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Retinopathy of PrematurityGeoffrey T. Tufty, MD
Sanford Clinic Ophthalmology
Failure of the peripheral retina to vascularize
Definition
ROP
To understand the etiology of ROP To understand the anatomy of the eye To understand the stages/severity of ROP To understand the zones/location of ROP To understand the screening guidelines for
ROP To understand the treatment options for ROP To understand the long term affects of ROP
Objectives
ROP-historical
1942- Terry Leading cause of
childhood blindness Retro lental
fibroplasia
4 million premature babies born each year
14,000 have ROP 90% of those are mild
cases and resolve
Retro lental fibroplasia
Fibrous mass behind the lens is detached retina
Risk factors
Low birth weight Early gestational age Anemia Respiratory distress Poor weight gain
Blood transfusion Multiples Intraventricular
hemorrhage Low vitamin E ? light exposure
When to Screen??
BW <1500 grams <32 weeks >32 weeks with a
difficult clinical course
4 weeks of age or 31 weeks which ever is first
Normal Retinal Development
Nasal(32 weeks) then temporal (40 weeks)
VEGF Stimulates normal
development-reduced by hyperoxia-cessation of growth
Hypoxic retina upregulates VEGF and thus ROP
Immature retina-hyperoxia-produces VEGF and neo grows- ROP
Anatomy of the Eye
Tear film Cornea Iris Lens Vitreous Retina-macula Optic nerve
Retina
Normal retina fully developed
Tools of the trade
Dilating drops-cyclomydril
Anesthetic drops
Tools of the trade
Indirect Ophthalmoscope
Good help
You need to swaddle the baby and take your time but be efficient.
Get a good look. Using the “force”
does not work
Ret-Cam
Used for retinal photos to detect ROP and other forms of retinal pathology
Let’s set the Stage
Stages are the severity of the ROP
The higher the stage the worse the disease
Stage 1 ROP
A demarcation line between normal retinal vasculature and avascular retina
Stage 1
Stage 1 ROP
Stage 2 ROP
The demarcation line between vascular retina has increased volume
Stage 2 ROP
The demarcation line has volume to it.
Stage 3 ROP
Neovascularization on the dividing line between vascular and avascular retina
Stage 3 ROP
Continuous neovascularization
Popcorn Sausage
Stage 3 ROP
Stage 4A ROP
Extra foveal retinal detachment
Stage 4A ROP
Peripheral retina is being pulled off of the attachments-traction
Stage 4B ROP
Traction and detachment of the fovea-center vision
Stage 5 ROP
Bad- total tractional retinal detachment
Stage 5 ROP
Poor overall visual outcomes despite aggressive treatment
Plus Disease
Increase in venous and arteriolar dilation
Due to blood shunting
Indicates severity
No Zoning Out
Get into the Zone
Location of ROP in the eye
Higher the zone-the better
Zone I
A circle with the optic nerve as the center and extends twice the distance from the optic disc to the macula
Zone II
From zone I to the nasal peripheral retina
Zone III
Temporal retinal crescent
Follow up Exams
1 week Early zone II Zone I stage 1 or 2 progression
2 weeks Zone II immature Zone II stage 1 or 2 Zone II no ROP
3 weeks Zone III
When to treat??
Zone 1 ROP any stage with plus disease
Zone I stage 3 no plus
Zone II stage 2 or 3 with plus
Should be treated within 72 hours
Treatment
In the NICU? In the OR?
Sit down with family and cover everything-layman’s terms
Treatment
Cryotherapy
Cryotherapy
Cryo ROP study in 1986 reduced unfavorable outcomes from
Eyes are red and sore
Cryotherapy
Laser
Portable Learning curve Less painful
Laser
Laser
ROP may get worse before it gets better
Avastin
Anti VEGF therapy
Injection
Dosage- half the adult dose
30 g needle Betadine Pars plana
Avastin
Risks of injection Infection Cataract Normal
vascularization
What is the correct dosage
Frequency Developing brain and
organs Long term follow up
Vitrectomy
Surgical reattachment of the retina 40% of stage 5 2/3rds of stage 4
Visual outcomes are generally poor
Risk Factors of Treatment
Blindness Retinal detachment-
traction Strabismus Myopia Anisometropia Cataract Amblyopia Low vision
Aids
Glasses Low vision aids
Magnifiers Computers/tablets CCTV Large print books Good lighting
Low vision teachers School for the blind
Good communication with parents and teachers
Questions???
When it comes to ROP there is no zoning out. If you do, you will set the stage for disasterThank you!!!
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