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The purpose of this case series is to consider whether preterm infants having gestational age (GA) ≥32 weeks and birth weight (BW) ≥1500 g exposed to unblended oxygen should be screened earlier than the current guidelines adopted from Kenya for the third epidemic of retinopathy of prematurity (ROP). Cases of such infants with severe, treatment-requiring ROP at St Francis Hospital Nsambya, Kampala, Uganda, were reviewed for severe ROP requiring treatment prior to 30 days of life. Since 2022, 3 infants required treatment prior to 30 days of life. All infants received unblended oxygen for 5-10 days after birth and were on room air at the time of treatment. GA ranged from 32 to 34 weeks, and all had BW >1500 g. All infants had chronological age of 2 weeks at treatment. Preterm babies who are born at GA ≥32 weeks and exposed to unblended oxygen may be at risk of developing severe, treatment-requiring ROP earlier than the adopted guidelines from other countries have suggested., (Copyright © 2024. Published by Elsevier Inc.)

Background: To address the threat of retinopathy of prematurity (ROP) in Sub-Saharan Africa (SSA), the Stop Infant Blindness in Africa (SIBA) project introduced a comprehensive program, including subspecialty training and oxygen management equipment., Methods: A before-and-after retrospective cohort study compared preterm infants < 1750 g or < 34 weeks' gestation before (2022) and after (2023) program implementation. Outcomes included: the proportion with severe ROP, the proportion with Zone III vascularization on first examination, and factors associated with severe ROP., Results: Overall, 140 infants were screened before and 122 after program implementation. The proportion with Zone III vascularization increased from 16.1% (N = 11) pre-intervention to 44.9% (N = 32) post-intervention (p = 0.001). The proportion with severe ROP decreased from 27.8% (N = 19) to 12.8% (N = 9, p = 0.03). Factors predicting severe ROP on adjusted analyses were gestational age and blood transfusion., Conclusion: In SSA, introduction of a comprehensive program to prevent and treat ROP can decrease the risk of severe ROP., (© 2024. The Author(s), under exclusive licence to Springer Nature America, Inc.)

Retinopathy of prematurity (ROP) is a leading cause of childhood blindness. Not only do the epidemiologic determinants and distributions of patients with ROP vary worldwide, but clinical differences have also been described. The Third Edition of the International Classification of ROP (ICROP3) acknowledges that aggressive ROP (AROP) can occur in larger preterm infants and involve areas of the more anterior retina, particularly in low-resource settings with unmonitored oxygen supplementation. As sub-specialty training programs are underway to address an epidemic of ROP in sub-Saharan Africa, recognizing characteristic retinal pathology in preterm infants exposed to unmonitored supplemental oxygen is important to proper diagnosis and treatment. This paper describes specific features associated with various ROP presentations: oxygen-induced retinopathy in animal models, traditional ROP seen in high-income countries with modern oxygen management, and ROP related to excessive oxygen supplementation in low- and middle-income countries: oxygen-associated ROP (OA-ROP).

Retinopathy of prematurity (ROP) is a significant cause of potentially preventable blindness in preterm infants worldwide. It is a disease caused by abnormal retinal vascularization that, if not detected and treated in a timely manner, can lead to retinal detachment and severe long term vision impairment. Neonatologists and pediatricians have an important role in the prevention, detection, and management of ROP. Geographic differences in the epidemiology of ROP have been seen globally over the last several decades because of regional differences in neonatal care. Our understanding of the pathophysiology, risk factors, prevention, screening, diagnosis, and treatment of ROP have also evolved over the years. New technological advances are now allowing for the incorporation of telemedicine and artificial intelligence in the management of ROP. In this comprehensive update, we provide a comprehensive review of pathophysiology, classification, diagnosis, global screening, and treatment of ROP. Key historical milestones as well as touching upon the very recent updates to the ROP classification system and technological advances in the field of artificial intelligence and ROP will also be discussed., (Copyright © 2022 by the American Academy of Pediatrics.)

