d. Sterile cotton-tipped applicators (CTA)

e. Sterile gloves

f. Topical Betadine

g. Topical antibiotic drops (ciprofloxacin 0.3%) and

ointment

h. Sterile syringe of bevacizumab (0.625 mg in

0.025 mL) with 30-gauge needle (one per eye)

7. Complications (Table 52.3)

a. The most worrisome risk is postinjection infection

(endophthalmitis). Babies with active or recent ocular surface or lid infections (e.g., conjunctivitis)

should not have intravitreal injection

b. The risk of adverse systemic side effects (bradycardia, oxygen desaturation) is mitigated by the absence

of systemic sedation/anesthesia, and the rapid nature

of the procedure. However, it is reasonable to follow

those precautions listed for laser treatment in

Section F4.

8. Technique

a. The baby’s eyes are dilated according to the standard

dilation protocol.

b. Sterile towels are placed around the baby’s head.

c. Topical anesthetics are instilled.

d. The lids are prepped with Betadine.

e. Wire lid speculum is placed.

f. The caliper is used to mark a spot on the sclera

1.7 mm posterior to the limbus in the inferotemporal quadrant.

g. A Betadine-soaked CTA is gently pressed over the

mark and excess Betadine is allowed to collect in the

inferior fornix.

h. The injection is given.

i. A topical antibiotic drop is given.

j. The ophthalmologist performs binocular indirect

ophthalmoscopy.

k. Dexamethasone/polymyxin B/dexamethasone ointment may be instilled.

Chapter 52 ■ Treatment of Retinopathy of Prematurity 377

9. Postinjection Care/Concerns

a. Topical antibiotic drops should be instilled 3 to

4 times a day for 3 days.

b. Portable slit-lamp examination should be performed

48 to 72 hours postinjection

c. Any signs of infection (lid edema and erythema,

conjunctival injection, clouding of the cornea)

should be reported immediately to the treating ophthalmologist.

d. Examination by treating ophthalmologist in 1 week.

E. Postdischarge Care

A critical component of treatment of ROP is postdischarge

care.

1. No baby with any ROP, or who has regressed ROP after

treatment, should leave the neonatal intensive care

unit (NICU) without a scheduled follow-up examination (1,18).

2. It is imperative that infants who develop any stage of

ROP, especially those with prethreshold stage 3 or those

that have received treatment, are seen within 1 to

2 weeks of discharge, or as directed by the ophthalmologist involved in the baby’s care.

3. A careful, reproducible tracking system for arranging

follow-up should be established by every NICU. A member of the staff of each NICU should be responsible for

maintaining and periodically auditing this system.

4. Verbal and written instructions for follow-up should be

given to the parents. Parents should be given a discharge

form indicating their baby’s scheduled follow-up among

their discharge instructions. The importance of scheduled follow-up should be prominently stated on the form.

F. Outcome

1. Early treatment for type I high-risk prethreshold ROP

has been shown to improve retinal structural outcome

and visual acuity outcomes at 6 years of age (11).

2. Favorable outcome with vision of 20/40 or better was

noted in 35% of treated eyes.

3. However, 65% of eyes receiving early treatment develop

visual acuity worse than 20/40.

4. Unfavorable outcome despite treatment: Visual acuity

20/200 in 15%; blindness or low vision in 9%.

5. The outcome for eyes with Zone I disease, although

poor, has improved with laser and incisional surgery (vitrectomy). Specifically, laser treatment of the posterior

avascular retina can be accomplished easily and without

necessitating conjunctival incisions, as in cryotherapy.

6. Treated eyes carry a risk of retinal dystopia, myopia, and

subsequent strabismus and amblyopia (11,19). To minimize the effect of refractive errors and strabismus, careful

follow-up by a pediatric ophthalmologist is mandatory.

7. Premature infants are at risk for intracranial pathologies

that may limit visual function. Pediatric ophthalmologists, neurologists, and others involved in the care of

former preemies should be in frequent contact in order

to address the often complex and changing visual deficits present in these children.

References

1. Section on Ophthalmology, American Academy of Pediatrics,

American Academy of Ophthalmology, American Association for