algorithm correctly identified type 1 ROP in 84.7% of very preterm infants but in only 5.3% of moderately preterm infants. For infants with GA less than 32 weeks, the specificity was 26.6%, and for those with GA 32 weeks or more, it was 88.3%. CONCLUSIONS In this Mexican population of preterm infants, WINROP detected type 1 ROP early in 84.7% of very preterm infants and correctly identified 26.6% of infants who did not develop type 1 ROP. Uncertainties in dating of pregnancies and differences in postnatal conditions may be factors explaining the different outcomes of WINROP in this population.

Paradoxical vascular–fibrotic reaction after intravitreal bevacizumab for retinopathy of prematurity

Paradoxical vascular–fibrotic reaction after intravitreal bevacizumab for retinopathy of prematurity

Retinopathy of prematurity as a major cause of severe visual impairment and blindness in children in schools for the blind in Guadalajara city, Mexico

Aim To determine the causes of blindness in students attending schools for the blind in Guadalajara city, Mexico and to assess the availability of screening for retinopathy of prematurity (ROP) in local neonatal intensive care units. Methods Information on causes of blindness was obtained by interview with parents and teachers, review of records and examination. Causes of visual loss in children with a distance visual acuity of <6/60 (ie, severely visually impaired or blind) were determined and classified according to the WHOs classification system for children. Results Of 153 children in the two participating schools, 144 were severely visual impaired or blind. Their ages ranged from 4 months to 15 years and 58% were female. ROP was the most common cause of visual loss (34.7%), followed by optic nerve lesions (17.4%) and glaucoma (14.6%). 25/59 (42.3%) children aged 0–4 years were blind from ROP compared with 6/32 (18.8%) children aged 10–15 years. 78% of children blind from ROP had psychomotor delay and less than half (46%) had not received treatment for ROP. All five privately funded neonatal intensive care units in the city regularly screen for ROP compared with only four of the 12 units in the public sector. Conclusions ROP is the leading cause of blindness in children in Mexico despite national guidelines being in place. Health policies promoting primary prevention through improved neonatal care need to be implemented. Advocacy is required so that the time ophthalmologists spend screening and treating ROP is included in their job description and hence salaried.

Temporary morphological changes in plus disease induced during contact digital imaging

ObjectiveTo compare and quantify the retinal vascular changes induced by non-intentional pressure contact by digital handheld camera during retinopathy of prematurity (ROP) imaging by means of a computer-based image analysis system, Retinal Image multiScale Analysis.MethodsA set of 10 wide-angle retinal pairs of photographs per patient, who underwent routine ROP examinations, was measured. Vascular trees were matched between ‘compression artifact’ (absence of the vascular column at the optic nerve) and ‘not compression artifact’ conditions. Parameters were analyzed using a two-level linear model for each individual parameter for arterioles and venules separately: integrated curvature (IC), diameter (d), and tortuosity index (TI).ResultsImages affected with compression artifact showed significant vascular d (P<0.01) changes in both arteries and veins, as well as in artery IC (P<0.05). Vascular TI remained unchanged in both groups.ConclusionsNon-adverted corneal pressure with the RetCam lens could compress and decrease intra-arterial diameter or even collapse retinal vessels. Careful attention to technique is essential to avoid absence of the arterial blood column at the optic nerve head that is indicative of increased pressure during imaging.

The Utility of Non-ophthalmologist Examination of Eyes at Risk for Serious Retinopathy of Prematurity

Background: Retinopathy of Prematurity (ROP) is the main cause of preventable blindness in premature babies. Currently, there is a shortage of trained ophthalmologists, which has resulted in an alarming increase in cases of vision loss and related complications. This study’s aim was to determine the utility of examinations conducted by non-ophthalmologist physicians to assess posterior pole vessel abnormalities in eyes at risk for ROP. Method: Non-ophthalmologist physicians (pediatrician and neonatologist) were trained to use an indirect ophthalmoscope to view the posterior pole of babies at risk for ROP. Examinations were conducted on both eyes of premature infants born before 35 weeks gestational age (GA) starting at the third week after birth and weekly thereafter. The presence of Plus disease was identified by the non-ophthalmologist and results compared to the clinical examination by a pediatric ophthalmologist experienced in ROP detection and treatment. Chi-square was used for proportions and the Mann Whitney U test for medians. Fagan’s nomogram was determined for diagnostic usability. The Kappa index was used to rate inter-observer agreement. Results: Results of 228 examinations performed on 150 premature infants were analyzed to determine the correlation of the non-ophthalmologist findings and the eye examination. For any vascular change in posterior pole diagnostic, findings were 87% and 87% accuracy for pediatrician and neonatologist, 82% and 83% sensitivity, 90% and 90% specificity respectively. There was no significant difference found in the detection of Plus disease for the examinations performed by the ophthalmologist compared to those performed by the non-ophthalmologist (P < 0.05). Conclusions: After training in the use of an indirect ophthalmoscope, non-ophthalmologist physicians can reliably detect posterior pole retinal vessel changes for ROP diagnosis.

RetCam compression artifact can mask plus disease.

consistent with a vascular malformation or extensive orbital varix. A surgical biopsy was carried out to obtain a tissue diagnosis and partially debulk the visible part of the lesion. The lesion had strong adhesions making dissection difficult. A slow persistent ooze was noticed from the lesion throughout the surgery. Histopathology showed numerous dilated interconnecting vascular channels in all the excised tissues, which included the mucosa and submucosa of the conjunctiva, Muller’s muscle fibres, fat, and connective tissue (Figure 2). The ramifying abnormally dilated channels were in keeping with a lymphaticvenous malformation or lymphangioma. This corroborated with the clinical and radiological picture.