Objective: The aim of this study was to evaluate the visual and structural outcomes of eyes that received ranibizumab as treatment for retinopathy of prematurity (ROP)., Methods: This was a retrospective case series of infants who received a 0.2 mg (0.02 mL) intravitreal injection of ranibizumab as the primary treatment for type 1 ROP. Outcome measures included regression or recurrence of ROP, complications of treatment, and assessment of visual acuity and refractive error., Results: Forty-two eyes of 21 infants (13 male) were included. Mean gestational age and birth weight were 24.6 ± 1.3 weeks and 613 ± 91 g, respectively. Mean age at injection was 37.4 ± 2.2 weeks postmenstrual age, and mean follow-up period was 10.1 ± 7 months. Active neovascularization regressed rapidly, and anatomical outcomes were favourable in all eyes. Twelve eyes of 6 infants received supplemental laser photocoagulation at a mean post-menstrual age (PMA) of 72.0 ± 27.3 weeks when vascularization had not advanced beyond zone II. Visual acuity was measurable in 28 of 42 eyes. Mean visual acuity was 0.94 ± 0.36 logMAR. Mean spherical equivalent was +1.00. There were no ocular or systemic complications in these patients and no cicatricial complications were observed with no progression to stage 4 or 5 disease., Conclusions: A single intravitreal dose of 0.2 mg (0.02 mL) ranibizumab showed favourable anatomical and functional outcomes in eyes with type 1 ROP., (Copyright © 2017. Published by Elsevier Inc.)

Purpose: To examine the feasibility of a retinopathy of prematurity (ROP) telemedicine evaluation system of providing timely feedback to a neonatal intensive care unit (NICU) with at-risk premature infants., Methods: This was a prospective observational study of premature infants with birth weights of <1251 g in five NICUs in the United States. Infants scheduled for clinically indicated ROP evaluations underwent indirect ophthalmoscopic examinations and digital imaging on the same day. Imaging was performed by nonphysician retinal imagers. Times required were determined from obtaining digital images of both eyes to submission via web-based system to a secure server for grading by trained readers at a central reading center to sending back grading results to the clinical center., Results: A total of 1,642 image sets of eyes of 292 infants were obtained, from 823 imaging sessions. The mean turnaround time from submission of image sets of both eyes to return of the grading results to the clinical center was 10.1 ± 11.3 hours (standard deviation), with a median of 12.0 hours (1st quartile, 0.9 hours; 3rd quartile, 16 hours). Overall, 95.5% of gradings (95% CI, 93.9%-96.7%) were returned within 24 hours. Subgroup analyses found, for image sets submitted to the reading center before 2 p.m. Eastern Standard Time, median time to report was 1.7 hours (1st quartile, 0.7 hours; 3rd quartile, 15.5 hours) compared with those submitted after 2pm (median, 14.1 hours; 1st quartile, 11.2, hours; 3rd quartile, 16.3 hours)., Conclusions: An ROP telemedicine approach can provide timely feedback to the NICU regarding the detection of potentially serious ROP and thus referral to an ophthalmologist for examination and consideration of treatment., (Copyright © 2016 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Retinopathy of prematurity (ROP), a disorder of the retina occurring in preterm infants, is the leading cause of preventable childhood blindness. An active phase of ROP that requires treatment is associated with the presence of plus disease, which is diagnosed clinically in a qualitative manner by visual assessment of the existence of a certain level of increase in the thickness and tortuosity of retinal vessels. The present study performs computer-aided diagnosis (CAD) of plus disease via quantitative measurement of tortuosity in retinal fundus images of preterm infants. Digital image processing techniques were developed for the detection of retinal vessels and measurement of their tortuosity. The total lengths of abnormally tortuous vessels in each quadrant and the entire image were then computed. A minimum-length diagnostic-decision-making criterion was developed to assess the diagnostic sensitivity and specificity of the values obtained. The area ([Formula: see text]) under the receiver operating characteristic curve was used to assess the overall diagnostic accuracy of the methods. Using a set of 19 retinal fundus images of preterm infants with plus disease and 91 without plus disease, the proposed methods provided an overall diagnostic accuracy of [Formula: see text]. Using the total length of all abnormally tortuous vessel segments in an image, our techniques are capable of CAD of plus disease with high accuracy without the need for manual selection of vessels to analyze. The proposed methods may be used in a clinical or teleophthalmological setting.

