13.9  Paediatrics

A CLASSIFICATION SYSTEM for the clinical features of ROP:

Defines Zone, Stage, Plus disease, Pre-plus disease and AP-ROP features

Defined threshold disease

Cryotherapy for threshold ROP in BW ≤ 1250g, halves risk of poor structural outcome and reduces poor VA outcome by 1/3, at 1 - 15 years

Threshold = 5 continuous, or total 8 clock hrs, of stage 3 disease in Zone 1, or 2 with plus

Defined pre-threshold disease Treat high risk (type 1) pre-threshold ROP with laser:

• Zone 1 any stage with plus
• Zone 1, Stage 3 without plus
• Zone 2, Stage 2 - 3 with plus

Observe low risk (type 2) pre-threshold ROP:

• Zone 1 Stage 1 - 2 without plus
• Zone 2 Stage 3 without plus

Supplemental O2 doesn’t affect progression from pre-threshold to threshold

Light exposure doesn’t alter incidence of ROP

IVB resulted in less chance of re-treatment compared with conventional laser treatment for Zone 1, but not posterior Zone 2 disease. Peripheral retinal vascularisation continued after treatment. Study not powered for safety. Significantly better refractive outcomes in eyes treated with IVB after 2.5 years

Greatest effect of patching in first few weeks (> 80% effect in first 6 weeks)

Need about 250 hours total, but doesn’t matter how or when (i.e. can “get it over with”)

Refractive correction alone in anisometropic amblyopia (75% improve 2 lines or more, 25% of which resolve fully)

Final VA significantly better in children < 4 years of age (i.e. earlier treatment)

No difference in vision at 4 ½ years between IOL and aphakic group

More complications and more surgeries in IOL group (P < 0.001)

Glaucoma in at least 1/3 of both groups

Leave children < 15 months old aphakic and correct with CL

Moderate Amblyopia (6/12 to 6/24): 3-7 Years Old

• 6 hours = 2 hours patching
• Daily = weekend atropine
• 6 - 12 hours patching = daily atropine
• Bangerter filters almost as good as 2 hours patching

Severe Amblyopia (6/24-6/120): 3 - 7 Years Old

• 6 hours patching = fulltime patching
• Atropine not appropriate as first line
• (Weekend atropine/2-hour patching can be effective)

Older Children Amblyopia Treatment (Moderate/Severe Only): (7 - 18 Years Old)

• 7 - 12: Patching 2 - 6hrs/day + Atropine = 53% improve 2 lines or more cf. 25% with optical correction alone
• 13 - 18: Patching 2 - 6hrs/day = 25% improve 2 lines or more cf. 23%, BUT subgroup of patients with no previous treatment: 47% improve cf. 20%

Recommendations

• Treat 7 - 12 years with patching + atropine even if previously treated
• Treat 13 - 18years with patching if no previous treatment
• Microtropia – patch PTO 2 hours

Prognosis

• About 50% get to ≥ 6/12
• More treatment for denser amblyopia
• Atropine works but more slowly
• The more you patch, the faster they get better
• Final vision independent of prescribed hours
• Younger patients get better more quickly
• Actual patching hours much lower than prescribed

Early (6-24 months) vs, late (32-60 months) surgery appears to increase gross stereopsis at 6 years of age, but high drop out and study design make definitive recommendations difficult

High drop out > 20%. At age 6years, 13.5% (early) vs. 3.9% (late) recognised Titmus housefly. 3% (early) vs. 3.9% (late) had higher stereopsis

Children with myopia (-1 to -6, aged 6 - 12 years, < 1.5D astigmatism) received either Atropine 1% or placebo eye drops nightly for 2 years. Myopia progression and axial length increase were significantly less in the treatment group (- 0.28D and - 0.02mm) compared with the control group (- 1.2D and +0.38mm)

Progression with the low dose atropine (0.01%) was half (-0.49D) compared to placebo (- 1.2D)

Progressing myopia > 0.5D over 12-months and myopia > 2D. RCT atropine 0.5% vs 0.1% vs. 0.01% vs placebo

Infants randomized to receive intravitreal ranibizumab (RBZ) 0.2mg, RBZ 0.1mg or conventional laser treatment. Treatment success (defined as no other treatment modality required before 24 weeks; no ROP recurrence by 24 weeks; and no unfavourable structural outcomes by 24 weeks) achieved in 80% RBZ 0.2; 75% RBZ 0.1 and 66% laser

No evidence of systemic suppression of VEGF after RBZ