A 4-week-old male infant born at 26 weeks’ gestation with a birth weight of 820 g is undergoing his first screening ophthalmologic examination in the neonatal intensive care unit. His neonatal course has been complicated by respiratory distress syndrome requiring mechanical ventilation and supplemental oxygen for 18 days. On dilated funduscopic examination, the ophthalmologist identifies a prominent ridge at the junction of the vascular and avascular retina in Zone II, with associated tufts of extraretinal fibrovascular proliferation. Additionally, there is significant dilation and tortuosity of the retinal vessels in the posterior pole.
Which of the following is the most appropriate next step in the management of this patient?
The correct answer is:
B) Laser photocoagularion
This infant is presenting with retinopathy of prematurity (ROP) characterized by extraretinal fibrovascular proliferation and dilation and tortuosity of the posterior retinal vessels (also known as “plus disease”). ROP is a vasoproliferative disorder caused by the interruption of normal retinal vascularization in premature infants, often exacerbated by hyperoxia, which downregulates vascular endothelial growth factor (VEGF), followed by relative hypoxia, which causes a surge in VEGF and pathological neovascularization. The presence of dilation and tortuosity of the posterior retinal vessels is a significant marker of disease activity and is the primary indication for treatment. Laser photocoagulation of the avascular peripheral retina is the gold standard treatment to reduce the production of VEGF and prevent progression to retinal detachment.
Answer choice A: Cryotherapy, is incorrect. While cryotherapy was the original treatment used to ablate the peripheral retina in ROP, it has largely been replaced by laser photocoagulation. Laser therapy is more precise, carries a lower risk of systemic complications during the procedure, and has better long-term functional outcomes.
Answer choice C: Observation and re-examination in 2 weeks, is incorrect. While lower stages of ROP (e.g., Stage 1 or 2 without plus disease) can be monitored closely, the presence of extraretinal fibrovascular proliferation combined with "plus disease" requires prompt treatment, usually within 48–72 hours, to prevent irreversible vision loss and retinal detachment.
Answer choice D: Oral propranolol, is incorrect. While propranolol is the first-line treatment for infantile hemangiomas, it has no established role in the standard management of ROP.
Answer choice E: Surgical vitrectomy, is incorrect. Vitrectomy, often combined with scleral buckling, is reserved for when there is partial retinal detachment or total retinal detachment ROP. This patient has Stage 3 disease and should be treated with laser to prevent progression to these surgical stages.
Key Learning Point
Retinopathy of prematurity (ROP) screening is indicated for infants born at ≤ 30 weeks’ gestation or with a birth weight ≤1500 g. The presence of "plus disease" (posterior vessel tortuosity and dilation) in conjunction with significant peripheral neovascularization (Stage 3) necessitates urgent treatment with laser photocoagulation or intravitreal anti-VEGF agents.