Changes in the characteristics of retinal vessels such as width and tortuosity can be signs of the presence of several diseases such retinopathy of prematurity (ROP) and diabetic retinopathy. Plus disease is an indicator of ROP which requires treatment and is signified by an increase in posterior venular width. In this work, we present image processing techniques for the detection, segmentation, tracking, and measurement of the width of the major temporal arcade (MTA), which is the thickest venular branch in the retina. Several image processing techniques have been employed, including the use of Gabor filters to detect the MTA, morphological image processing to obtain its skeleton, Canny's method to detect and select MTA vessel-edge candidates, least-squares fitting to interpolate the MTA edges, and geometrical procedures to measure the width of the MTA. The results, obtained using 110 retinal fundus images of preterm infants, indicate a statistically highly significant difference in MTA width of normal cases as compared to cases with plus disease (p<0.01). The results provide good accuracy in computer-aided diagnosis (CAD) of plus disease with an area under the receiver operating characteristic curve of 0.76. The proposed methods may be used in CAD of plus disease and timely treatment of ROP in a clinical or teleophthalmological setting., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

An increase in retinal vessel tortuosity can be indicative of the presence of various diseases including retinopathy of prematurity (ROP). Accurate detection and measurement of such changes could help in computer-aided diagnosis of plus disease, which warrants treatment of ROP. We present image processing methods for detection and segmentation of retinal vessels, quantification of vessel tortuosity, and diagnostic-decision-making criteria that incorporate the clinical definition of plus-diagnosis. The obtained results using 110 retinal fundus images of preterm infants (91 without plus and 19 with plus) provide high sensitivity = 0.89 (17/19) and excellent specificity = 0.95 (86/91) in the diagnosis of plus disease.

Purpose: We tested the hypothesis that the openness of the major temporal arcade (MTA) changes in the presence of plus disease, by quantification via parabolic modeling of the MTA, as well as measurement of an arcade angle for comparative analysis. Such analysis could assist in the detection and treatment of progressive retinopathy of prematurity., Methods: Digital image processing techniques were applied for the detection and modeling of the MTA via a graphical user interface (GUI) to quantify the openness of the MTA. An arcade angle measure, based on a previously proposed method, also was obtained via the GUI for comparative analysis. The statistical significance of the differences between the plus and no-plus cases for each parameter was analyzed using the P value. The area (Az) under the receiver operating characteristic curve was used to assess the diagnostic performance of each feature., Results: The temporal arcade angle measure and the openness parameter of the parabolic model were used to perform discrimination of plus versus no-plus cases. Using a set of 19 cases with plus and 91 with no plus disease, Az=0.70 was obtained using the results of dual-parabolic modeling in screening for plus disease. The arcade angle measure provided comparable results with Az=0.73., Conclusions: Using our proposed image analysis techniques and software, this study demonstrates, for the first time to our knowledge, that the openness of the MTA decreases in the presence of plus disease., (Copyright 2014 The Association for Research in Vision and Ophthalmology, Inc.)

Diagnosis of plus disease is crucial for timely treatment and management of retinopathy of prematurity. An indicator of the presence of plus disease is an increase in the tortuosity of blood vessels in the retina. In this work, we propose a new angle-variation-based measure for quantification of tortuosity in retinal fundus images of preterm infants. The methods include the use of Gabor filters to detect vessels as well as to obtain their orientation at each pixel. Morphological image processing methods are used to obtain a skeleton image of the vessels for measurement of tortuosity. Out of 11 vessel segments, marked by an expert ophthalmologist as showing high levels of tortuosity due to plus disease, all were correctly identified using the proposed methods.

