2. INTRODUCTION
โข Disease of retinal vasculature in immature retina of
a premature neonate
โข Results from interruption of normal vascularization
โข Characterized by vaso-obliteration/ vaso cessation
followed by abnormal neovascularization and
ultimately cicatrisation
3. โข Leading cause of childhood blindness in US
โข Epidemic in low to middle income countries
like India โ โTHE THIRD EPIDEMICโ
โข VISION 2020
4.
5. LANDMARK STUDIES
Corroborative study for role of
O2 - 1950s
ICROP - 1984, 1987, 2005
CRYO ROP
ETROP
LIGHT ROP
STOP ROP
HOPE ROP
PHOTO ROP
BEAT ROP
6. EMBRYOLOGY
Retinal Vascularization begins โ 16 weeks
Phase 1 โ vasculogenesis โ posterior pole
21-22 weeks
Phase 2 โ angiogenesis - progression to ora serrata
Nasal ora โ at term (37th week PMA)
Temporal ora โ 38th week PMA (post natal)
Choroidal Vascularization complete by 21 weeks
7. โข Hypoxic state in utero - mixed venous blood
PaO2 = 25 mm Hg ๏ VEGF
โข Placental IGF 1
โข Functional maturation of photoreceptors and
visual pathways at 28 to 32 weeks PMA.
Increase in metabolic demand at 28 to 32 weeks
8. PATHOGENESIS OF ROP
โข Premature birth ๏ relative hyperoxia
(PaO2 = 60-80 mm Hg - low VEGF)
๏ Low IGF
โข PHASE I โ birth to 32 weeks PCA
Vaso cessation
โข PHASE II โ after 32 weeks PCA - relative hypoxia
(high VEGF and low IGF)
Vaso proliferation
โข REGRESSION / CICATRIZATION - >38 weeks PCA
(decrease in VEGF and increase inTGF beta)
21. STAGE IV a STAGE IV b
Macula Spared Macula involved
STAGE IV : PARTIAL RETINAL DETACHMENT
22. โข STAGE IV RETINAL DETACHMENT
-Exudative, if early
-Tractional, as part of the change over from
acute to cicatricial disease.
-Rhegmatogenous detachments, years later
25. PLUS
โข posterior venous dilation and arteriolar
tortuosity of at least 2 quadrants
โข Arises gradually or very rapidly.
โข Due to AV shunting mainly in ridge tissue
โข Severity indicator
26. โข Often associated
iris vessel engorgement
miosis
resistance to dilating medications
vitreous haze
tunica vasculosa lentis
27. Preplus disease: vascular abnormalities of the
posterior pole more than normal, less than
PLUS
The newly accepted preplus serves as a warning
28. CLINICALLY SIGNIFICANT TERMS
โข Threshold ROP: CRYO ROP study
Zone I stage III with Plus
Zone II Stage III with Plus
( 5 contigous or total 8 clock hours)
โข Prethreshold ROP: ETROP study
High risk Prethreshold
Zone I Stage I, II, III with plus
Stage III without plus
Zone II Stage II and III with plus
๏ Plus disease has increased in importance while the extent
(clock hours) of disease has diminished
29. โข AP-ROP: aggressive posterior ROP
-Earlier known as โRUSH Diseaseโ
-posterior location,
-rapidly evolving preplus and plus disease
neovascularization that may be subtle or even intraretinal
in nature.
-Progress to stage IV & V in 2-3 weeks without passing
through characteristic stages II and III
- requires laser treatment more than once
33. โข Under GA
โข Distance from ridge to limbus noted
โข Applied to the anterior avascular area wherever
ridge is present
โข Ridge avoided
โข SPOTS โ Preferrably Transconjunctival
Contiguous
15 โ 30
End point โ creamy white
Copious irrigation
34.
35. โข Delivered through INDIRECT OPHTHALMOSCOPE + 28D
โข Ridge Avoided
โข SPOTS
Size =100 microns
Half burn width apart
End point โ grade II gray burn
36. After LASER treatment
โข zone 2 ROP
โ generally regresses after a single treatment session.
โข APROP
โ may regresses but can reactivate with return of plus
disease
โ progressive posterior hyaloidal contraction, and
progression to tractional posterior retinal detachment
โ Post-treatment vigilance is necessary
37. AP ROP : Treatment in 2 Steps
Ist โ upto Flat Neovascular Fronds
IInd โ after regression of Fronds
(area beneath fronds continue to remain source
of VEGF and hence reappearance of disease)
38.
39. SCLERAL BUCKLE
Under GA
Peritomy
2.5 mm encircling band passed beneath 4 Recti
One anchoring mattress suture applied in all
quadrants
Removal after 3-6 months
40. VITRECTOMY
Necessary in advanced cases
Lensectomy avoided
Peeling of membranes
Relieve of traction
No attempt to drain Sub Retinal Fluid
AIM : Ambulatory vision ie being able to see objects
and move around a room without stumbling or
bumping into obstacles.
47. INTERNATIONAL
Birth Weight <1500 g
GA < 32 weeks
Higher BW/GA with risks(unstable babies)
31 weeks PCA or 4 weeks CA, which is later
INDIAN
BW <1500 g / 1750 g
GA < 34-35 weeks
Higher BW/GA with risks(unstable babies)
31 weeks PCA or 4 weeks CA, which is earlier
(VLBW babies at 2-3 weeks CA)
RECOMMENDATIONS
48. โข Neonatal ICU
โข Combined to neonatal checkup
โข Monitoring of systemic status
โข Antisepsis
โข Warm, dry and fed
49. โข Pupillary Dilation : 2.5% phenyl ephrine + 0.5%
Tropicamide โ Twice, 15 mins apart 30 mins
before exam
โข Speculum
โข INDIRECT ophthalmoscope ( with small pupil
attachment ), 28/30D lens, scleral depressor
โข PLUS DISEASE to be looked for before
speculum and scleral depression
50. END OF SCREENING
โข COMPLETE VASCULARIZATION
โข VASCULARIZATION in ZONE III (till 1 DD of
temporal ora) โ if no previous ROP in zone I & II
โข REGRESSED ROP ( b/w 40 -44 weeks PCA)โ no
active disease left
โข 45 weeks PCA with less than pre threshold
disease
51. RETCAM
โข WIDE FIELD CONTACT RETINAL PHOTOGRAPHY โ 130 deg
โข Easy use by nurses and technicians
โข Eliminates inter observer variability
โข Teaching tool
โข Overcomes logistics of screening
โข More cost effective than examination
โข Tele ophthalmological screening
โข โREFFERAL WARRANTED ROPโ
โข PHOTO ROP
โข KID ROP
Fluorescein Angiography can be done
