How should the neonatologist and ophthalmologist ideally interact when it comes to therapy, screening, and treatment?
Prof. Marlow: This is a key question because ROP involves a small number of patients for whom treatment is time critical. It can be very difficult to examine the eyes of a baby in a neonatal unit who’s undergoing critical care, who’s on a ventilator, and who may have other headgear on for other forms of ventilation. Of course, these babies are the ones who we really don’t want to miss. The level of skill required on the part of the ophthalmologist to identify those that need to be considered for treatment is very high. For this reason, in the United Kingdom, standards of care for ROP were developed by a group of clinicians that included both neonatologists and ophthalmologists. Our National Audit program records not whether ROP was screened for successfully or what the retinal stage was, but rather did the retinal screening occur on time, because that’s the most critical thing.
Prof. Martinez-Castellanos: In Mexico, the situation is complicated. As in any middle-income country, we have both very good and very bad NICUs. We can see the results of this, both good and bad, in the babies that are treated there. In the worst NICUs, oxygen is given at 100% concentration without oximetry, resulting in very severe cases of ROP. What standard of NICU a premature infant is treated at depends on the economic background of the family. There are fewer cases of ROP in families that are able to pay for a better standard of care, but in poorer families many babies go blind because of poor oxygen management in the NICU.
Do you as a neonatologist ask ophthalmologists their opinion when it comes to setting the right oxygen level?
Prof. Marlow: No, because clinical trials have been performed, which provide us with this information. However, although the relationship of ROP with oxygen was recognized in the 1940s, it has only been over the last 10 years that these studies have been performed to refine the relationship further, and there is still more to learn in terms of understanding how we use oxygen. To improve mortality and reduce the risk of necrotizing enterocolitis, which is a systemic and quite catastrophic disease, we currently have to tolerate levels of retinopathy that we would have hoped to reduce.
What are the factors that influence your decision on the treatment modality to use?
Prof. Martinez-Castellanos: In Mexico, the decision depends on what is available in that area. Laser is available in some, but not all, NICUs. This means that anti-VEGF therapy is the only treatment option available for ROP in some units.
Prof. Stahl: Where possible, however, the availability of treatment shouldn’t affect the treatment decision. Whenever the options of laser therapy versus anti-VEGF injections are presented, we should be able to offer both at an equal quality. This is why treatment for ROP should always take place at centers with expertise in this area and with both treatment options available at the same quality, because otherwise there is always a tendency to favor one treatment over another depending on what is available or what we can do best. These factors should not, however, be guiding our treatment decisions.
Prof. Marlow: I agree; it is clear that ROP cases should be managed in specialized centers by doctors with a high level of expertise. Another factor to consider is the circumstances of the patient’s family. It can be quite challenging for families to go to the expense of traveling to a center frequently over a number of months, but if they are not able or willing to bring the child back to the clinic for follow-up then it might actually be dangerous to use an anti-VEGF agent. If anti-VEGF therapy is to be used, it is the responsibility of the ophthalmologist to educate the family on the importance of follow-up.
What are the next steps in ROP that you would like to see following these developments in anti-VEGF therapy?
Prof. Martinez-Castellanos: Having access to screening is a key point, as not every country has a real screening program for ROP yet. Next, good communication between ophthalmologists and neonatologists is important, so that they can liaise efficiently to ensure that all babies at risk of developing ROP receive screening. Finally, in cases where babies do develop ROP, good communication with the parents regarding treatment and follow-up is required. Parents need to understand that ROP is a lifetime disease. Even though we can cure it, it can have long-term consequences, following either laser or anti-VEGF therapy.
Prof. Stahl: Yes, we need a screening program that detects ROP before the disease reaches its worst extent. We then need a second lifelong ‘screening phase’ to ensure that we limit the number of amblyopia from strabismus or from refractive errors and that we pick up retinal changes that may lead to late retinal detachment.
Prof. Marlow: Neonatologists should attempt to reduce the amount of respiratory disease in our client population. Currently in the United Kingdom, the majority of women who deliver prior to 32 weeks receive antenatal steroids. We are also now beginning to use much less oxygen in the delivery room, as it may cause hyperoxia, which we know is potentially very dangerous, even over a relatively short period of time. In addition, we are learning that cutting the umbilical cord immediately after birth promotes respiratory disease, if it is done too quickly, so we are trying to delay this procedure until the circulation becomes stable. With these developments, plus others relating to treating infection and preventing lung disease, which drives the need for oxygen, we should be able to reduce the risk of ROP considerably.