Monitoring the openness of the major temporal arcade (MTA) and how it changes over time could facilitate diagnosis and treatment of proliferative diabetic retinopathy (PDR). We present methods for user-guided semiautomated modeling and measurement of the openness of the MTA based on Gabor filters for the detection of retinal vessels, morphological image processing, and a form of the generalized Hough transform for the detection of parabolas. The methods, implemented via a graphical user interface, were tested with retinal fundus images of 11 normal individuals and 11 patients with PDR in the present pilot study on potential clinical application. A method of arcade angle measurement was used for comparative analysis. The results using the openness parameters of single- and dual-parabolic models as well as the arcade angle measurements indicate areas under the receiver operating characteristics of A z = 0.87, 0.82, and 0.80, respectively. The proposed methods are expected to facilitate quantitative analysis of the architecture of the MTA, as well as assist in detection and diagnosis of PDR.

Screening for retinopathy of prematurity (ROP) and the optimum treatment of sight-threatening disease requires detailed understanding of the infants at risk and timely identification. Despite a plethora of guidelines, not all populations and situations are adequately covered, so that what should be preventable visual disability still occurs. This article considers the design of screening guidelines and the possibility of a global guideline, although in certain parts of the world manpower for ROP screening is not available. Algorithms linked to the increase in weight of preterm infants over time may refine the number of babies needing to undergo treatment., (Crown Copyright © 2013. Published by Elsevier Inc. All rights reserved.)

Background: Current methods of treating the avascular retina with laser photocoagulation for severe retinopathy of prematurity (ROP) are not completely effective in the reduction of visual morbidity. We report a case series in which additional laser treatment, called 'posterior laser', was delivered posterior to the neovascular ridge, for eyes with severe stage 3 ROP in zone II with avascular retina posterior to the ridge., Design: Retrospective chart review., Participants: Infants who underwent laser treatment, posterior to the neovascular ridge for severe ROP at the Alberta Children's Hospital, between January 2005 and October 2008., Methods: Charts were reviewed for 18 eyes of 11 patients and collected information included demographic data, clinical examination results, and digital retinal images., Main Outcome Measures: Structural and functional outcomes of treatment., Results: Four (22%) of 18 eyes received 'posterior laser' as primary treatment and the remainder of eyes (78%) received 'posterior laser' following previous laser photocoagulation anterior to the neovascular ridge. Mean birthweight was 688 g (552-930) and mean gestational age was 24 weeks (23-28). There were no complications because of the posterior laser treatment. In all, 16 of 18 eyes experienced rapid regression of the ridge and subsequent decrease in vascular dilation and tortuosity within 1 week. Two eyes required vitrectomy for 4A retinal detachment; however, no eyes developed stage 4B ROP., Conclusion: Posterior to the ridge laser in the setting of the morphological criteria described had no increased safety concerns and resulted in rapid regression of ROP with good outcomes.

The publication of the BEAT-ROP study of bevacizumab (Avastin) treatment for Zone I and II retinopathy of prematurity (ROP) has raised hopes that there might now be a simpler, cheaper and more effective treatment than laser therapy, the current standard of care. However, we would urge caution at this point in time. We review the scientific background to the use of intravitreal anti-vascular endothelial growth factor for ROP, highlight a number of design issues in the BEAT-ROP study and problems with interpretation of the results. For example, no visual outcomes were reported and the study was underpowered to assess longer term safety. Intravitreal bevacizumab leaks into the systemic circulation in animals and adult humans and there are real concerns of potential harm to the developing preterm infant because vascular growth factors play a critical role in organogenesis. We conclude that bevacizumab should be reserved for exceptional circumstances and compassionate use pending further studies. Laser remains the proven effective therapy for first line treatment of all forms of ROP with little systemic morbidity. Neonatology and ophthalmology have an impressive record of conducting collaborative multicentre studies and we urgently need further rigorously designed, adequately powered randomised trials of anti-VEGF agents that evaluate visual outcomes as well as short and long term ocular and systemic safety.

