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Excerpt
I read the article by Hartnett entitled “Features associated with surgical outcome in patients with stages 4 and 5 retinopathy of prematurity.” 1 I would like to emphasize a few points before sharing my contribution related to this issue.
The author retrospectively reviewed preoperative ocular features with postoperative surgical results of 35 eyes of 22 premature patients with stages 4 and 5 retinopathy of prematurity (ROP). Almost all infants were treated with laser/cryotherapy elsewhere before referral for vitreoretinal surgery. Fourteen eyes had zone 1 and 20 eyes had zone 2 ROP with threshold disease. Fourteen of 35 eyes had stage 5 ROP and 21 eyes had stage 4 ROP. All patients had undergone vitreoretinal surgery, scleral buckle with/without lens-sparing vitrectomy.
Despite recent major advances, ROP is a still challenging childhood problem especially in developing countries. The stimulation of vascular endothelial growth factor (VEGF) by retinal hypoxia is the main contributing factor in the pathophysiology of ROP, 2 because VEGF is a major regulator of angiogenesis in neovascular eye diseases. As mentioned in the article, retinal hypoxia strongly induces VEGF expression and stimulates pathologic vasoproliferation of both avascular and vascularized retina. Any skipped area in laser ablation continues to stimulate VEGF production in ROP eyes even treated with near-confluent laser photocoagulation. Therefore, anti-VEGF therapy is a promising new therapy for the treatment of all neo-vascular eye diseases, including age-related macular degeneration, diabetic retinopathy, and ROP. 3 Inhibitors of VEGF might replace conventional treatment modalities in the near future.
We currently have long-acting angiostatic cortisone for inhibition of VEGF. Cortisone has an inhibitory effect at least in part on VEGF expression. 4 Intravitreal triamcinolone is in clinical usage, especially for macular edema. Intravitreal triamcinolone might contribute to improvement of blood–retina barrier and regression of neovascularization in stage III and even stage IV ROP with threshold disease. Lakhanpal et al 5 showed that intravitreal steroid may stabilize the findings in stage III eyes with plus disease without any progression. In stage IV eyes progression with cicatrization of neovascularization was demonstrated. This condition gives more possibility to safe vitreoretinal surgery. Finally, intravitreal triamcinolone injection from pars plicata is a good adjunct method to laser ablation and safe vitreoretinal surgery.
