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Dr Azad on ROP: Need for training and screening
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Dr Azad on ROP: Need for training and screening

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    Dr Azad on ROP: Need for training and screening Dr Azad on ROP: Need for training and screening Presentation Transcript

    • Need for Training and Screening in Retinopathy of Prematurity Prof. Rajvardhan Azad MD, FRCS, FAMS Professor and ChiefDr. R.P. Centre for Ophthalmic Sciences AIIMS New Delhi
    • Presentation Layout ROP: Defined Magnitude of Problem: Demography Training Types:  Awareness programs/ workshops  Training in ROP Management Screening Need Screening net quantum vs. manpower available Capacity building and infrastructure development Summary and Conclusion
    • ROP: Definition Primarily a vasoproliferative disorder of retina Principally occurring in premature children but not exclusively Spontaneous regression Potentially blinding If detected early and timely blindness preventable
    • Magnitude of the Problem 50 million (world) 2 million blind children (4% of the total)Blinds 57% is preventable {ROP} 22% has retinal causes {ROP}0.2% of blind school survey – lower estimate
    • ROP – World Perspective  Highly developed Countries  HDI Ranking 1 -3 3 to 13%  Sweden, US*, UK+ Nordic countries, Eire  Modularly Developed  HDI ranking - 30-100  Argentina+, Brazil, Chile, Peru 0 -60%  Paraguay, Ecuador, Colombia Cuba, Bulgaria, Romania, Albania Hungary, China, SriLanka*, Thailand  Poorly Developed  South Africa+, Mongolia 0 to 10% Cambodia, Uganda, Ghana Kenya, Nigeria, Malaysia Ethiopia, India, Pakistan* Guatemala , Uzbekistan * - Minimum + - Maximum
    • ROP – Asian perspective Name of UNDP Source of Data No of % Countries Rank samples Malaysia 59 Blind school 332 6.0% Thailand 76 Blind school 65 16.9%Philippines 83 Blind school 179 8.4% China 94 Blind school 1131 1.9% Srilanka 96 Blind school 226 0.0% India 127 Blind school 2360 0.2% Pakistan 142 Blind school 760 0.0%
    • ROP - Indian Disease BurdenChild birth / year Premature At risk to develop ROP26 million 2 million ROP Screening net: 7.5 lakhs All ROP: 2.25lakhs Treatable ROP: 0.5 lakhs
    • ROP: Blinding Statistics Azad et al 1999 2.3% (<1600gm) Bassi et al 1998 3.35% (very premature) Phelp DL 1992 2.4% (<1Kg)
    • ROP India Agenda Summit Insufficient medical care  State of Art Medical Care
    • ROP- Typical to India More severe cases Lack of awareness Lack of access to care Referral reluctance among colleagues Late arrivals
    • R.P. Centre, AIIMS – Apex Centre  Comprehensive ROP Eye Care Centre  Screening  Laser Treatment  Surgery  Research  Training
    • Tertiary ROP Care centre Chandigarh PGI Delhi RPC Hyderabad LVPEI Coimbatore Arvind eye hospital Chennai Shankar Netralaya
    • Are we ready to face the challenge??( GOI Data)India 2008:27 million live births annually2% premature : 260,000 – 520,000 infants. Every two hours, 3 babies in India are reaching the threshold of treatment of ROP Ophthalmologist population ratio: 1:40,000 VR surgeons : 280 Paediatric retina specialists: <20
    •  ROP Pursuits: Public Health & Social A ROP child blind will remain so for 60 years Rs.2000 maintenance cost, Rs.2000 lost productivity cost = Rs.4000 per month. For sixty years - Rs.28.8 lakh (57600 US$) The average cost of treatment of treatable ROP in India - Rs.15,000 (300 US$) (treatment charges + consumables) Azad R. Retinopathy of prematurity a giant in the developing world. Indian Pediatr. 2009 Mar;46(3):211-2.
    • Training Type Awareness Programs/ Workshops:  Concept of Paired workshop  Training of pediatrician and ophthalmic nurse in Asian situation(Retinopathy of prematurity screening by non-retinologists.Azad RV et al. Indian J Pediatr. 2006 Jun;73(6):515-8.) Training in ROP Management:  Screening of ROP (Diagnostic Skills)  Laser Management of ROP (Therapeutic Skills)  Surgical Management of ROP (Therapeutic Skills)
    • ROP Awareness Program in India Initiation by Ministry of Health & WHO Paired Workshop – New concept Neonatologist Ophthalmologist 2 day - 7 workshops all over India New Delhi (3) Hyderabad (1) Mysore (1) Patna (1) Lucknow (1)
    • Impact of workshop and awareness Initiative of Ministry of Health, Govt. of India 180 Neonatologist and Ophthalmologist trained in a two days paired workshop during 1999-2001. Pre and Post workshop questionnaire scores showed a highly significant result (p<0.0001)using paired T test. Outcome of this workshop has resulted in emergence of new viable ROP Centres (12) all over the country.