Purpose: To evaluate vessel selection methods to distinguish between eyes with and without retinopathy of prematurity (ROP) and between different stages of ROP when quantifying the associated vessel changes in width and tortuosity semiautomatically from digital retinal images., Methods: Color digital images from 75 infants screened for ROP were cropped to a standardized diameter of 240 pixels and evaluated by semiautomated vessel analysis software, Computer-Aided Image Analysis of the Retina (CAIAR), to measure retinal vessel width and tortuosity. Two methods of vessel selection were used: (1) clinical observer selecting the most prominent arteriole or venule in each retinal quadrant (4-vessel analysis) and then separately the 4 most prominent arterioles and venules from each quadrant (8-vessel analysis); (2) CAIAR selecting, regardless of retinal quadrant, the 4 widest or most tortuous arterioles or venules. Selected vessels were measured by CAIAR for tortuosity and width., Results: When comparing ROP stages, whether observer or CAIAR selected and whether 4 or 8 vessels were analyzed, we found that arteriolar tortuosity was significantly greater with advancing ROP stage for stage 0 versus stage 2; stage 0 or 1 versus stage 3; stages 1+2 combined versus stage 3; and stage 0 versus 1+2+3 combined (P < 0.01). Venular tortuosity was significantly greater with advancing ROP stage for stage 0 versus stage 3 and stage 0 versus stages 1 and 2+3 combined (P < 0.01). Width parameters did not help us to distinguish between stages., Conclusions: Distinguishing between arterioles and venules is not necessary to differentiate stage 0 ROP from stage 2 or 3 ROP when one is using CAIAR. Tortuosity shows more promise than width at providing a reliable vessel parameter for distinguishing between eyes without and with ROP., (Copyright © 2012 American Association for Pediatric Ophthalmology and Strabismus. All rights reserved.)

Monitoring the openness of the major temporal arcade (MTA) and how it changes over time could facilitate improved diagnosis and timely treatment of proliferative diabetic retinopathy (PDR). We present methods for user-guided modeling and measurement of the openness of the MTA based on a form of the generalized Hough transform for the detection of parabolas, and to compare it with a method of arcade angle measurement. The methods, implemented via a graphical user interface, were tested with retinal fundus images of 10 normal individuals and 15 patients with PDR. The results using the openness parameters of single- and dual-parabolic models as well as the arcade angle measurements indicate areas under the receiver operating characteristics of A(z)= 0.94, 0.87, and 0.84, respectively. The proposed methods should facilitate improved quantitative analysis of the architecture of the MTA, as well as assist in detection, diagnosis, and improved treatment of PDR.

We propose a method using Gabor filters and phase portraits to automatically locate the optic nerve head (ONH) in fundus images of the retina. Because the center of the ONH is at or near the focal point of convergence of the retinal vessels, the method includes detection of the vessels using Gabor filters, detection of peaks in the node map obtained via phase portrait analysis, and an intensity-based condition. The method was tested on 40 images from the Digital Retinal Images for Vessel Extraction (DRIVE) database and 81 images from the Structured Analysis of the Retina (STARE) database. An ophthalmologist independently marked the center of the ONH for evaluation of the results. The evaluation of the results includes free-response receiver operating characteristics (FROC) and a measure of distance between the manually marked and detected centers. With the DRIVE database, the centers of the ONH were detected with an average distance of 0.36 mm (18 pixels) to the corresponding centers marked by the ophthalmologist. FROC analysis indicated a sensitivity of 100% at 2.7 false positives per image. With the STARE database, FROC analysis indicated a sensitivity of 88.9% at 4.6 false positives per image.

