Neonatology. 2016;110(2):135-40. doi: 10.1159/000445040.

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

Zepeda-Romero LC1, Lundgren P, Gutierrez-Padilla JA, Gomez-Ruiz LM, Quiles Corona M, Orozco-Monroy JV, Barragan-Sánchez A, Razo-Cervantes JC, Löfqvist C, Hård AL, Hellström A.
  • Clinic of Retinopathy of Prematurity and Blindness Prevention, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, Mexico.

Abstract

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.

PMID: 27088589

 

Supplement:

Retinopathy of prematurity (ROP) arises when abnormal vascularization occurs in the maturing retina in preterm infants. ROP causes blindness or severe visual impairment in approximately 20 000 infants each year around the world [1]. In most cases, blindness caused by ROP is preventable by timely detection and treatment. Gestational age (GA) and birth weight (BW) are well-known major risk factors for ROP that reflect the infants’ degree of immaturity [2] and most commonly used ROP screening guidelines are based on GA and/or BW. However, while the quality of neonatal care is improving, not all neonatal intensive care units (NICUs) have ROP screening programs, adequate screening equipment, and ophthalmologists who are trained to detect and treat ROP [3]. Zepeda-Romero et al. reported that in Guadalajara city, Mexico, only 50% of the NICU’s had a regular ROP program. In schools for the visually impaired in Guadalajara city more than 40% of the children (under the age of 5 years) were blind due to ROP. The majority of these infants had not been treated for ROP [4].

Excessive oxygen supplementation was the first identified and best-known risk factor for ROP [5] and caused the “first epidemic” of ROP in the 1950’s. A “new epidemic” of ROP is presently being seen in middle income regions, such as Latin America, Asia and Eastern Europe, where neonatal care is still developing [3,6]. ROP is increasing around the world again due to lack of basic equipment for administration/ monitoring of oxygen and insufficient training. However several studies have showed the favorable impact of improved oxygen administration and personal education on ROP rates [7,8].

In settings with advanced neonatal care, poor pre- and postnatal weight gain have been found to predict severe ROP [9-11]. Based on these findings, WINROP (weight, insulin-like growth factor-1, and neonatal ROP) was developed in Gotheburg, Sweden, as a prediction tool for severe ROP based on postnatal weight development. By recording the infant’s BW and GA along with weekly weight measurements, WINROP accumulates and calculates the infant’s risk of developing severe ROP that requires treatment. The WINROP system has an alarm function that signals if an infant is at high risk of developing ROP requiring treatment. Even if WINROP does not give this signal, weekly weight measurements must be performed until the infant is at PMA 33–34 weeks. Not until then can the infant be completely free of risk as evaluated by WINROP. WINROP is free of charge. The sensitivity and specificity of WINROP varies slightly between the cohorts; this is proposed to be due to the characteristics of the infants that are born preterm. WINROP could predict severe ROP with high sensitivity in settings with highly developed neonatal care, [12-14] but with lower sensitivity in settings with poor oxygen control [15]. It has been suggested that WINROP could be more useful if it was adapted to the characteristics of different populations [16]. WINROP is meant to be a supplement to rather than a substitute for established ROP screening practices. The aim of WINROP is to safely minimize the number of ROP screening examinations in infants at low risk of ROP requiring treatment and to alert physicians to infants who are at high risk.

The study presented was initiated as a consequence of a previously performed study; a WINROP validation of infants screened for ROP at the NICU at the Hospital Civil de Guadalajara, Mexico in 2005˗2010. This prior WINROP study (2005˗2010) alerted the clinicians to the high ROP rates at the NICU, and the infants exposure to high levels of oxygen saturations were evaluated. Several implements and improvements concerning monitoring and control of oxygen supplementation were initiated at the NICU in 2011, such as installation of individual infant oxygen pulse oximeters for constant surveillance (in 2005-2010 oxygen saturations were monitored but not on an individual constant basis). In 2011 the target saturation was set to 85-95% and alarms were set to ring when oxygen saturationns reached 90-95% (in 2005-2010 oxygen saturation was set at a minimum of 85% and most infants reached 100% oxygen saturation). Additional education to the neonatologists and nurses at the NICU was initiated.

In the present study, including infants screened for ROP at NICU at the Hospital Civil de Guadalajara, Mexico in 2012-2014 the frequency of ROP treatment was dramatically reduced to 9.3% compared to 44.0% at the same NICU in 2005-2010. In 2012-2014 only one infant (3%) over the GA of 32 weeks needed ROP treatment compared to 36% in 2005-2010. We believe that the dramatic reduction in ROP frequency reflects that unrestricted oxygen supplementation is a major risk factor for ROP, especially for the more mature infants. The WINROP sensitivity was similar between the study cohorts and lower than in earlier studies performed in Sweden and in North America. We suspect that innacurate dating of GA could contribute to the lower sensitivity. And discrepancies in constitutions of the infants screened at the NICU at the Hospital Civil de Guadalajara during borth study periods compared to from whom WINROP was developed and validated (Sweden and North America).

The first WINROP study drew attention to the high frequency of ROP at the NICU at the Hospital Civil de Guadalajara, Mexico in 2005˗2010. Improved control of oxygen supplementation in 2011 lead to a significant reduction in ROP rates in the present study in 2012-2014. We can only speculate what impact this dramatic reduction in ROP treatment frequency might have for the individual infants and from a socioeconomic viewpoint. Using WINROP in different populations of preterm infants predicts ROP and also alert clinicians to outcome differences in study populations, which may initiate improvements in neonatal care.

