Vascular Endothelial Growth Factor in Stage V ROP

Study Overview
=================
Brief Summary
-----------------
Vascular Endothelial Growth Factor (VEGF) is a dimeric glycoprotein, naturally expressed in epithelial and tumor cells (1). Normal Retinal vascularization has two phases: In the first fase, cells of mesenquimatous origin form the first superficial plexus (14-21 weeks of gestation). In the second phase, denominated angiogenesis phase, the superficial and deep capillary plexus are formed (15,20). The Retinopathy of Prematurity (ROP) was described for the first time in 1942 (4), at the present moment it is a public health problem in the developing countries. The International Classification of ROP classifies it in 5 stages, dividing it in 3 anatomical zones. It is a public health problem that continuous without having an effective prophylaxis. The early diagnosis and treatment in thresholds stages have changed the prognosis of this disease (11,12).

Detailed Description
-----------------
Vascular Endothelial Growth Factor (VEGF) is a dimeric glycoprotein, naturally expressed in epithelial and tumor cells (1). In conditions of hypoxia it is secreted by the pericytes, the Retina Pigmented epithelium (RPE)and glial cells, including a the Müller cells (1,2,4,5) favoring the formation of new abnormal vessels (1). Its activity is mediated by two high affinity receptors: the receptor VEGF 1 (FLT-1) and VEGF 2 (FLT-2) (1,9). The FLT-1 promotes cellular proliferation whereas FLT-2 the migration and cell- extracellular matrix interaction (9). The VEGF is essential as much for the normal retinal vascularization as for pathological (5,14). Normal Retinal vascularization has two phases: In the first fase, cells of mesenquimatous origin form the first superficial plexus (14-21 weeks of gestation). In the second phase, denominated angiogenesis phase, the superficial and deep capillary plexus are formed (15,20). The second phase is highly dependent of VEGF induced by hypoxia (15,20). In the normal retina the growth occurs from the optical nerve to the periphery (17). The scientific progress in the neonatal intensive care units in the last years has allowed the survival of a larger number of premature newborns(15). The Retinopathy of Prematurity (ROP)(ROP) was described for the first time in 1942 (4), at the present moment it is a public health problem in the developing countries. Of each 100.000 blind child in Latin America, 24.000 are due to ROP (240/1000 blind child) (17). It is the main cause of blindness in premature new born (1,4,5). It is of multifactorial etiology (17) but it has been related to a short gestational age (smaller to 32 weeks of gestation) (4), to low birth weight (less of 1500gr) or very low birth weight (less 1250gr)(1,4,5,17,18,20), to the administration of high oxygen concentration immediately after birth (1,3,18), low levels of the Insulin-like growth factor(IGF-I) and excessive production of VEGF (3,17). All this, combined with large periods of hyperoxia-hypoxia, Produces that the normal vascularization of the retina stops. This also produces vascular-occlusive changes, arteriovenous anastomoses in the edge of the vascularized with the none-vascularized retina (18), begins the formation of abnormal vessels towards the vitreous, finally lead to retina detachment in the most severe cases (2,3,4,5). The International Classification of ROP classifies it in 5 stages, dividing it in 3 anatomical zones. A threshold stage is considered when we have the presence of stage 3, in zone 1 or 2 in 5 continuous hour uses or 8 discontinuous with plus disease (15,16,17). The pre-threshold stage is divided in two types: type 1 is any stage of the disease in zone 1 with plus disease, stage 3, without plus disease in zone 1 or stage 2 or 3 with plus in zone 2. Type 2 is stage 1 or 2 without plus disease in zone 1 or stage 3 without plus disease in zone 2 (17,19). The threshold stage happens approximately in 5% of the patients with very low weight to the birth, of which the 10-15% develop blindness (6,8) It is a public health problem that continuous without having an effective prophylaxis (5), nevertheless the use of constant oxygen concentrations, avoiding the periods of hyperoxia-hypoxia, has demonstrated to produce a decrease of the presentation of advanced stages of the disease and the necessity of ophthalmological surgery (5). The early diagnosis and treatment in thresholds stages have changed the prognosis of this disease (11,12). The use of the laser as treatment in the threshold and prethreshold stages is successful in the 91-95% of the cases(10), the ablative effect on the neurons, probably diminishes the VEGF production (15). The use of the vitrectomy in the early cases of retinal detachment also has good results (13). For the determination and the quantification of VEGF several laboratory techniques have been used, as they are the Westernblot (1), the flow cytometry (7), CBA (7). Nevertheless, the Enzyme-linked immunoabsorbent assay (ELISA) remains the gold standard for the measurement of interleukins, growth factors and other cytokines in corporal fluids, including the vitreous, aqueous and subretinal fluid (1,5,7). It has been demonstrated in humans that there are high vitreous concentrations of VEGF in eyes with active neovascularization (6,14). In the same way, the animal models of ROP report high levels of VEGF (2,21). The levels of this growth factor are altered in both stages, with a more marked increase during the first stage (2). Some clinical studies in patients with ROP in stage 4 and 5 have reported an increase of up to 90 times greater of the concentration of VEGF in the subretinal liquid in comparison with the found in patients with retinal detachment of any other cause (1). Finally, when it has been possible to examine retinas immediately after the treatment (due to death of the patient) have been found a low expression of mRNA of VEGF in the treated cells (6).

Official Title
-----------------
Vascular Endothelial Growth Factor Levels in Aqueous, Vitreous and Subretinal Fluid in Patients With Retinopathy of Prematurity Stage V.

Conditions
-----------------
Retinopathy of Prematurity

Intervention / Treatment
-----------------
* Procedure: Open-Sky Vitrectomy


Participation Criteria
=================
Eligibility Criteria
-----------------
Inclusion Criteria: Premature newborns with less than 32 weeks of gestation. Low birth weight (less than 1500gr) Stage V ROP. The parents has signed the informed consent. Exclusion Criteria: Previous treatment of ROP. Surgery or another ocular pathology of any type. Systemic diseases, including diabetes mellitus, congestive heart failure acute renal insufficiency, Chronic renal insufficiency, high blood pressure. Lack of Informed consent.

Ages Eligible for Study
-----------------
Minimum Age: 2 Months
Maximum Age: 10 Years

Sexes Eligible for Study
-----------------
All

Accepts Healthy Volunteers
-----------------
No

Study Plan
=================
How is the study designed?
-----------------

Design Details

Primary Purpose: Basic Science
Intervention Model: Single Group Assignment
Masking: None (Open Label)


Arms and Interventions

| Intervention/Treatment |
| --- |
|Procedure: Open-Sky Vitrectomy|Open-Sky vitrectomy with removal of the Tunica vasculosa lentis and retinal reattachment|

What is the study measuring?
-----------------
Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| To determine the degree of VEGF in aqueous, vitreous and SRF in patients with ROP in stage V. Verifying that it is greater to that found in healthy newborn patients with different ocular pathology |  | 4 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| To establish a relation between the low and very low birth weight with the VEGF levels. |  | 4 months | 
| To prove that the VEGF level found in ROP patients is greater than in other pathologies that normally produce neovessels (like in DM). |  | 4 months | 

 Terms related to the study
=================
Keywords Provided by Centre Hospitalier Valida
-----------------
Retinopathy of Prematurity., ROP., Vascular Endothelial Growth Factor., VEGF., Vitreous., Subretinal Fluid., ELISA.