Detection of the optic nerve head (ONH) is a key preprocessing component in algorithms for the automatic extraction of the anatomical structures of the retina. We propose a method to automatically locate the ONH in fundus images of the retina. The method includes edge detection using the Sobel operators and detection of circles using the Hough transform. The Hough transform assists in the detection of the center and radius of a circle that approximates the margin of the ONH. Forty images of the retina from the Digital Retinal Images for Vessel Extraction (DRIVE) dataset were used to test the performance of the proposed method. The center and boundary of the ONH were independently marked by an ophthalmologist for evaluation. Free-response receiver operating characteristics (FROC) analysis as well as measures of distance and overlap were used to evaluate the performance of the proposed method. The centers of the ONH were detected with an average distance of 0.36 mm to the corresponding centers marked by the ophthalmologist; the detected circles had an average overlap of 0.73 with the boundaries of the ONH drawn by the ophthalmologist. FROC analysis indicated a sensitivity of detection of 92.5% at 8.9 false-positives per image. With an intensity-based criterion for the selection of the circle and a limit of 40 pixels (0.8 mm) on the distance between the center of the detected circle and the manually identified center of the ONH, a successful detection rate of 90% was obtained with the DRIVE dataset.

Purpose: To determine, with novel software, the feasibility of measuring the tortuosity and width of retinal veins and arteries from digital retinal images of infants at risk of retinopathy of prematurity (ROP)., Methods: The Computer-Aided Image Analysis of the Retina (CAIAR) program was developed to enable semiautomatic detection of retinal vasculature and measurement of vessel tortuosity and width from digital images. CAIAR was tested for accuracy and reproducibility of tortuosity and width measurements by using computer-generated vessel-like lines of known frequency, amplitude, and width. CAIAR was then tested by using clinical digital retinal images for correlation of vessel tortuosity and width readings compared with expert ophthalmologist grading., Results: When applied to 16 computer-generated sinusoidal vessels, the tortuosity measured by CAIAR correlated very well with the known values. Width measures also increased as expected. When the CAIAR readings were compared with five expert ophthalmologists' grading of 75 vessels on 10 retinal images, moderate correlation was found in 10 of the 14 tortuosity output calculations (Spearman rho = 0.618-0.673). Width was less well correlated (rho = 0.415)., Conclusions: The measures of tortuosity and width in CAIAR were validated using sequential model vessel analysis. On comparison of CAIAR output with assessments made by expert ophthalmologists, CAIAR correlates moderately with tortuosity grades, but less well with width grades. CAIAR offers the opportunity to develop an automated image analysis system for detecting the vascular changes at the posterior pole, which are becoming increasingly important in diagnosing treatable ROP.

Purpose: To determine the feasibility in a middle-level human development country of onsite training, image collection, Internet transfer, and remote grading of digital retinal images from babies screened for retinopathy of prematurity (ROP)., Methods: Two experienced nurses in a neonatal nursery in Lima, Peru, were trained to take posterior pole (30 degrees ) digital retinal images. Nurses obtained posterior pole retinal images from babies undergoing routine ROP screening and selected images for uploading via Internet for remote evaluation by five masked ROP experts. Results of gradings were compared with same-day clinical diagnostic examinations by an experienced ophthalmologist. Success rates for image acquisition and transfer for grading by expert readers were calculated., Results: Serial image sets from 26 of the 28 babies enrolled in this study were obtained; two babies were too unstable for imaging. Fifty-six of 58 (96.6%) imaging sessions were successful in obtaining retinal images. Three hundred thirty of 336 (98.2%) images obtained were successfully uploaded to an interactive database. Remote graders judged 93.6% to 97.3% of image sets suitable for ROP grading. Preliminary results indicate sensitivities for detection of serious ROP from 45.5% to 95.2% among individual readers, with specificities of 61.7% to 96.2% when images were gradable., Conclusions: A telemedicine approach for ROP screening using digital retinal images obtained by nonophthalmologists is feasible in rapidly developing countries that lack ROP-trained ophthalmologists. If remote grading of digital images is validated as an effective method for identifying referral-warranted ROP (RW-ROP), images obtained by nonphysicians may provide a means of identifying babies who require a diagnostic examination by an ophthalmologist.