Higher prolactin and vasoinhibin serum levels associated with incidence and progression of retinopathy of prematurity

Background:Retinopathy of prematurity (ROP) is a potentially blinding, retinal neovascular disease. Systemic prolactin accesses the retina to regulate blood vessels. Prolactin is proangiogenic and can be cleaved to antiangiogenic vasoinhibins. We investigated whether circulating prolactin and vasoinhibins associate with incidence and progression of ROP.Methods:A prospective, longitudinal, case–control study covering postnatal weeks 1 to 9 measured serum prolactin, vasoinhibins, and vascular endothelial growth factor (VEGF) weekly in 90 premature infants diagnosed as ROP or control.Results:Prolactin levels were higher in ROP than in control patients before (106.2 ± 11.3 (SEM) vs. 64.7 ± 4.9 ng/ml, postnatal week 1) and during (120.6 ± 10 vs. 84.7 ± 7.5ng/ml, postnatal week 5) ROP diagnosis. Prolactin, but not gestational age, birth weight, Apgar score, sepsis, or ventilation time, correlated with ROP. The relative risk (RR) of developing ROP increased if Prolactin (PRL) levels were higher than thresholds of 80 ng/ml (RR = 1.55, 95% CI: 1.06–2.28), 100 ng/ml (RR = 1.63, 95% CI: 1.14–2.34), or 120 ng/ml (RR = 1.95, 95% CI: 1.41–2.68). Vasoinhibin levels were 39.7% higher (95% CI: 4.5–77.5) in the circulation of ROP than in control patients at postnatal week 1 and similar thereafter, whereas VEGF serum levels were always similar.Conclusion:High serum prolactin and vasoinhibin levels predict and may impact ROP progression.

Oxygen Monitoring Reduces the Risk for Retinopathy of Prematurity in a Mexican Population

Background: Retinopathy of prematurity (ROP), a potentially blinding disease, affects preterm infants. High levels of oxygen saturation are a well-known risk factor for ROP. Objectives: To assess the frequency of ROP type 1 needing treatment after improved oxygen monitoring (2011) in a Mexican preterm population selected for WINROP analyses and to retrospectively revalidate WINROP, an online surveillance system identifying infants at risk of developing ROP type 1. Methods: Preterm infants born with birth weight (BW) <1,750 g and/or at gestational age (GA) ≤34 weeks, screened for ROP in 2012-2014 at the Hospital Civil de Guadalajara, Mexico were included (n = 151). Eighty-five infants with GA <32 weeks qualified for WINROP analyses. GA, BW, maximal ROP stage, ROP treatment and weekly weights were recorded. The results in the present study were compared to those of a previous WINROP study in the same hospital (2005-2010; n = 352). Results: In the present WINROP cohort, 11.8% of the infants born at GA <32 weeks received treatment compared to 51.0% of the infants in the previous WINROP cohort. One infant (3%) born at GA ≥32 weeks received treatment during the present study period compared to 35.6% during the previous period. WINROP displayed 80.0% sensitivity in infants born at GA <32 weeks in the present study compared to 84.7% in the previous study. Conclusions: Uncontrolled oxygen supplementation is the major risk factor for severe ROP in infants born at GA ≥32 weeks. After improved oxygen monitoring, the frequency of ROP treatment was dramatically reduced at the Hospital Civil de Guadalajara, Mexico.

Propofol for Procedural Anaesthesia During Laser Treatment of Retinopathy of Prematurity in the Neonatal Intensive Care Unit (NICU)

Background: Anaesthesia in preterm neonates poses certain risks due to such patients’ systemic instability and concurrent pathologies, as the procedure itself can accentuate such instability and morbidity in these patients. Anaesthesia for LASER procedures for ROP must be a safe procedure that ensures the patient’s stability during and after the procedure. The purpose of this paper is to describe the anaesthesia techniques used in the neonatal intensive care units (NICUs), and evaluate their results. Methods: Retrospective cross-sectional study carried out from January to December 2012, which included 79 out of 102 patients operated on during such period using laser photocoagulation for ROP under general anaesthesia with intravenous Fentanyl and Propofol administered by a Paediatric Anaesthesiologist. Results: The anaesthesia had a median duration of 75 minutes, and no periods of hypotension were reported. Seventy-eight patients (98%) were extubated at the end of the surgery and one patient remained intubated due to hemodynamic instability related to sepsis. Additionally, it was necessary to re-intubate 2 patients (3%) and 1 patient (1%) required nasal cannulas for 12 hours due to low O2Sat. Conclusions: In the NICU, a combination of Fentanyl and Propofol-without administration of muscle relaxants— is a safe, useful technique for treatment of preterm neonates undergoing brief surgical procedures such as laser photocoagulation. The rapid recovery associated to this technique helps to meet the increasing demand for ROP surgeries and reduces the length of hospitalization. A multivariate regression model considering the complications of intravenous general anesthesia with propofol as the dependent variable was carried out. We observed that the Durbin-Watson test score presented independence of errors (2,135). For the regression model with independent variables, we found that none of them explains the variance of the dependent variable as shown in Table 5. The ANOVA of the regression model with these variables indicates that this does not significantly improve the prediction of complication DV (F = 1.607 and p = 0.129). For the coefficients of the regression model, T-scores reflect that the variables taken into account do not significantly contribute to the prediction model, and therefore that the values obtained can not be generalized to the greater population