Chapter 52 ■ Treatment of Retinopathy of Prematurity 375

f. Stabilize the infant: Correct electrolyte imbalances,

platelet deficiency, etc.

g. Use only 1% phenylephrine if there is a history of

hypertension.

h. Wipe off any excess drops spilling onto the skin to

avoid transcutaneous absorption (skin vessel blanching occurs with phenylephrine).

6. Technique

a. General preparation

(1) Instill eyedrops (per orders from ophthalmologist) into both eyes in the hour prior to procedure. Maximal dilation is critical for optimum

laser; therefore, several (three or four) instillations of drops may be required, especially in eyes

with neovascularization/vascular engorgement

of the iris.

(2) Transport the patient to surgical suite or designated procedure room in the nursery.

(3) Ensure monitors are attached and functioning.

b. Immobilize infant: Swaddle in a clean towel or blanket to immobilize arms and legs.

c. Ensure that the IV tubing is accessible.

d. Administer IV sedation.

If local anesthesia is to be used, a combination of

topical (e.g., tetracaine, proparacaine) and systemic

analgesic/sedative (e.g., IV morphine) medications

are administered prior to injection.

e. Distribute laser safety goggles and dim overhead

lights.

f. Retract lids.

g. Perform laser: Cover the avascular retina with confluent gray–white burns (Fig. 52.5).

h. Have an assistant count and record the number of

spots and the duration and power of each spot.

7. Postoperative Care

a. Instill 0.25% scopolamine hydrobromide in treated

eye(s) daily for 3 to 5 days.

b. Apply antibiotic–steroid preparation (e.g., tobramycin–

dexamethasone) to treated eye(s) three to four times

daily for 5 to 7 days.

c. Monitor the patient with a cardiorespiratory monitor

for 24 to 72 hours.

d. Perform a dilated retinal exam 1 to 2 weeks after

treatment.

e. If opaque media are present at the time of laser, or if

the pupil does not dilate adequately, complete treatment of the avascular retina may be impossible, and

“skip areas” may be visible in the weeks after treatment. Treatment of these areas should be considered if there is not marked resolution of the adjacent

plus disease and/or neovascularization.

f. Follow the infant every 1 to 2 weeks until the ROP

resolves completely. If at the time of discharge ROP

is still present, ensure that the parents and the physicians responsible for the care of the infant after discharge are aware of the extreme importance of

maintaining a regular schedule of outpatient examinations. Once the ROP has resolved completely, the

baby should be seen by a pediatric ophthalmologist

within 1 to 2 months to assess vision, ocular alignment and motility, refractive status, etc.

g. Long-term follow-up over several years is necessary.

See outcomes and postdischarge follow-up below.

D. Intravitreal Injection for ROP

1. Background

Recently, the efficacy of anti-VEGF drug bevacizumab for

use in ROP has been reported (13). The drug halts the

development of new vessels and halts disease progression.

Intravitreal injections of anti-VEGF agents have been used

to treat wet (neovascular) age-related macular degeneration (AMD), proliferative diabetic retinopathy, neovascular

glaucoma, etc. Although there is considerable debate and

no consensus on its use in ROP, this section is being

included in the Atlas for completeness, and to provide

additional treatment options if laser therapy is not possible

(14–16).

2. Precautions

a. The major concern with bevacizumab in premature

infants with ROP is systemic absorption and its

effect on the developing infant. Bevacizumab is

absorbed systemically after intravitreal injection.

The risks of systemic effects on developing neonates

have not been established.

b. The optimal and safe dose of bevacizumab in ROP

has not been determined; the current dose (0.625 mg)

Fig. 52.5. Freshly lasered avascular retina. is extrapolated from that used in adults with ocular