Background: To determine the outcomes and circumstances of retinal injuries caused by blunt trauma from paintball pellet projectiles., Methods: Retrospective case series of all patients who presented with retinal injuries due to paintball-related trauma to 2 retina specialists in a clinical setting from 2004 to 2005. Patients were followed for a mean of 7.3 months, and retinal trauma was documented with retinal photographs and ocular coherence tomography as needed. Best corrected visual acuity (BCVA) was the main outcome measure., Results: Three eyes of 3 patients suffered severe retinal injuries after blunt trauma from a paintball pellet. Together, the 3 eyes demonstrated extensive retinal findings, including commotio retinae, choroidal rupture, and macular hole. BCVA at last follow-up ranged from 20/80 to hand motions., Interpretation: Our small case series indicates that retinal trauma from paintball injuries is not uncommon and results in severe long-term visual morbidity. The sale of paintball guns and pellets should be strictly prohibited for minors, and adults should be educated about the need for appropriate ocular protection and the potentially serious consequences of the use of these guns outside of commercial settings.

Background: There is currently a widespread use of intravitreal triamcinolone acetonide (IVTA) for age-related macular degeneration, diabetic macular edema, cystoid macular edema secondary to retinal vein occlusions, and uveitis. The aim of this investigation was to assess the rates of various complications associated with this treatment and to determine which factors are associated with the development of these complications., Methods: A retrospective interventional case series of all patients from one retina specialist undergoing IVTA was conducted in a clinical setting from 2002 to 2005. All disease entities were included. Patients were followed for a mean of 9.5 months after receiving 4 mg (0.1 mL) of nonfiltered triamcinolone acetonide (TA). All complications associated with the injection procedure or with the TA were noted., Results: Two hundred and twenty-three (223) eyes of 192 patients received a total of 336 IVTA injections between 2002 and 2005. The mean age was 73.3 years and mean follow-up was 9.5 months. A single injection was performed in 144 eyes (64.6%); 2 IVTAs in 55 eyes (24.7%); 3 IVTAs in 16 eyes (7.2%), and 3.6% of eyes had more than 3 injections at a minimal interval of 3 months. The only immediate complication was a single injection (0.3%) associated with a temporary occlusion of the central retinal artery, which opened immediately following anterior paracentesis. Late complications included endophthalmitis in 1 of 336 (0.3%) injections and a steroid response requiring glaucoma medication in 60 of 192 patients (31.3%). In patients with preexisting glaucoma, 58.8% required additional glaucoma medication. Glaucoma-filtering surgery was required in 2 of 192 patients (1.0%)., Conclusions: In the study center, the IVTA is extremely safe in patients without a history of glaucoma. However, patients with preexisting glaucoma with progressive optic neuropathy must be treated with great caution.

Purpose: To evaluate the use of remote reading of digital retinal photographs in the diagnosis of severe (referral-warranted) retinopathy of prematurity (ROP) during longitudinal screening for ROP., Study Design: Prospective, longitudinal cohort study., Subjects: Forty-four consecutive premature infants at risk for ROP., Methods: All infants were examined longitudinally, over a series of examinations, by indirect ophthalmoscopy (gold standard) and digital photography using the RetCam-120 Digital Retinal Camera (Massie Research Laboratories Inc., Dublin, CA) equipped with an ROP lens. Images were stored and read remotely by a masked reader. Referral-warranted ROP was defined as ROP in zone 1, the presence of plus disease or the presence of any stage 3 ROP. We determined whether and when referral-warranted ROP was diagnosed for each eye, of each infant, on each examination, during the course of each of the infant's screening., Results: Severe (referral-warranted) ROP was diagnosed in 23 eyes by indirect ophthalmoscopy during their series of examinations. Digital photography had a sensitivity of 100% and a specificity of 96% in detecting referral-warranted ROP. The positive predictive value of digital photography was 92%, and the negative predictive value was 100%. In 87% of eyes, referral-warranted ROP was diagnosed by digital photography before or at the same time as indirect ophthalmoscopy., Conclusions: Longitudinal remote reading of digital photographs using the RetCam-120 system has excellent specificity and sensitivity in detecting referral-warranted ROP. This pilot study has shown that remote reading of digital photographs has promise for telemedicine strategies in ROP screening.

