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!!!