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Retinopathy of Prematurity Geoffrey T. Tufty, MD Sanford Clinic Ophthalmology
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Failure of the peripheral retina to vascularize Definition
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ROP
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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
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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
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Retro lental fibroplasia Fibrous mass behind the lens is detached retina
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Risk factors Low birth weight Early gestational age Anemia Respiratory distress Poor weight gain Blood transfusion Multiples Intraventricular hemorrhage Low vitamin E ? light exposure
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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
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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
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Anatomy of the Eye Tear film Cornea Iris Lens Vitreous Retina-macula Optic nerve
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Retina Normal retina fully developed
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Tools of the trade Dilating drops-cyclomydril Anesthetic drops
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Tools of the trade
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Indirect Ophthalmoscope
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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
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Ret-Cam Used for retinal photos to detect ROP and other forms of retinal pathology
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Let’s set the Stage Stages are the severity of the ROP The higher the stage the worse the disease
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Stage 1 ROP A demarcation line between normal retinal vasculature and avascular retina
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Stage 1
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Stage 1 ROP
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Stage 2 ROP The demarcation line between vascular retina has increased volume
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Stage 2 ROP The demarcation line has volume to it.
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Stage 3 ROP Neovascularization on the dividing line between vascular and avascular retina
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Stage 3 ROP Continuous neovascularization Popcorn Sausage
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Stage 3 ROP
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Stage 4A ROP Extra foveal retinal detachment
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Stage 4A ROP Peripheral retina is being pulled off of the attachments-traction
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Stage 4B ROP Traction and detachment of the fovea-center vision
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Stage 5 ROP Bad- total tractional retinal detachment
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Stage 5 ROP Poor overall visual outcomes despite aggressive treatment
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Plus Disease Increase in venous and arteriolar dilation Due to blood shunting Indicates severity
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No Zoning Out
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Get into the Zone Location of ROP in the eye Higher the zone-the better
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Zone I A circle with the optic nerve as the center and extends twice the distance from the optic disc to the macula
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Zone II From zone I to the nasal peripheral retina
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Zone III Temporal retinal crescent
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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
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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
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Treatment In the NICU? In the OR? Sit down with family and cover everything- layman’s terms
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Treatment Cryotherapy
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Cryotherapy Cryo ROP study in 1986 reduced unfavorable outcomes from Eyes are red and sore
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Cryotherapy
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Laser Portable Learning curve Less painful
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Laser
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ROP may get worse before it gets better
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Avastin Anti VEGF therapy
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Injection Dosage- half the adult dose 30 g needle Betadine Pars plana
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Avastin Risks of injection Infection Cataract Normal vascularization What is the correct dosage Frequency Developing brain and organs Long term follow up
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Vitrectomy Surgical reattachment of the retina 40% of stage 5 2/3rds of stage 4 Visual outcomes are generally poor
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Risk Factors of Treatment Blindness Retinal detachment-traction Strabismus Myopia Anisometropia Cataract Amblyopia Low vision
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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
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Questions??? When it comes to ROP there is no zoning out. If you do, you will set the stage for disaster Thank you!!!
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