Background: Congenital absence of the inferior rectus muscle is a rare cause of apparent inferior rectus palsy especially in the absence of associated cranial facial anomalies., Methods: We report three cases of isolated congenital absence of the inferior rectus muscle and its successful surgical management., Results: Failure of the normal embryologic development of the mesodermal complex around the eye can lead to agenesis of the extraocular muscles. In apparent palsies of the inferior rectus muscle and no definite cause, a high index of suspicion and orbital imaging can confirm the diagnosis of congenitally absent inferior rectus preoperatively. Surgical correction may involve inferior transposition of the horizontal rectus muscles., Conclusions: Although rare, congenital absence of the inferior rectus muscle is a possible cause of apparent inferior rectus muscle palsy particularly in the absence of another identifiable cause. Strabismus surgery in conjunction with intramuscular botulinum toxin injection can offer significant improvement in function and cosmesis of these patients.

Shaken baby syndrome is a constellation of injuries resulting from the intentional shaking type movement of a child who is usually younger than 3-years-old. This rapid acceleration-deceleration movement of the head is responsible for lesions attributed to shearing forces placed on the vitreoretinal structures and meningeal vessels across the dura. The ophthalmic findings include intraocular hemorrhages, perimacular retinal folds, and peripheral retinoschisis in the presence of intracranial injuries such as subdural hematomas without obvious external signs of head trauma. We describe a case of late development of an epiretinal membrane in a child with a history of shaken baby syndrome and propose a differential diagnosis list for epiretinal membrane formation in the pediatric age group.

Clostridial gas gangrene (myonecrosis) is a rapidly progressive, life-threatening infection. The occurrence of clostridial gas gangrene in the orbit is uncommon. We present a case of gas gangrene in the orbit of a child, with Clostridium perfringens isolated from the wound. Our patient was successfully treated with extensive surgical débridement, anti-microbial therapy, and hyperbaric oxygen therapy. Hyperbaric oxygen is established as an adjuvant therapy of clostridial gas gangrene and has been shown to significantly reduce morbidity and mortality. To our knowledge, this is the first reported case of using hyperbaric oxygen therapy in the treatment of orbital gas gangrene.

Purpose: To evaluate photorefractive keratectomy (PRK) in pediatric patients who fail traditional methods of treatment for myopic anisometropic amblyopia and high myopia., Setting: Nonhospital surgical facility with follow-up in a hospital clinic setting., Methods: Photorefractive keratectomy was performed in 40 eyes of 27 patients. The patients were divided into 4 groups based on the type of myopia: myopic anisometropic amblyopia (15 eyes/13 patients), bilateral high myopia (20 eyes/10 patients), high myopia post-penetrating keratoplasty (3 eyes/2 patients), and combined corneal scarring and anisometropic amblyopia (2 eyes/2 patients). All procedures were performed under general anesthesia using the VISX 20/20 B laser and a multizone, multipass ablation technique. Appropriate corneal fixation was achieved with appropriate head positioning (turn and tilt) and an Arrowsmith fixation ring. Myopia was as high as -25.00 diopter (D) spherical equivalent (SE), but no treatment was for more than -17.50 D SE., Results: The mean SE decreased from -10.68 D to -1.37 D at 1 year, a mean change of -9.31 D. At 1 year, the mean best corrected visual acuity improved from 20/70 to 20/40 in the entire group. Forty percent of eyes were within +/-1.0 D of the targeted refraction. There was no haze in 59.5% of eyes. Three eyes initially had 3+ haze; 1 improved to 2+ and 2 required repeat PRK with significant haze reduction. Five eyes (3 patients) with greater than -17.00 D SE myopia before PRK (range -17.50 to -25.00 D) had 3.42 D more effect than predicted (range 0.50 to 5.50 D). A functional vision survey demonstrated a positive effect on the children's ability to function in their environments after the laser treatment., Conclusion: Photorefractive keratectomy in children represents another method of providing long-term resolution of bilateral high myopia and myopic anisometropic amblyopia.