1. The Intertwined Paths of Retinopathy of Prematurity and Neonatal Intensive Care P. Mohagheghi Iran University of Medical Sciences

2. Clin Perinatol 40 (2013) Blindness from retinopathy of prematurity (ROP) has become a disease no longer confined to the countries that developed NICUs more than a half century ago; the vast majority of babies blinded from the disease are cared for in countries where the development of NICUs has become a logical extension of improving medical care.

3. Action Plan Since identifying babies at risk requires integration of efforts by neonatology, ophthalmology, and nursing, a plan for setting up an effective program is presented by just such an interdisciplinary team (a neonatologist, an ophthalmologist, and a NICU nurse) working together with parents. They also emphasize the importance of collaboration with other health care professionals, funding organizations, administration, and policymakers.

4. Retinopathy of Prematurity- Incidence Today ROP is still a common cause of childhood blindness in high income countries, although it no longer occurs in epidemic proportions. In middle-income countries, where there are often high rates of premature birth, ROP is now occurring in epidemic proportions ; it often occurs in babies of higher gestational age and birth weights than high-income countries, probably because of suboptimal neonatal care.

5. Setting Up and Improving ROP Programs Interaction of Neonatology, Nursing, and Ophthalmology The concept of a ROP program will vary according to the setting. However there should be 2 main aspects: primary prevention of ROP through better overall care, and secondary prevention through case detection The ultimate aim will be to reduce the incidence and severity of ROP, and detect and treat cases optimally so that the overall burden of childhood blindness, low vision, and other visual sequelae from ROP is minimized.

6. Setting Up and Improving ROP Programs Primary prevention of ROP involves quality improvement involving obstetric, delivery room, and neonatal care. Secondary prevention of ROP involves agreeing criteria for, and providing the means to achieve case detection (screening), treatment and follow-up.

7. Primary prevention of ROP Primary prevention of ROP in middle- income countries includes measures aimed at reducing rates of prematurity (now a major focus for WHO); improving antenatal and perinatal care, including access to services and use of antenatal steroids; and improving neonatal care, including care in the delivery room and the crucial first hour of life.

8. Secondary prevention (Case Detection Problems) Transfer to another hospital before eye examination starts or is completed. Clear information on past examinations (if any) and date of next scheduled examination is not recorded in referral letter. Parents does not have copy of letter. They are not aware of eye exam time table. The neonatologist has responsibility to see that receiving team is aware of this schedule.

9. Secondary prevention (Case Detection Problems) Discharged home before eye examinations completed. At discharge: date and time of next exams are not confirmed and arrangements for family to attend are not made. Family are not contacted again before examination. Scheduled eye examination deferred for any reason and next date is not arranged.

10. Secondary prevention (Case Detection Solutions) As soon as decision is made to examine, enter details and time of examination in ROP book or electronic system. Inform parents deciding when examinations are complete; standard is when the eye fully vascularized or the vessels are well into zone 3 If infant has postmenstrual age less than 37 weeks, a further examination should still be considered even if vessels are into zone.

11. Secondary prevention (Tx and Follow-ups Solutions) Organizing timely treatment: All treatment should be within 48 hours of decision to treat even if that entails transfer elsewhere. ROP can progress very rapidly to a worse situation. Organizing follow-up: Time and place of appointment made when decision to follow up is made, and is clearly documented in the main body of the notes and in a letter to all professionals involved in follow-up, of which parents have a copy. Ideally eye appointments should be coordinated with those in other services.

12. Screening in High-income countries In high-income countries, with a relatively uniform high level of neonatal care, there have been 2 approaches to devising inclusion criteria-based on GA and BW alone, and GA and BW combined with sickness criteria. GA and BW alone: In preparation for the 2008 UK guideline, data from 10,481 babies, of whom 643 developed sight- threatening ROP, were analyzed. All babies fell within the existing inclusion criteria guidelines of less than 32 weeks GA and/or 1500 g or greater BW, but without a sickness criterion. Had the GA criterion been reduced by 1 week or the BW by 250 g, respectively, 9 babies requiring treatment would have been missed. Accordingly, the criteria were not changed substantially but a lower level of recommendation, “should” be screened, was made for babies between 31 and 32 weeks GA and 1251 to 1501 g BW.

