Miracle

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Miracle

  1. 1. Retinopathy of Prematurity (ROP) By Dr. Irene Subharngkasen M.D.กลุมงานจักษุวิทยา สถาบันสุขภาพเด็กแหงชาติมหาราชินี
  2. 2. •Retinopathy of prematurity (ROP)•Retrolental fibroplasia•Abnormal retinal vascularization of premature infant•Retinal detachment and cicatrization
  3. 3. 1942 Terry : Retrolental Fibrophasia (RLF)1951 Heath : Pathology of RLF, ROP1951 Cambell and Patz : Intensive oxygen therapy ~ ROP Reese : classification by direct ophthalmoscope1977 Kingham : classification by indirect ophthalmoscope term “ROP” replaced term “RLF”1982 International classification of ROP1987 AP-ROP, Pre-plus disease
  4. 4. • Active stage• Cicatricial (regressed) stage
  5. 5. Retinal vessels• Optic disc 16 weeks• Nasal 36 weeks• Temporal 40 weeks
  6. 6. • Immature retinal vessels• Oxygen :vasoconstriction and vasoobliterate of retinal vessels• Hypoxia• Retinal neovascularization• Total retinal detachment
  7. 7. 1. Birth weight2. Gestational age3. Prolonged (wk.) use of oxygen4. Blood transfusion5. Days of respirator used6. Sepsis7. Apnea of prematurity8. Apnea9. Number of abnormal O2 and CO2
  8. 8. 1. Localization • Zone 1 • Zone 2 • Zone 32. Extend of the disease3. Staging of the disease
  9. 9. Stage 1 Stage 2Stage 3 Stage 4 Stage 5
  10. 10. • Pathognomonic sign : line between avascular immature peripheral retina and vascularized posterior retina• Abnormal terminal arborizations
  11. 11. • Line Ridge• Small isolated neovascular tufts into the ridge
  12. 12. •Fibrovascular proliferation on the ridge•Fibrovascular proliferation into vitreous•Retinal blood vessels dilate and tortuous•Retinal or vitreous hemorrhage
  13. 13. •Severe fibrovascular proliferation•Tractional retinal detachment
  14. 14. • Dilatation of veins and tortuousity of arterioles in posterior fundus• Quick and severe progression of the disease
  15. 15. • Vascular abnormal dilatation and tortuosity of the posterior pole than normal• May progress to frank plus disease
  16. 16. • Highly malignant, quickly progressive type of ROP• “Ridge” tissue formation & vascular engorgement progress to complete retinal detachment within a few days
  17. 17. • Lowest –birth weight infants• Rapid progress severe form of ROP• Posterior location , Zone 1• Prominence of plus disease vessels increase dilatation and tortuosity
  18. 18. 80% of cases of ROP regress
  19. 19. 1. Plus disease2. Vitreous haze3. Pre-retinal and vitreous hemorrhage4. Engorgement of iris vessels5. Failure of the pupil to dilate
  20. 20. ปงบประมาณ 2549 2550 2551 ผลการรักษา จํานวนผูปวย ROP (คน) 481 558 570 225 239.5 246 ตรวจพบ ROP (คน) 46.77% 42.92% 43.15% 120.5 144 167.5รักษาดวยการจี้ความเย็นหรือ Laser (คน) 25.05% 25.80% 29.38% รักษาหาย (คน) 89.5 105 118.5 เปอรเซ็นตการหาย 82.8% 86.1% 91.10%
  21. 21. • ROP • Stage 3(severe) –< 1250 g. = 66% – 1000 - 1250 g. = 8.5% –< 1000 g. = 82% – 750 - 999 g. = 21.9% –< 750 g. = 90% – < 750 g. = 37%
  22. 22. • ทารกน้ําหนักแรกคลอด < 1251 กรัม 4099 คนพบ ROP 65.8% น้ําหนักแรกคลอด พบ ROP 1001-1250 กรัม 47% 751-1000 กรัม 78% < 750 กรัม 90%
  23. 23. รายใดจําเปนตองรับการตรวจตา โดยจักษุแพทย แนวทางการตรวจคัดกรองของ สถาบันสุขภาพเด็กฯ กรมการแพทย / AAP & AAOน้ําหนักแรกคลอด ≤ 1500 กรัม ≤ 2000 กรัม อายุครรภ ≤ 28 สัปดาห ≤ 35 สัปดาห
  24. 24. แนวทางการตรวจคัดกรองของ สถาบันสุขภาพเด็กฯกรมการแพทย / AAP & AAO 4-6 week 4-6 week 31-33 week 31-33 week (Post conception age) (Post conception age) Follow up q 1-4 week until refress
  25. 25. 1. In premature infant (B.W. < 2000g) with oxygen treatment.2. Gestational age < 35 wk.3. Every premature infant B.W. < 1300g & G.A. < 30 wk.4. Timing •4-6 wk. after birth = G.A. 28-30 wk. •When discharge5. No active ROP sign, repeat every 2 wk. or 1 mo.6. Active ROP, repeat every week or more7. After discharge •No active ROP, repeat until full vascularization •Active ROP, repeat every 1-2 weeks until regress
  26. 26. 1. Dilate pupil by mixture of 1% Tropicamide and 10 % Phenylephrine HCL ratio 9 : 1 for every 5 min. 4-6 times2. Fundus exam by indirect ophthalmoscope3. Screening according to guideline4. Classify by International Classification
  27. 27. 1. Laser Photocoagulation2. Cryotherapy3. Scleral bucking with or without pars plana vitrectomy in case of tractional retinal detachment4. Open sky vitrectomy5. Bevacizumab (Avastin)
  28. 28. 1. AP-ROP2. Quick progression of ROP from any stage to stage 33. Moderate to sever in fibrovascular proliferation4. Plus and Pre Plus sign
  29. 29. • Bevacizumab• Genentech Drug• Intravitreal injection 0.4-0.75 mg• Very small premy ,low birth weight• Severe ROP, salvage therapy• Japan(5eyes),Mexico city (18eyes),• Portugal (6 eyes), off-lable used• Need further study
  30. 30. เครื่องถายภาพจอประสาทตา Retinal Camera (Ret-cam®)
  31. 31. • Digital retinal images ( Ret Cam)• Trained nurses, Doctor• Digital reading center• Example: Stanford University Network for Diagnosis of Retinopathy of Prematurity
  32. 32. 20% of active ROP Cicatricial complication
  33. 33. 1. Minimal peripheral retinal pigmentary disturbance and haze at the vitreous base2. Myopia3. Peripheral retinal breaks and lattice degeneration4. Fibrous band, at temporal retinal periphery5. Traction of retinal blood vessels6. Retrolental cyclitic fibro vascular sheets7. Funnel-shaped total retinal detachment8. Secondary angle-closure glaucoma

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