    • SightSavers ROP Workshops 12 ROP workshops in collaboration with Sightsavers India (2009-2010) in various cities To spread ROP awareness and train ophthalmologists and neonatologists. Trained nearly 650+ such doctors
    • SightSavers ROP Workshops Pune 1-2 November 2008 Mumbai 11 January 2009 Lucknow 25-26 April 2009 Four more workshops Delhi 25-26 July 2009 under MOHFW Belgaum 29-30 August 2009 •March 2012: PGI Kolkata 4 October 2009 Chandigarh Trichy 6-7 March 2010 •April 2012: Arvind eye Cuttack 20-21 March 2010 hospital, Coimbatore Sangli 24-25 July 2010 •May 2012: BHU Mussoorie 29 August 2010 Varanasi Bangalore 5 September 2010 •June 2012: Shankara Ranchi 2-3 October 2010 Netralya Chennai Forthcoming: Hyderabad (4-5 January 2012)
    • RPC: Sightsavers ROP WorkshopsIndia Pune Mumbai Lucknow Delhi Belgaum Kolkata Trichy Cuttack Sangli Mussoorie Bangalore Ranchi Patna
    • REPUTED FACULTY
    • INTERACTIVE WORKSHOPS
    • SightSavers ROP Workshops The pre and post workshop questionnaires analysis of 200 forms (with MCQs) have revealed significant improvement in knowledge of the delegates (P<0.005). Post workshop feedback on phone: Of the 236 people who were willing to respond to the survey, 57 had a ROP screening program, and 45 more were able to start a screening program successfully.
    • ROP Status AmongPediatricians Prevailing clinical practices regarding screening for retinopathy of prematurity among pediatricians in India: a pilot survey. Azad R et al. Indian J Ophthalmol. 2011 Nov- Dec;59(6):427-30. A total of 234 pediatricians responded out of 406 calls made. Hundred percent awareness of ROP and need for screening in premature babies was found.
    • ROP Status AmongPediatricians Only 135 (58 %) pediatricians always screened for ROP, 80 (34%) did not screen at all and 19 (8%) screened sometimes. Screening protocols were not consistent with only 25% of pediatricians of those who were screening regularly with standard screening guidelines. Major deterrent in screening for ROP was perceived as non availability of trained ophthalmologists.
    • ROP Status AmongPediatricians Retinopathy of prematurity screening by non- retinologists. Azad RV et al. Indian J Pediatr. 2006 Jun;73(6):515-8. To detect screening efficiency of general ophthalmologists/ non-ophthalmologists (pediatric residents and nurses posted in NICU) in screening ROP on the basis of posterior pole vascular changes Given adequate training, general ophthalmologists and non-ophthalmologists are independently reliable in detecting posterior pole changes in ROP babies.
    • What is screening in ROP? ROP fulfills the criteria for screening First possible Final criticalDisease Onset detection point Usual time of diagnosis OUTCOME A B Screening time A Usual outcome Lead time B Improved outcome
    • PurposeScreening intends to: Detect retinopathy of prematurity at or before threshold stage – Critical point. Treat all babies reaching the critical point. Redefine critical point – Early treatment. Prevent or reduce unfavorable outcome.
    • Important Periods in ScreeningWhom to screen (Include all babies at risk)  1200gm and 32wks  1600gm and 32 wks  1600gm and 36wksWhen to Screen (Three critical stages ) • First - 32 -34 weeks • Second - 35-37 weeks • Third - 39-42 weeks First screening At 32 weeks or 4 weeks postnatal whichever is earlier
    • Benefits of a good screening program Targets all the “at risk” babies. Can be easily performed “in the field” Treatment institution possible before irreversible damage occurs. Laser Ablation known to affect the outcome. Reduced incidence of unfavorable outcome through screening and timely treatment. Studying course of disease, changing pattern and aggressive behavior of zone І ROP has instituted ETROP.
    • Benefits of a good screening program? Changing Profile of ROP in two study period Period I Period II 1993-94 1999-2000 No. of patients 66 76 No. of patients with ROP 13/66(19.69%) 24/76(31.5%) Grades of ROP Stage I & II 7/66(10.6%) 19/76(25%) Stage III 6/66(9.0%) 5/24(6.57%)*Results of ongoing screening programme at AIIMS Nursery by RPC Consultants Threshold ROP treated cases
    • Conclusions•ROP is emerging as a giant of childhood blindness•Indian epidemic is sitting on summit of two volcanoes•Insufficient expertise in ROP may cause blindness amongneonates who have to live for 50 years or longer•Screening intends to detect ROP before it reaches criticalstage (Type I ROP) and prevents blindness due to ROP•Screening involves combined efforts from ophthalmologist,neonatologist and parents•Benefits of screening include earlier detection andmanagement of ROP which is changing profile of thesepatients.
    • Dr. Rajendra Prasad Centre for Ophthalmic Sciences,All India Institute of Medical Sciences, New Delhi, India