13. Screening in High-income countries GA and BW combined with sickness criteria :This approach, which is used in the United States, Sweden, and Canada, permits lower GA and BW criteria than those of the United Kingdom but requires knowledge of the additional risk factors that pose a risk for ROP. As yet there are very few data on the specificity of illness factors that are risk factors for ROP.

14. Screening Who? UK <31 wk or <1251 g; (1 criterion to be met): Must be screened. No additional sickness criteria. 31 to <32 wk or 1251–1501g; (1 criterion to be met): Should be screened. USA 30 wk if unstable clinical course with cardio respiratory support and at high risk for ROP.

15. Middle-income countries In these countries, with variations in the standard of neonatal care, larger and more mature babies are at risk of developing sight-threatening ROP in comparison with those in high-income countries. Recent publications from India serve to illustrate the issue, with babies of less than 36 weeks GA and greater than 2500 g BW requiring treatment. It is clear that basing inclusion criteria on GA and BW alone under these circumstances would be inappropriate, as many babies would be unnecessarily screened and the demand on ophthalmic services for screening simply could not be met. In some circumstances GA is unknown.

16. Middle-income countries The GA and BW inclusion criteria are wider in those middle-income countries that have guidelines such as Brazil and India, but even so, additional sickness criteria are required to identify the larger and more mature babies falling out with these criteria. Inappropriate excessive oxygen administration, sometimes unblended, has long been suspected to be a factor. Shah recently reported a high incidence of AP-ROP in babies of less than 35 weeks GA who had received unblended oxygen and that, following crude oxygen blending, this incidence fell dramatically, thus conclusively proving that in these babies oxygen was the dominant risk factor for ROP.

17. Inclusion criteria: final comments Whereas neonatal care in high-income countries is relatively uniformly excellent, in middle- and low-income countries care may range from excellent to low between NICUs, even in one city; thus, the income of the country does not describe the full picture of individual units. Neonatal management is continually changing, so reevaluation of inclusion criteria will be necessary from time to time.

18. چه نوزادی باید معاینه شود ( ایران ) ؟ کلیه نوزادان با سن حاملگی 32 هفته یا کمتر یا وزن 1500 گرم یا کمتر در هنگام تولد نوزادان با سن حاملگی بیش از 32 هفته تا 36 هفته یا وزن تولد 1500 تا 2000 گرم به شرط داشتن سیرناپایدار بالینی

19. برخی از مشکلاتی که ممکن است نوزادان را در معرض خطر رتینوپاتی قرار دهد نياز به حمایت قلبی-تنفسی سندرم دیسترس تنفسی، نیاز به تهویه مکانیکی، نیاز به تجویز داروهایی مانند دوپامین جهت افزایش فشار خون خونریزی داخل بطنی نیاز به تجویز خون کامل یا گلبولهای قرمز متراکم یا تعویض خون دریافت اکسیژن به مدت طولانی بیماری مزمن ریوی(BPD) حملات مکرر آپنه و يا سایر مشکلاتی که از نظر متخصص اطفال يا فوق تخصص نوزادان، بیمار را در معرض خطر ROP قرار دهد

20. درچه زمانی اولین نوبت معاینه چشم باید انجام شود؟ سن مناسب اولین معاینه چشم نوزادان نارس، بر مبنای سن اصلاح شده است که مجموع سن داخل رحمی ( سن حاملگی ) و سن پس از تولد ( هفته های پس از تولد ) است. بر این اساس هرچه نوزاد نارس تر باشد، زمان بیشتری طول می کشد تا رتینوپاتی پیشرفت کند و لازم است در سن دیرتری پس از تولد معاینه انجام شود.

21. Age at First ROP Screening Examination GA (wk) Postnatal Age (wk) Postmenstrual Age (wk) 22 8 30 23 7 30 24 6 30 25 5 30 26 4 30 27 4 31 28 4 32 29 4 33 30 4 34 31 4 35 32 3 35 33 2 35 34 2 36 35 2 37