 

Figure 1: Percentage of infants developing ROP type 1, requiring treatment, during the previous (2005-2010) and the present (2012-2014) study period.

 

References:

1              Blencowe H, Lawn JE, Vazquez T, Fielder A, Gilbert C: Preterm-associated visual impairment and estimates of retinopathy of prematurity at regional and global levels for 2010. Pediatric research 2013;74 Suppl 1:35-49.

2              Darlow BA, Horwood LJ, Clemett RS: Retinopathy of prematurity: risk factors in a prospective population-based study. Paediatric and perinatal epidemiology 1992;6:62-80.

3              Gilbert C, Fielder A, Gordillo L, Quinn G, Semiglia R, Visintin P, Zin A: Characteristics of infants with severe retinopathy of prematurity in countries with low, moderate, and high levels of development: implications for screening programs. Pediatrics 2005;115:e518-525.

4              Zepeda-Romero LC, Barrera-de-Leon JC, Camacho-Choza C, Gonzalez Bernal C, Camarena-Garcia E, Diaz-Alatorre C, Gutierrez-Padilla JA, Gilbert C: Retinopathy of prematurity as a major cause of severe visual impairment and blindness in children in schools for the blind in Guadalajara city, Mexico. The British journal of ophthalmology 2011;95:1502-1505.

5              Ashton N, Ward B, Serpell G: Effect of oxygen on developing retinal vessels with particular reference to the problem of retrolental fibroplasia. The British journal of ophthalmology 1954;38:397-432.

6              Owen LA, Hartnett ME: Current concepts of oxygen management in retinopathy of prematurity. Journal of ophthalmic & vision research 2014;9:94-100.

7              Gordillo L, Villanueva AM, Quinn GE: A practical method for reducing blindness due to retinopathy of prematurity in a developing country. Journal of perinatal medicine 2012;40:577-582.

8              Urrets-Zavalia JA, Crim N, Knoll EG, Esposito FA, Collino E, Urrets-Zavalia ME, Saenz-de-Tejada G, Torrealday JI, Serra HM, Gilbert C: Impact of changing oxygenation policies on retinopathy of prematurity in a neonatal unit in Argentina. The British journal of ophthalmology 2012;96:1456-1461.

9              Binenbaum G, Ying GS, Quinn GE, Dreiseitl S, Karp K, Roberts RS, Kirpalani H: A clinical prediction model to stratify retinopathy of prematurity risk using postnatal weight gain. Pediatrics 2011;127:e607-614.

10           Hellstrom A, Hard AL, Engstrom E, Niklasson A, Andersson E, Smith L, Lofqvist C: Early weight gain predicts retinopathy in preterm infants: new, simple, efficient approach to screening. Pediatrics 2009;123:e638-645.

11           Allegaert K, Vanhole C, Casteels I, Naulaers G, Debeer A, Cossey V, Devlieger H: Perinatal growth characteristics and associated risk of developing threshold retinopathy of prematurity. Journal of AAPOS : the official publication of the American Association for Pediatric Ophthalmology and Strabismus / American Association for Pediatric Ophthalmology and Strabismus 2003;7:34-37.

12           Wu C, Lofqvist C, Smith LE, VanderVeen DK, Hellstrom A: Importance of early postnatal weight gain for normal retinal angiogenesis in very preterm infants: a multicenter study analyzing weight velocity deviations for the prediction of retinopathy of prematurity. Archives of ophthalmology (Chicago, Ill : 1960) 2012;130:992-999.

13           Lofqvist C, Hansen-Pupp I, Andersson E, Holm K, Smith LE, Ley D, Hellstrom A: Validation of a new retinopathy of prematurity screening method monitoring longitudinal postnatal weight and insulinlike growth factor I. Archives of ophthalmology (Chicago, Ill : 1960) 2009;127:622-627.

14           Wu C, Vanderveen DK, Hellstrom A, Lofqvist C, Smith LE: Longitudinal postnatal weight measurements for the prediction of retinopathy of prematurity. Archives of ophthalmology (Chicago, Ill : 1960) 2010;128:443-447.

15           Zepeda-Romero LC, Hard AL, Gomez-Ruiz LM, Gutierrez-Padilla JA, Angulo-Castellanos E, Barrera-de-Leon JC, Ramirez-Valdivia JM, Gonzalez-Bernal C, Valtierra-Santiago CI, Garnica-Garcia E, Lofqvist C, Hellstrom A: Prediction of retinopathy of prematurity using the screening algorithm WINROP in a Mexican population of preterm infants. Archives of ophthalmology (Chicago, Ill : 1960) 2012;130:720-723.

16           Choi JH, Lofqvist C, Hellstrom A, Heo H: Efficacy of the screening algorithm WINROP in a Korean population of preterm infants. JAMA ophthalmology 2013;131:62-66.

 

 

Comments

There are currently no comments on this post, be the first by filling out the form below.

Speak Your Mind

*

Multiselect Ultimate Query Plugin by InoPlugs Web Design Vienna | Webdesign Wien and Juwelier SchönmannMultiselect Ultimate Query Plugin by InoPlugs Web Design Vienna | Webdesign Wien and Juwelier Schönmann