Pediatric ophthalmologists must take 'ownership' of ROP patients, speaker says

KEYSTONE, Colorado – Pediatric ophthalmologists must overcome their apprehension and take “ownership of care” when it comes to treating babies with retinopathy of prematurity, according to a pioneer in the field.

To confront the high-risk nature of retinopathy of prematurity (ROP), specialists must accept complete responsibility for these patients “from birth through maturity,” said Earl A. Palmer, MD, FAAP, who gave the Frank D. Costenbader Lecture here at the meeting of the American Association for Pediatric Ophthalmology and Strabismus.

ROP management should be viewed as a single encounter with a patient, but on an extended time scale, Dr. Palmer suggested.

“I would like to persuade you today that there is no more reason to fear ROP care, but it requires us to take ownership of care,” Dr. Palmer said. “Just as the microsurgeon keeps an eye on the surgical field, so then do we – on a much longer time scale – need to accept responsibility to monitor the [premature baby’s] fundi throughout this protracted encounter.”

Dr. Palmer said the factor of time is closely tied to effective management of ROP, lending it a dynamic and challenging nature. The disease is most aggressive within the first few months of the premature infant’s life, although the sequence of events varies from patient to patient.

While much has been learned in the past few decades about how to manage the disease surgically, he said, clinical data are conspicuously lacking. Dr. Palmer said he and other leaders, including AAPOS president Michael X. Repka, MD, are calling for the start of randomized clinical trials to study the management of retinal detachments associated with ROP.

“The past 20 years have brought important progress in our attempts to surgically blunt the effects of ROP, but until medical methods appear that deal with retinal detachment, we must renew our efforts to push back the veils of uncertainty that still obscure our own understanding of best practices,” Dr. Palmer said.

He called for a randomized, prospective clinical trial that would include patients with stage 4-A ROP, for whom it is unclear whether observation or immediate intervention is the better approach.

“[Such a study] would trigger a sequence of treatments by stages, each with defined selection criteria,” he said. “The results would inform us of the value of current vitreoretinal surgeries and offer evidence to provide a basis of managing these cases.”

Dr. Palmer also addressed the new ROP screening guidelines published in the February issue of Pediatrics.

These guidelines, he said, “have changed our standard of care as rapidly as the Cryo-ROP study,” he said, referring to the landmark multicenter study published in 1988 that investigated the use of cryotherapy in patients with ROP. Dr. Palmer is perhaps best known as the organizer of that study.

While “attorneys will be paying attention” to the new guidelines in terms of their effect on malpractice issues, physicians who are meticulous in their follow-up and who are “redundant” in communicating risk to parents should be safe, Dr. Palmer said.